29   Intraocular Lens Fixation in the Absence of Support: The Glued Intraocular Lens

Posterior capsular rent (PCR)^1,2 can occur in the early learning curve in phacoemulsification. Intraoperative dialysis or a large PCR precludes intraocular lens (IOL) implantation in the capsular bag. Implantation of an IOL in the sulcus is possible in cases of adequate anterior capsular support. The first glued posterior chamber IOL (PCIOL) implantation in an eye with a deficient capsule was performed at my eye hospital on December 14, 2007. In eyes with inadequate anterior capsular rim and deficient posterior capsule, the new technique of IOL implantation is the fibrin glue–assisted sutureless IOL implantation with scleral tuck.^3–7 The scleral tuck of a PCIOL was first performed by Gabor Scharioth from Germany (erroneously referred to as S.G. Gabor in the Journal of Cataract and Refractive Surgery⁸). Maggi had previously performed a sutureless scleral fixation of a special IOL.⁹

Surgical Technique

Under peribulbar anesthesia, the superior rectus is caught and clamped. Localized peritomy and wet cautery of the sclera at the desired site of exit of the IOL haptics is performed. A 23-gauge sutureless trocar infusion cannula or an anterior chamber maintainer is inserted. Two partial-thickness limbal-based scleral flaps ∼ 2.5 mm by 2.5 mm are created exactly 180 degrees diagonally apart. Two straight sclerotomies with a 20- or 22-gauge needle are made ∼ 1.0 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 sclera flap. A clear corneal/scleral tunnel incision is then prepared for introducing the IOL. While the IOL is being introduced (Figs. 29.1 and 29.2), an end gripping 23- or 25-gauge micro-rhexis forceps (MicroSurgical Technology, Redmond, WA) is passed through one of the sclerotomies with the other hand. One can use any end-opening forceps such as a microrhexis forceps. The tip of the leading haptic (Figs. 29.3 and 29.4) 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. For this step, a handshake technique can be used (Fig. 29.5). The limbal wound is sutured with 10-0 monofilament nylon if it is a sclera tunnel incision. The tip 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.

Fibrin Glue

The fibrin kit we used is Reliseal (Reliance Life Sciences, Mumbai, India). Another widely used tissue glue is Tisseel (Baxter, Deerfield, IL). 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 risk of transmission of infection is very low. But with tissue derivatives, there is always a theoretical possibility of transmission of viral infections.

Advantages

This fibrin glue–assisted sutureless PCIOL implantation technique is useful in a myriad of clinical situations in which scleral-fixated IOLs (SFIOLs) are indicated, such as luxated IOL, dislocated IOL, zonulopathy, and secondary IOL implantation.

No Need for Special Intraocular Lenses

This procedure can be performed well with rigid polymethylmethacrylate (PMMA) IOLs, three-piece PCIOLs, or IOLs with modified PMMA haptics. Therefore, there is no need to maintain an inventory of various special SFIOLs with eyelets, unlike with sutured SFIOLs. In dislocated PMMA PCIOLs, the same IOL can be repositioned, thereby reducing the need for further manipulation. Furthermore, there is no need for newer haptic designs or special instruments other than the 25-gauge forceps.

No Tilt

Because the overall diameter of the routine IOL is ∼ 12 to 13 mm, with the haptic being placed in its normal curved configuration and without any traction, there is no distortion or change in shape of the IOL optic. Externalization of the greater part of the haptics along its curvature stabilizes the axial positioning of the IOL and thereby prevents any IOL tilt.¹⁰

Less Pseudophakodonesis

When the eye moves, it acquires kinetic energy from its muscles and attachments and the energy is dissipated to the internal fluids as it stops. Thus, pseudophakodonesis is the result of oscillations of the fluids in the anterior and posterior segments of the eye. These oscillations, initiated by movement of the eye, result in shearing forces on the corneal endothelium as well as vitreous motion, which leads to permanent damage. Because the IOL haptic is stuck beneath the flap, it would prevent the further movement of the haptic, thereby reducing pseudophakodonesis.¹¹

Fig. 29.1 Leading haptic externalization. (a) The haptic tip is slightly out of the cartridge. The glued intraocular lens (IOL) forceps is passed through the sclerotomy site. (b) The tip of the haptic is grasped with the glued IOL forceps. (c) Injection of the IOL continues. (d) The haptic is externalized and held by an assistant. (From Agarwal A, Jacob S, Kumar DA, et al. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg 2013;39:317–322. Reprinted with permission.)

Visually significant complications due to late subluxation,¹² which has been known to occur in sutured SFIOLs, may also be prevented as sutures are totally avoided in this technique. Another important advantage of this technique is the prevention of suture-related complications,^13,14 such as suture erosion, suture knot exposure, or dislocation of IOL after suture disintegration or broken suture.

Rapidity and Ease of Surgery

Passing sutures into the IOL haptic eyelets for SFIOLs, to ensure good centration before tying down the knots, and suturing scleral flaps and closing the conjunctiva take significantly less time with this procedure. The risk of retinal photic injury,¹⁵ which is known to occur in SFIOLs, would also be reduced in our technique due to the short surgical time. Fibrin glue takes less time (Reliseal, 20 seconds; Tisseel, 3 seconds) to act in the scleral bed, and it aids in adhesion as well as hemostasis. The preparation time can also be reduced in elective procedures by preparing the glue prior to surgery, as it remains stable for up to 4 hours from the time of reconstitution. Fibrin glue has been shown to provide airtight closure, and by the time the fibrin starts degrading, surgical adhesions would have already occurred in the scleral bed. This is well shown in the follow-up anterior-segment optical coherence tomography (OCT) in which postoperative perfect scleral flap adhesion is observed.

Fig. 29.2 Leading haptic externalization. (a) The haptic is outside the cartridge. The glued IOL forceps is ready to grasp the haptic tip. (b) The haptic tip is caught with the forceps. (c) Injection of the IOL continues until the optic unfolds inside the anterior chamber. (d) Haptic externalization is started. (From Agarwal A, Jacob S, Kumar DA, et al. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg 2013;39:317–322. Reprinted with permission.)

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