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1523. Available at: http://hera.ugr.es/doi/15014654.pdf. Accessed February 19, 2014 nez JR, Anera RG, Jime  nez del Barco L, Hita E, Pe rez3. Jime n F. Correction factor for ablation algorithms used in corneal Oco refractive surgery with gaussian-profile beams. Opt Express 2005; 13:336–343. Available at: http://www.opticsinfobase.org/ oe/viewmedia.cfm?uriZoe-13-1-336&seqZ0. Accessed February 19, 2014 4. Fang L, He X, Chen F. Theoretical analysis of wavefront aberration from treatment decentration with oblique incidence after conventional laser refractive surgery. Opt Express 2010; 18:22418–224311. Available at: http://www.opticsinfobase.org/ oe/viewmedia.cfm?uriZoe-18-21-22418&seqZ0. Accessed February 19, 2014

Is this really sutureless scleral intraocular lens fixation? In their recent article, Ohta et al.1 describe a technique of sutureless intrascleral fixation of a posterior chamber intraocular lens (IOL). This definition does not seem to be correct. As the authors fixated the haptics in the scleral bed in the scleral groove using a nonabsorbable suture to prevent slippage, this is a modified sutured technique. If they had used an absorbable suture, the definition would apply. Ohta et al.1 stated that they encountered difficulty placing the haptics in the scleral tunnel with the 24gauge needle technique of Gabor et al.2 We agree with the authors because placement of the haptics using this technique may be difficult in some cases. Therefore, we developed the trocar-assisted sutureless intrascleral fixation IOL method.3 In previously reported techniques of sutureless intrascleral fixation, a nonabsorbable suture was not used.2–5 In our trocar-assisted technique, we placed a nonabsorbable suture transconjunctivally after placing the haptics in the scleral groove for stabilization during the early postoperative period and removing it 1 week later.3 Ohta et al. obtained a triangular-shaped flap.1 They did not mention how much of the haptics were inserted into the scleral bed. Despite a permanent suture, they reported IOL-related complications as 5%,1 which is higher than the rates in previous studies2–5 of sutureless intrascleral IOL fixation (0% to 4.8% except traumatic dislocations). The authors concluded that their technique was more secure and simpler than the others. We do not agree with this for the reasons mentioned above. Our trocar-assisted technique appears to be simpler and quicker.3,4 In conclusion, the technique that Ohta et al. presented may be considered a modified intrascleral fixation of the IOL rather than a sutureless method. In this

technique, the main procedure ensuring IOL stability is the use of a permanent suture. Remzi Karadag, MD Huseyin Bayramlar, MD Unsal Sari, MD Istanbul, Turkey REFERENCES 1. Ohta T, Toshida H, Murakami A. Simplified and safe method of sutureless intrascleral posterior chamber intraocular lens fixation: Y-fixation technique. J Cataract Refract Surg 2014; 40:2–7 2. Gabor SGB, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2007; 33:1851–1854 3. Totan Y, Karadag R. Trocar-assisted sutureless intrascleral posterior chamber foldable intra-ocular lens fixation. Eye 2012; 26:788–791. Available at: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3376277/pdf/eye201219a.pdf 4. Totan Y, Karadag R. Two techniques for sutureless intrascleral posterior chamber IOL fixation. J Refract Surg 2013; 29:90–94 5. Scharioth GB, Prasad S, Georgalas I, Tataru C, Pavlidis M. Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2010; 36:254–259

Reply : Kobayakawa et al.1 reported trocar-assisted sutureless intrascleral posterior chamber IOL fixation in 2010 before Totan et al.,2 and they noted a high incidence of vitreous hemorrhage (3 of 5 eyes [60%]). They concluded that bleeding was likely to have been caused by erroneous insertion of the 25-gauge trocar into the pars plicata because of the thickness of the instrument. Totan et al. reported similar complications. In addition, a scleral hole made with a 25-gauge trocar is less likely to close than one made with a 24-gauge microvitreoretinal (MVR) knife, so it is difficult to close the wound. Our 24gauge MVR knife for performing a sclerotomy is thinner than the 25-gauge trocar, which means that erroneous insertion into the pars plicata is less likely. Haptic extraction is also easier than extraction through a scleral hole made by needle puncture. For these reasons, trocarassisted sutureless intrascleral posterior chamber IOL fixation is not currently performed in Japan. We use a single 8-0 nylon suture to fixate the haptic to the scleral bed to prevent it from shifting immediately after surgery. For this purpose, Totan et al.2 also placed a nonabsorbable suture transconjunctivally after placing the haptics in the scleral groove for stabilization during the early postoperative period and removing it 1 week later in their trocar-assisted technique. However, permanent fixation cannot be expected with a nylon suture because it rapidly becomes loose due to hydrolysis. We believe that short-term stability of the haptic is achieved by a nylon suture, whereas permanent stability is achieved by a scleral

J CATARACT REFRACT SURG - VOL 40, MAY 2014

Is this really sutureless scleral intraocular lens fixation?

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