Shin Yamane, MD, PhD
The intrascleral intraocular lens (IOL) fixation technique was first reported by Scharioth and then Agarwal as a sutureless technique for IOL fixation.1,2 This technique has become a popular procedure because it has some advantages over conventional transscleral suturing of the IOL.3–7 Flanged IOL fixation was developed to realize minimally invasive and reliable IOL fixation without using suture or glue.8 This technique is simple but not easy. The surgeon needs to understand some key points of the technique.
Materials and Devices
- Thirty-gauge thin-walled needle (Figure 45-1). This needle (TSK Ultra Thin Wall Needle) is available in Japan (Tochigi Seiko), the United States (Delasco Dermatologic Lab and Supply, Inc), and the Netherlands (TSK Laboratory Europe). The inner diameter of the needle must be 0.18 mm or more. The outer diameter of the needle should not be larger than the flange of the IOL haptics. A 27-gauge needle may work if the diameter of the flange is more than 0.4 mm.
- Ophthalmic cautery. High-temperature cautery is recommended. The author uses Accu-Temp Cautery (Beaver Visitec).
- Forceps. Special forceps for intrascleral IOL fixation (Yamane IOL fixation forceps, Katalyst Surgical) are recommended. Coaxial forceps for capsulorrhexis can be used. However, forceps for vitreous surgery are not suitable because the shaft of this type of forceps is straight and too long.
- IOL. Most 3-piece IOLs can be used. However, an IOL with thick haptics that do not fit inside the needle cannot. Polyvinylidene fluoride (PVDF) is recommended as the material of the haptics. This material resists breakage or deformation during surgery due to its flexibility. The haptics of the X-70 (Santen), PN6A (Kowa), and CT Lucia 602 (Carl Zeiss Meditec; former Aaren Scientific Aaris EC-3 PAL) IOLs are made of PVDF. The author mainly uses X-70 because it has a large optic, helping avoid iris capture.
Surgical Technique (Video 45-1)
- Peripheral iridotomy using the vitrectomy cutter before mydriasis.
- Pars plana vitrectomy or anterior vitrectomy.
- Subluxated crystalline lens or dislocated IOL removal.
- Three-piece IOL insertion into the anterior chamber: The trailing haptic must be kept outside to prevent the IOL from falling into the vitreous cavity.
- An angled sclerotomy made with a 30-gauge thin-walled needle through the conjunctiva 2 mm behind the limbs (Figure 45-2).
- Insertion of the leading haptic into the lumen of the needle using forceps (Figure 45-3).
- A second sclerotomy made with a 30-gauge thin-walled needle 180 degrees from the first sclerotomy.
- Insertion of the trailing haptic into the lumen of the second needle while the first needle was laid down on the conjunctiva (double-needle technique; Figure 45-4).
- Externalization of the haptics onto the conjunctiva with the needles (Figure 45-5).
- Cauterization of the ends of the haptics used to make a flange with a diameter of 0.3 mm (Figure 45-6).
- Fixation of the flange of the haptics into the scleral tunnels (Figure 45-7).
- Insertion of the trailing haptic into the lumen of the second needle while the first needle was laid down on the conjunctiva (double-needle technique; Figure 45-4).
Figure 45-1. (A) A 30-gauge thin-walled needle has a larger lumen than (B) a normal 30-gauge needle.
Figure 45-2. An angled sclerotomy is created 2.0 mm from the limbus using a 30-gauge thin-walled needle.
Figure 45-3. Introduction of the leading haptic into the lumen of the 30-gauge needle.
Figure 45-4. Introduction of the trailing haptic into the lumen of the 30-gauge needle using the double-needle technique.
Figure 45-5. Externalization of the haptics with 2 needles.
Figure 45-6. Cauterization of the haptics to make flanges.
Figure 45-7. Pushing back of the haptics to fix the flanges in the scleral tunnel.
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