GLUED IOL

OUR TECHNIQUE

Soosan Jacob, MS, FRCS, DNB and Amar Agarwal, MS, FRCS, FRCOphth

Maggi and Maggi in 1997 first used armed sutures on 3 equidistant supple loops of a special intraocular lens (IOL) for intrascleral sutureless fixation.¹ Intrascleral haptic fixation of a 3-piece IOL was originally started by Gabor Scharioth.^2,3 This was further modified by Agarwal et al to include scleral flaps and fibrin glue as part of the procedure.⁴ This now has become a popular technique for secondary IOL fixation in the absence of capsular support.

Indications

This technique is used for IOL fixation in aphakia, torn anterior or posterior capsule, or patients with extensive zonulopathy.

Technique

A conjunctival peritomy is created on either side. Two partial-thickness scleral flaps are created 180 degrees apart. A conventional anterior chamber maintainer or a trocar anterior chamber maintainer⁵ is then fixed for constant infusion into the eye. A pars plana infusion cannula is another alternative if the surgeon prefers. However, the unobstructed tip of the pars plana infusion cannula should be clearly visualized before turning on pars plana infusion. Two sclerotomies are also created under the scleral flaps exactly 180 degrees apart with a 23-gauge needle. While creating the sclerotomy, it is advisable to point the needle downward toward the optic nerve if infusion is through the anterior chamber maintainer, as the flow from the anterior chamber maintainer pushes the iris backward. With the pars plana infusion cannula, the flow pushes the iris forward, so an angulated entry is not essential. Anterior vitrectomy is then performed through the sclerotomies with a 23-gauge cannula, changing sides to get 360-degree access. Intravitreal triamcinolone acetonide is used to stain the vitreous for better visualization. A side-port and a main-port incision are then created. A 3-piece IOL is loaded into the cartridge in such a way that the leading haptic protrudes slightly out—the Lucky 7 sign.⁶ The entry port may be extended slightly and the cartridge placed so that it lies within the incision. Wound-assisted implantation should be avoided. The tip of the leading haptic is then grasped with 23-gauge microforceps that are passed through the sclerotomy. The leading haptic is externalized while the IOL is gently injected forward. With the first haptic externalized, the cartridge is slowly withdrawn from the incision in such a way that the trailing haptic lies outside the eye on the sclera in an upright C configuration⁶ (Figures 41-1A through C and 41-2). With an assistant holding the leading haptic, the trailing haptic is flexed into the main incision and then transferred into the jaws of microforceps passed through the side port. Using the handshake technique,⁷ the tip of the trailing haptic is transferred to microforceps passed through the second sclerotomy, and the trailing haptic is also thus externalized (Figures 41-1D through F). Vitrectomy is again done over the sclerotomy site and for any vitreous present in the anterior chamber. The haptics are then tucked into 2 limbus-parallel 26-gauge intrascleral Scharioth tunnels that are created. The anterior chamber maintainer or the pars plana infusion cannula is removed, and air is injected into the anterior chamber. The scleral flaps and conjunctiva are closed with glue. All incisions are hydrated. Sutures may be applied if required. After removing the speculum, any hypotony is checked for, and balanced salt solution is instilled into the anterior chamber if required to make the eye normotensive. Subconjunctival antibiotic and steroid injection is given into the fornix away from the sclerotomies and the scleral flaps.

• A silicone tire, in which the haptic is threaded through8
  
• No-assistant technique⁹
  
• A microbulldog that holds the first haptic¹⁰
  
• A suture-assisted sutureless technique¹¹

VITRECTOMY

In the absence of 23-gauge vitrectors, a 20-gauge vitrector can also be used through a 20-gauge sclerotomy. Intracameral triamcinolone should be used for staining the vitreous in order to perform a complete anterior vitrectomy and avoid vitreous traction.

The horizontal white-to-white diameter is measured. If more than 12 mm, a vertically oriented glued IOL may be planned, taking advantage of the lesser white-to-white in the vertical axis.12 The surgeon sits temporally if a vertical glued IOL is planned. The width of the scleral flaps can be decreased proportionately if the expected amount of haptic that will be externalized is less. This positioning helps to give a greater length of haptic to tuck into the tunnel. Similarly, for larger eyes, the sclerotomy can be made more anteriorly to increase the amount of haptic tuck. Posteriorly externalized haptics can be reinternalized and, using the handshake technique, externalized once again through fresh sclerotomies made more anteriorly.¹³ In case wider flaps have already been created, the haptic tuck may be initiated within the scleral bed itself. Use of IOLs with a larger overall diameter, such as the Staar AQ2010V IOL (13.5 mm), increases the available haptic for tucking. Customized IOLs may also be ordered. Prof. Agarwal has also described a technique of externalizing the haptics much more anteriorly through peripheral iridectomies and using a pupilloplasty technique to prevent optic capture.

SMALL EYES

Excessively long externalized haptics can be difficult to tuck. The haptics can be trimmed with Vannas scissors and then tucked into the intrascleral tunnels. A small optic diameter IOL may also be used to avoid anterior chamber crowding in case of small eyes, microcornea, microphthalmos, etc.¹⁴

KINKED HAPTIC

An unintentionally kinked haptic can generally be straightened out. However, excessive manipulation of the haptic should be avoided, as the haptic can crack, necessitating IOL explantation. If only the extreme tip of the haptic is kinked, it may be trimmed provided sufficient haptic is still available for tucking.

PREVENTION OF TILT AND DECENTRATION

Decentration is avoided by ascertaining that the sclerotomies are exactly 180 degrees opposite each other while also being centered on the pupil. Tilt is avoided by keeping both sclerotomies equidistant from the limbus.¹⁵

Closed Chamber Translocation of Subluxated Three-Piece IOL or Single-Piece PMMA IOL Into Glued IOL

A dislocated 3-piece foldable IOL may be translocated into a glued IOL with a closed-chamber technique using microforceps passed through diametrically opposite glued IOL sclerotomies.¹⁶ One of the haptics of the IOL is grasped with microforceps and vitrectomy done around it to free it from any entangled vitreous. Any capsular remnants can also be removed with the vitrector. The handshake technique is then used to pass the haptic from hand to hand till the tip is grasped. The same is done with the haptic on the other side (Figures 41-3 and 41-4). This may also be done with a single-piece PMMA (polymethylmethacrylate) IOL, taking care not to flex the haptic too much to prevent it from cracking.

Glued IOL for Subluxated Single-Piece Foldable IOL

A subluxated single-piece acrylic IOL cannot be fixed as a glued IOL. It may be attempted to be fixed in a closed-chamber technique by other means, such as suture fixation of the bag-IOL or sutureless techniques such as glued capsular hooks and the Jacob paperclip capsule stabilizer (Morcher GmbH) for subluxated in-the-bag IOL, as described by one of the authors (SJ).¹⁷ These techniques are described in greater detail in Chapter 12. If the IOL cannot be fixed by these means, it can be cut and explanted followed by implantation of a 3-piece IOL as a glued IOL.

Glued IOL for Subluxated Cataract

Subluxated cataract with one quadrant of zonular loss can be managed with implantation of a capsular tension ring. Three to about 7 clock hours of zonular loss is managed with sutured rings/segments^18–20 or the glued capsular hook or Jacob paperclip capsule stabilizer technique^17,21,22 together with a capsular tension ring. More than 7 clock hours of subluxation may be managed by a lensectomy^23,24 or intracapsular cataract extraction (ICCE)²⁵ with scleral-fixated IOL (glued or sutured). Other alternatives include fixation of more than one site to the scleral wall using sutured segments/rings or glued capsular hooks^26–29 or the supracapsular glued IOL technique.³⁰ Dangling cataracts are generally managed by lensectomy or ICCE and secondary IOL fixation. Iris-fixated and anterior chamber IOLs are other options for secondary IOL fixation.

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