Glued IOL technique. (a) Aphakia with posterior capsule rupture. (b) Two partial scleral thickness flaps made 180° opposite to each other. Sclerotomy being performed beneath the scleral flaps with a 20 G needle about 1.5 mm from the limbus. (c) Tip of the haptic of a three-piece foldable IOL grasped with a glued IOL forceps introduced from the left sclerotomy site. (d) Handshake technique being performed for externalization of the trailing haptic. (e) Haptic being tucked into the scleral pockets created with a 26 G needle. (f) Corneal wound sutured. Pupilloplasty being performed with modified Siepser slipknot technique. (g) Air bubble introduced into the eye and fibrin glue being applied beneath the scleral flaps. (h) Conjunctival peritomy incision sealed with fibrin glue
Pupilloplasty is often done in cases that have pupil disfigurement (Fig. 27.1f). Air bubble is injected into the anterior chamber, infusion is stopped, and the scleral bed is dried up for fibrin glue application. One drop of reconstituted fibrin glue is applied beneath the scleral flaps on either side (Fig. 27.1g), and the flaps are pressed for a few seconds to facilitate proper adhesion. The remaining glue is used to seal the conjunctival peritomy sites and all the corneal incisions (Fig. 27.1h).
27.3.1 Postoperative Medications
The postoperative drug regime comprises of moxifloxacin and prednisolone acetate eye drops to be instilled at least six times a day for the initial first week followed by tapering over a period of next 4–6 weeks. Cycloplegic drugs are also prescribed at least two times a day for the initial 1-week.
27.4 Modifications in Glued Surgery
The glued IOL technique introduced by Agarwal et al. has been widely adopted by surgeons, and subsequently the technique has undergone various modifications over a period of time. These modifications help to increase the surgical ease of technique and make it more applicable.
27.4.1 No-Assistant Technique (NAT)
This technique [3, 4] is also known as “two-handed technique” as it obviates the need of an assistant to grasp the haptics during the glued IOL surgery. This procedure makes the technique more surgeon dependent than assistant dependent, as complications such as haptic break and kink have been reported while the assistant grasps the leading haptic . This occurs due to enthusiastic approach on the part of an assistant to hold the haptic tightly in order to prevent its slippage into the eye from the sclerotomy wound during the surgery.
The technique of NAT works on the principle of “vector forces,” and the midpupillary plane plays a major factor in reversing the direction of vector forces that help in more extrusion of the leading haptic while the trailing haptic is being externalized. In NAT, when the trailing haptic is introduced into the eye it is flexed so that it crosses the midpupillary plane toward 6 o’clock position. This movement reverses the direction of the vector forces and causes the leading haptic to be extruded constantly from the left sclerotomy site without a chance of slipping it back into the eye.
The initial steps are similar to the technique described by Agarwal et al. that involve the making of scleral flaps (Fig. 27.2a), sclerotomy (Fig. 27.2b), and vitrectomy (Fig. 27.2c).
No-assistant technique. (a) Conjunctival peritomy done followed by two partial thickness scleral flaps at 180° opposite to each other. Trocar infusion is introduced. (b) Sclerotomy done with a 20 G needle. (c) Lensectomy with vitrectomy being done with a 23 G vitrectomy cutter. (d) Side-port incision created midway between the left sclerotomy port and the corneal tunnel. (e) A three-piece foldable IOL introduced into the eye. Tip of the haptic is grasped with a glued IOL forceps. (f) Once the entire IOL has unfolded, the tip of the leading haptic is pulled and externalized
A 2.8 mm corneal tunnel is fashioned, and a side-port incision is framed between the left sclerotomy site and the corneal tunnel (Fig. 27.2d). A three-piece foldable IOL is loaded on to the cartridge, and the tip of the haptic is slightly extruded from the cartridge end. The cartridge is introduced into the eye, and simultaneously a glued IOL forceps is introduced from the left sclerotomy site and the tip of the haptic is grasped (Fig. 27.2e). The IOL is slowly injected into the eye, and once the entire IOL has unfolded, the tip of the leading haptic is grasped and is externalized (Fig. 27.2f).
The surgeon grasps the leading haptic and flexes the trailing haptic with another glued IOL forceps into the eye. When the trailing haptic crosses the midpupillary plane, the vector forces reverse their direction. In other words, when the surgeon flexes the trailing haptic more toward 6 o’clock position, the leading haptic extrudes more from the left sclerotomy site and does not tend to slip back into the eye (Fig. 27.3a).
No-assistant technique. (a) The trailing haptic is flexed into the eye toward 6 o’clock position. The leading haptic lies free and does not tend to slip into the eye. Second glued IOL forceps is introduced from the side-port incision, and the trailing haptic is transferred to the left hand. (b) The right glued IOL forceps is withdrawn and is re-introduced from the right sclerotomy site. The tip of the trailing haptic is then grasped. (c) The trailing haptic is pulled and is externalized. During the entire process of haptic externalization, the leading haptic lies free. (d) Scleral pocket being created with a 26 G needle. (e) Haptics are tucked into the scleral pockets. (f) Fibrin glue is applied and the flaps are sealed. Corneal wound is secured with a 10–0 suture, and air bubble is injected
At this stage, the surgeon leaves the leading haptic and re-introduces the glued IOL forceps from the side-port incision followed by transferring of the haptic from the right hand to the left hand (Fig. 27.3b). The trailing haptic is then externalized by handshake technique as described in the Agarwal technique (Fig. 27.3c). During the entire process of haptic externalization, the leading haptic lies free without a need of an assistant to hold the haptic. The haptics are then tucked into the scleral pockets (Fig. 27.3d, e), and the flaps are sealed with fibrin glue (Fig. 27.3f).
27.4.2 Beiko and Steinert Technique
This technique  incorporates the use of silicon tires or stoppers that are attached to the iris hooks. Following the externalization of the leading haptic, a silicon tire is plugged on to the haptic that prevents the slippage of the haptic into the eye (Fig. 27.4). This is a very effective technique, but it incurs extra cost due to the need to use silicon tires.
Silicon tire is plugged on to the haptic to prevent its slippage into the eye from the sclerotomy incision (Beiko and Steinert technique)
27.4.3 Ohta’s Y-Fixation Technique
Toshihiko Ohta started the “Y-fixation” technique . In this technique, two Y-shaped incisions are made 2 mm away from the limbus, exactly 180° opposite to each other. In this procedure, a 23 G MVR blade is used to perform a sclerotomy parallel to the iris at the Y-shaped incision, and a scleral tunnel is made parallel to the limbus at the end of Y-shaped incision.
27.5 Complications of Glued IOL
Complications are an inherent part of a surgery, and occasionally unavoidable complications may occur during surgery. Taking proper steps during the surgery, and calibrating and executing the surgical steps with adequate precision, can prevent many of these complications. It is impossible to predict which patients are more prone to complications as compared to others. The main complications of glued IOL surgery have been listed below.
27.5.1 Decentration of the IOL
Intraoperative decentration of the IOL is a sign of off-axis scleral flap fashioning. When the scleral flaps are not made 180° opposite to each other, decentration of IOL is often seen. To be more precise, the sclerotomy wound created beneath the scleral flaps also should be 180° opposite to each other, as it is from this site that the haptics are externalized. Any deviation from this rule leads to decentration of the IOL. If decentration is detected intraoperatively, then the surgeon should cross check the 180° axis marking and make a fresh sclerotomy followed by re-internalization of the haptic and re-externalization from the fresh sclerotomy site . For postoperative detection of decentration, the scleral flaps should be lifted, and the similar procedure as described above should be performed.
Inadequate haptic tuck into the scleral pockets can be another reason for decentration of the IOL. This situation arises due to either an inadequate length of haptic available for tucking or due to improper tucking of the haptics despite the available length for adequate tuck.
27.5.2 Haptic Break/Kink
Improper pressure exerted on the haptics during the process of externalization often leads to a kink, and in extreme cases it can even lead to a haptic break . Subsequently, various problems are encountered as the haptic falls short of length to achieve adequate tucking. The IOL often needs to be explanted, and a fresh IOL is then used to overcome this problem. In cases of mild kink, the haptic can still be tucked by gently maneuvering the haptic into the scleral pockets.