SUPRACAPSULAR GLUED IOL TECHNIQUE FOR PROGRESSIVE ZONULOPATHY

Soosan Jacob, MS, FRCS, DNB

There are essentially 2 broad means of managing subluxated cataracts, one that retains the intact capsular bag and another that uses either lensectomy or intracapsular cataract extraction (ICCE). In the former, the intraocular lens (IOL) is implanted in the bag, whereas the latter uses secondary IOL implantation in the form of scleral-fixated IOL (glued or sutured), iris-fixated IOL, or anterior chamber IOL. The author has described a technique called supracapsular glued IOL, where following phacoemulsification of the nucleus and cortex aspiration, intrascleral haptic fixation is used to fixate the IOL over the intact capsular bag via a glued IOL technique.

Indications

This technique can be used for progressive zonulopathy where the lens is still not subluxated posteriorly into the vitreous cavity and where conventional means of surgery can have disadvantages. Implantation of a capsular tension ring or scleral fixation via sutured rings and segments or sutureless hooks are some of the techniques employed for subluxated cataract depending on the degree of subluxation. However, in case of progressive etiologies such as pseudoexfoliation, megalophthalmos, high myopia, aniridia, Marfan syndrome, or homocystinuria, continuing zonulopathy and subluxation after phacoemulsification with in-the-bag IOL can result in delayed complications.^1–7 Therefore, for such etiologies, stable support on 2 or 3 equidistant sides should be aimed for during the primary surgery itself. Stability may be attained by either performing a lensectomy^8–12/ICCE^13,14 with IOL fixation as a suture-fixated (glued or sutured)/iris-fixated/anterior chamber IOL depending on the surgeon’s choice or by phacoemulsification with in-the-bag IOL with equidistant fixation of sutured segments^15–17 or the sutureless Jacob paperclip capsule stabilizer (Morcher GmbH) and glued capsular hook techniques described in greater detail in Chapter 12.^18–24 The advantage of the capsular bag–retaining approach is that it avoids the need for entry into the vitreous cavity and maintains a separation between the anterior chamber and posterior segment during surgery as well as postoperatively. The lensectomy/ICCE approach provides stable IOL fixation but causes disturbance of the vitreous face. Equidistant sutured or sutureless fixation of the capsular bag is a good option for retaining the capsulozonular barrier. The supracapsular glued IOL technique offers an alternative means for intrascleral haptic fixation via the glued IOL technique without disturbing the capsular bag complex or entering into the vitreous cavity and is indicated in cases with progressive zonulopathy.

Surgical Technique

Two partial-thickness scleral flaps are created 180 degrees apart. An anterior chamber maintainer is fixed to prevent anterior chamber shallowing in later steps. A rhexis is done following all precautions for subluxated cataract. If required, translimbal capsular hooks may be used for supporting the capsular bag during the subsequent maneuvers. Phacoemulsification of the nucleus is done carefully followed by gentle cortex aspiration. The capsular hooks are then loosened to create space for the supracapsular glued IOL procedure. This is done by instilling viscoelastic in the space between the iris and the anterior capsule. Ab interno sclerotomies are then created under the scleral flap with a bent 23-gauge needle by passing it parallel to the iris in the plane between the iris and the anterior capsule (Figure 43-1). The supracapsular space is again expanded with viscoelastic. The bag is also filled with dispersive viscoelastic to prevent it from moving forward.

A 3-piece IOL is loaded into the injector with the leading haptic projecting slightly out as in the Lucky 7 sign described with the glued IOL technique. The injector is introduced into the anterior chamber through the main port. A pair of 23-gauge end-gripping forceps is then carefully passed through the sclerotomy parallel to the iris and above the anterior capsule, and the leading haptic of the 3-piece IOL is grasped with it. The haptic is externalized through the sclerotomy while the rest of the IOL is injected into the anterior chamber. The trailing haptic is allowed to rest outside on the scleral surface in the upright C configuration described with the glued IOL technique. After again expanding the supracapsular space with viscoelastic, the handshake technique is used to externalize the second haptic as well in a supracapsular plane. The capsular hooks are then removed, and the 2 haptics are tucked into limbus-parallel intrascleral Scharioth tunnels. The anterior chamber maintainer is also removed, and fibrin glue is used to close the scleral flaps and conjunctiva (Figure 43-2).²⁵

Any vitreous prolapse around the capsular bag or under the scleral flap is handled by staining with preservative-free triamcinolone acetonide and anterior vitrectomy. The Lucky 7 sign and the upright C configuration for easy externalization of the haptics are shown in Figures 43-3A and B, respectively.

Prevention of Capsular Phimosis

This may be avoided either intraoperatively by putting relaxing incisions on the anterior capsule or postoperatively in a more controlled environment by doing YAG anterior capsulotomy incisions. Though a capsular tension ring implanted into the bag at the time of primary surgery would also help prevent capsular phimosis, it would increase the risk of a late capsular tension ring–bag dislocation, and unless combined with an optic capture to a well-centered rhexis is not preferred.

Advantages of Supracapsular Glued IOL

The advantages of this technique are that it retains the capsular bag and avoids the need for entry into the vitreous cavity. Vitreous disturbance is therefore limited to only any prolapsed vitreous around the zone of subluxation. The anterior chamber is separated from the posterior segment during surgery as well as postoperatively. Since the nucleus is being emulsified above the capsular bag, the chances of nuclear fragments or epinucleus dropping into the vitreous cavity are reduced (Figure 43-4A). The intrascleral haptic fixation gives long-term stability and centration. Postoperatively, the lack of vitreous handling as well as decreased endophthalmodonesis contribute toward a decreased risk of posterior segment complications. This may be especially important in eyes with a preexisting risk of posterior segment complications such as high myopia, Marfan syndrome, post-retinal detachment eyes, or vitrectomized eyes (Figure 43-5).

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