24 Intrascleral Haptic Fixation of a PCIOL (Glued IOL)
10.1055/b-0036-134495
24 Intrascleral Haptic Fixation of a PCIOL (Glued IOL)
Amar Agarwal and Nisha Sinha
24.1 Introduction
Posterior capsule rent (PCR)s. Literatur,2can occur even with experienced surgeons. Intraoperative dialysis or a large PCR will prevent intraocular lens (IOL) implantation in the capsular bag. Implantation of an IOL in the sulcus will be possible in cases of adequate anterior capsule support. The first glued posterior capsule IOL (PCIOL) implantation in an eye with a deficient capsule was performed by the authors on December 14, 2007. In eyes with an inadequate anterior capsule rim and a deficient posterior capsule, the new technique of IOL implantation is the fibrin glue–assisted sutureless IOL implantation with a scleral tuck.s. Literatur,s. Literatur,s. Literatur,s. Literatur,7Gabor and Pavlidis performed the first scleral tuck of a PCIOL.8Maggi and Maggi had previously performed a sutureless scleral fixation of a special IOL.9
24.2 Surgical Technique
Under peribulbar anesthesia, the superior rectus is caught and clamped (see Video 24.1). Localized peritomy and wet cautery of the sclera at the desired site of exit of the IOL haptics is done. A 23-gauge sutureless trocar infusion cannula or an anterior chamber maintainer is inserted. Two partial-thickness limbal-based scleral flaps about 2.5 × 2.5 mm are created exactly 180° diagonally apart. Two straight sclerotomies with a 20/22-gauge needle are made ~ 1 mm from the limbus under the existing scleral flaps. This is followed by a 23-gauge vitrectomy via the pars plana or anterior route to remove all the vitreous traction. The 23-gauge vitrectomy probe can be passed through the sclerotomy created under the scleral flap. A clear corneal/scleral tunnel incision is then prepared for introducing the IOL. While the IOL is being introduced (Fig. 24.1, Fig. 24.2) an end-gripping 23/25-gauge micro rhexis forceps (MicroSurgical Technology) is passed through one of the sclerotomies with the other hand. One can use any end-opening forceps like a micro rhexis forceps. The tip of the leading haptic (Fig. 24.3, Fig. 24.4) is then grasped with the micro rhexis forceps, pulled through the sclerotomy following the curve of the haptic, and externalized under the scleral flap. Similarly, the trailing haptic is also externalized through the other sclerotomy under the scleral flap. A handshake technique can be used for this (Fig. 24.5). The limbal wound is sutured with 10–0 monofilament nylon if it is a scleral tunnel incision. The tips of the haptics are then tucked inside a scleral tunnel made with 26-gauge needle. The scleral flaps are closed with fibrin glue. The anterior chamber maintainer or the infusion cannula is removed. The conjunctiva is also closed with the same fibrin glue.
Fig. 24.1 (a) Leading haptic externalization. Note the haptic tip slightly out of the cartridge. The glued intraocular lens (IOL) forceps passed through the sclerotomy site. (b) Tip of the haptic grasped with the glued IOL forceps. (c) Injection of the IOL continued. (d) Haptic externalized and held by an assistant. (Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S, Agarwal A. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg. 2013 Mar;39(3):317-22. Used with permission.)Fig. 24.2 Leading haptic externalization. (a) Haptic outside the cartridge. Glued intraocular lens (IOL) forceps ready to grasp the haptic tip. (b) Haptic tip caught with the forceps. (c) Injection of the IOL continued until the optic unfolds inside the anterior chamber. (d) Haptic externalization started. (Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S, Agarwal A. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg. 2013 Mar;39(3):317-22. Used with permission.)Fig. 24.3 Trailing haptic externalization. (a) Trailing haptic caught with the first glued intraocular lens (IOL) forceps. (b) Haptic flexed into the anterior chamber. (c) Haptic transferred from the first forceps to the second forceps using the handshake technique. The second forceps is passed through the side port. (d) First forceps is passed through the sclerotomy under the scleral flap. Haptic is transferred from the second forceps back to the first using the handshake technique. Haptic tip is grasped with the first forceps. (e) Haptic is pulled toward the sclerotomy. (f) Haptic externalized. (Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S, Agarwal A. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg. 2013 Mar;39(3):317-22. Used with permission.)Fig. 24.4 Handshake technique for trailing haptic. (a) Glued intraocular lens (IOL) forceps passed through the side port. (b) Trailing haptic grasped with a forceps and flexed to make it enter the anterior chamber. (c) Trailing haptic passed into the anterior chamber and with handshake technique, haptic grasp shifted from the first forceps to the second forceps. Note the dimpling on the cornea as the main incision is open due to the forceps passage. (d) Trailing haptic caught with the forceps passed through the side port. Note no dimpling on the cornea as the main port incision is closed. The tip of the haptic is easily seen. (e) Glued IOL forceps passed through the sclerotomy and tip of the haptic grasped. (f) Trailing haptic externalized. (Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S, Agarwal A. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg. 2013 Mar;39(3):317-22. Used with permission.)Fig. 24.5 Handshake technique to regrasp the haptic. (a) Foldable intraocular lens (IOL) haptic is below the iris. (b) Glued IOL forceps is passed through the opposite sclerotomy site while the second forceps is ready to receive the haptic. (c) The leading haptic is grasped with the forceps and the haptic tip is fed into another forceps. (d) One haptic is externalized and the assistant holds the haptic. (e) Trailing haptic caught with the glued-IOL forceps. (f) Both the haptics are externalized under the scleral flaps. (Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S, Agarwal A. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg. 2013 Mar;39(3):317-22. Used with permission.)
24.2.1 Fibrin Glue
The fibrin kit we used is Reliseal (Reliance Life Sciences). Another widely used tissue glue, TISSEEL (Baxter Healthcare Corporation), can also be used. The fibrinogen and thrombin are first reconstituted according to the manufacturer’s instructions. The commercially available fibrin glue is virus inactivated and is checked for viral antigen and antibodies with polymerase chain reaction; hence the chances of transmission of infection are very low. But with tissue derivatives, there is always a theoretical possibility of transmission of viral infections.
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