Glued intrascleral fixation of an IOL

When the posterior capsule is ruptured or damaged.

By Dr. Priya Narang, MS, and Dr. Amar Agarwal, MS, FRCS, FRCOphth

	About the Author
	Dr. Priya Narang, MS, is affiliated with the Narang Eye Care and Laser Centre, Ahmedabad, India.
	Dr. Amar Agarwal, MS, FRCS, FRCOphth operates Dr. Agarwal’s Eye Hospital and Research Centre in Chennai, India. Dr. Narang’s e-mail is narangpriya19@gmail.com. Disclosure: Neither doctor reports any conflicts relevant to products mentioned in the article.

IOL implantation in the absence of the posterior capsule has always been a daunting task for the surgeon. The past decade has seen a paradigm shift in the management of secondary IOL implantation from sutured scleral fixation and iris retro-claw fixation to sutureless intrascleral¹ and glued intrascleral fixation of the IOL.² In adopting these advanced techniques, a surgeon can produce outstanding outcomes with this specific patient cohort. Here, we will explain the technique pioneered by Dr. Agarwal for IOL implantation in these difficult cases.

BASICS OF THE GLUED TECHNIQUE

Types of cases

Surgical complication such as posterior capsule rupture may preclude the placement of an IOL in the capsular bag. Glued IOL is universally applicable in all cases of phacoemulsification that have gone awry due to a posterior capsular rupture irrespective of the size of the capsular break. This technique helps implant a posterior chamber IOL in eyes with deficient posterior capsule.

Fig 1A. Two scleral flaps are made 180° opposite each other.

Fig 1B. Side port incision is framed for introduction of an anterior chamber maintainer.

Fig 1C. Sclerotomy is done with a 20-gauge needle beneath the flaps.

Fig 1D. Vitrectomy is done with a 23-gauge vitrectomy cutter. (In this case lensectomy was also done as it was a case of lens coloboma).

Fig 1E. Thorough vitrectomy being done.

Fig 1F. A three-piece foldable IOL is loaded into the cartridge.

A quick-acting surgical fibrin sealant derived from human blood plasma, which has both hemostatic and adhesive properties, is used to seal the scleral flaps. Fibrin glue has been used in various medical specialities as a hemostatic agent to arrest bleeding and seal tissues and as an adjunct to wound healing. The glue also helps in sealing the sclerotomy site, which would otherwise act as a filtration site and cause hypotony.

A superior procedure

This technique has an advantage in that it can be performed in the presence of significant structural abnormalities of the anterior chamber (AC) and that it mitigates many of the adverse outcomes associated with AC IOLs, iris-fixated IOLs and sutured scleral fixated IOLs.

In this technique, we implant a standard threepiece IOL with a haptic design fitting to the diameter of the ciliary sulcus. We place the haptic in its normal curved configuration without traction; there is no distortion or change in the shape of the IOL optic. Externalization of the greater part of the haptic along its curvature stabilizes the axial positioning of the IOL and prevents IOL tilt. The use of scleral pocket fixation is less technically demanding because it stabilizes the IOL in the posterior chamber without difficult suturing procedures.

Placing the IOL haptic beneath the flap prevents further movement of the haptic, reducing the pseudophacodonesis that can lead to constant motion in the vitreous and, ultimately, retinal damage. We leave the haptic ends in the tunnel to prevent foreign- body sensation and conjunctival erosion, and to reduce the risk of inflammation.

THE TECHNIQUE

13 surgical steps

1. After limited conjunctival peritomy, fashion two partial-thickness scleral flaps 2.5 x 2.5 mm 180° opposite each other (Figure 1A).

"This decade has seen a paradigm shift in the management of secondary IOL implantation”

Fig 2A. Tip of the leading haptic grasped by glued IOL forceps.

Fig 2B. The entire IOL unfolded with trailing haptic lying at the corneal incision.

Fig 2C. Leading haptic pulled and externalized.

Fig 2D. The trailing haptic flexed in to the eye; second glued IOL forceps is introduced from the side port incision and the haptic is transferred.

Fig 2E. The glued IOL forceps in the right hand is reintroduced from the right sclerotomy incision and the tip of haptic is grasped.

Fig 2F. The trailing haptic is pulled and externalized. Vitrectomy done at sclerotomy site.

2. Introduce infusion into the eye either by a trocar or an anterior chamber (AC) maintainer (Figure 1B).

3. Make a sclerotomy with a 20-gauge needle about 1.5 mm from the limbus beneath the flaps (Figure 1C).

4. Introduce a 23-gauge vitrectomy probe and perform a thorough vitrectomy (Figures 1D and 1E). Triamcinolone can be used to stain the vitreous for easy visualization.

5. Fashion a corneal tunnel with a 2.8-mm keratome and frame a side-port incision mid-way between the left sclerotomy site and the tunnel.

6. Load a three-piece monofocal foldable IOL with modified C-loop haptic configuration and bring the tip of the haptic slightly out from the cartridge (Figures 1F, 2A).

7. Introduce a 23-gauge glued IOL forceps from the left sclerotomy site, then introduce the loaded cartridge into the eye and grasp the tip of the IOL haptic (Figure 2B).

8. Slowly inject the IOL in to the eye. Once the entire IOL has unfolded, pull and externalize the tip of the leading haptic (Figure 2C). The assistant holds the leading haptic to prevent its slippage into the eye.

9. Flex the trailing haptic with the glued IOL forceps in the right hand and introduce it into the eye. Then, reintroduce the glued IOL forceps in the left hand from the side-port incision into the eye (Figure 2D).

10. Transfer the haptic from the right glued IOL forceps to the left hand. (This is the so-called “handshake “ technique we will describe in the next section of the article).

11. Withdraw the right glued IOL forceps from the eye and reintroduce it from the right sclerotomy site (Figure 2E). Transfer the trailing haptic from the left hand to the right hand (“handshake” technique again). Hold the haptic from its tip and pull it to externalize it.

12. Create a scleral pocket with a 26-gauge needle parallel to the sclerotomy site along the edge of the flap. Tuck the haptics and perform a vitrectomy to cut down any vitreous strands at the sclerotomy site (Figures 2F, 3A).

13. Stop infusion, dry the scleral bed and apply glue to seal the flaps (Figure 3B). Fibrin glue can also be used to seal all the conjunctival peritomy sites and corneal incisions (Figure 3C).

The “handshake” technique

The “handshake” technique³ is a modification in the glued IOL procedure in which the surgeon bimanually transfers the IOL haptic from one glued IOL forceps to another under direct visualization in the pupillary plane until grasping the haptic tip to facilitate easy externalization.

The handshake technique is applicable in cases of slippage of the haptic during externalization or in cases of subluxation of three-piece IOLs in which one can easily approach the haptic tip by transferring the haptic between the two glued IOL forceps. It is essential to hold the haptic at its tip so that it does not snag on the sclerotomy wound during exteriorization.

Continue the handshake transfer of the haptic between the two glued IOL forceps until the forceps catch the haptic tip on the side to which the haptic is to be exteriorized.

Fig 3A. Haptic tucked in scleral pocket.

Fig 3B. Corneal wounds hydrated with stromal hydration. Air bubble injected in anterior chamber.

Fig 3C. Fibrin glue applied and flaps sealed.

The no-assistant technique

When using the “no-assistant” technique,^{4, 5} after the externalization of the leading haptic, the surgeon flexes the trailing haptic more towards the six o’clock position so as to cross the mid-pupillary plane. This causes a change in the direction of vector forces, which cause more extrusion of the haptic from the sclerotomy site, eliminating the role of an assistant to hold the leading haptic.

Authors have described various methods to prevent the leading haptic from slipping back into the eye. One is the silicone “tire” technique Drs. George Beiko and Roger Steinert⁶ described so the surgeon does not need an assistant to hold the haptic. OM

A video of the basic procedure can be viewed at: www.youtube.com/watch?v=1XDJNXW0CpE Two more videos demonstrate specific types of cases: Vertical glued IOL www.youtube.com/watch?v=jHcCzQNlizs Subluxated IOL to glued IOL www.youtube.com/watch?v=UYZkHPojJ7Y

"The glued IOL technique helps to implant a posterior chamber IOL in eyes with a deficient posterior capsule.”

REFERENCES:

1. Gabor SGB, Pavilidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2007; 33:1851-1854.

2. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg 2008; 34(9):1433-1438.

3. 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.

4. Narang P. No assistant technique- Modified method of haptic externalization of posterior chamber intraocular lens in fibrin glue assisted intrascleral fixation. J Cataract Refract Surg 2013; 39:4-7.

5. Narang P. Postoperative analysis of glued intrascleral fixation of intraocular lens and comparison of intraoperative parameters and visual outcome with 2 methods of haptic externalization. J Cataract Refract Surg 2013; 29, 1118-1119.

6. Beiko G, Steinert R. Modification of externalized haptic support of glued intraocular lens technique. J Cataract Refract Surg 2013 39 323-329.