Surgical Technique
Edited by George A. Williams
Scleral Fixation of Posterior Chamber Intraocular Lenses Using Gore-Tex Suture With Concurrent 23-Gauge Pars Plana Vitrectomy
I
sutured PCIOL placement using Gore-Tex suture at Wills Eye Hospital, Philadelphia, PA. The Supplemental Digital Content 1 (see Video, http://links.lww.com/IAE/A294) demonstrates the key steps to this procedure. In each case, a superior 270° conjunctival limbal peritomy is performed. A superior 7-mm scleral tunnel is created without entering the anterior chamber. A toric lens marker is used to mark the cornea at 2 points 180° apart (Figure 1). Four 23-gauge sclerotomies are made in the ciliary sulcus, located 2 mm posterior to the limbus and 1.5 mm apart from each other, with 2 sclerotomies flanking each of the corneal marks (Figure 2). Vitrectomy is then performed. A standard three-port pars plana vitrectomy may be performed with the superotemporal and superonasal trocars displaced superiorly. Alternatively, vitrectomy can be completed through two of the four ciliary sulcus sclerotomies described above. The anterior chamber is entered through the previously created scleral tunnel using a 2.75-mm phaco keratome. With the infusion clamped, the anterior chamber is then stabilized using viscoelastic. After being cut in half and removing the needle, the 8-0 Gore-Tex suture is then threaded through each eyelet of a CZ70BD (Alcon Laboratories, Fort Worth, TX) IOL at equal lengths. To minimize torsion, care is taken to ensure that the suture passed through the superior sclerotomy goes through the lens eyelet from anterior to posterior on one side of the IOL and is passed from posterior to anterior on the contralateral side. Each end of the Gore-Tex suture is then passed into the anterior chamber and pulled out of each corresponding sclerotomy using 25-gauge forceps (Figure 3). The internal lip of the scleral wound is enlarged to 7 mm, and the CZ70BD IOL is placed into the anterior chamber. All four ends of the Gore-Tex suture are pulled and the IOL is centered (Figure 4). The scleral wound is closed using interrupted 10-0 nylon sutures. The GoreTex sutures are tied using a 3-1-1 technique. The knots are trimmed and rotated into the eye using 25-gauge forceps, with nasal and temporal knots buried in
n the absence of capsular support, options for intraocular lens (IOL) placement include anterior chamber intraocular lenses, iris-fixated posterior chamber intraocular lenses (PCIOLs), and scleral-fixated PCIOLs. In a 2003 Ophthalmic Technology Assessment report for the American Academy of Ophthalmology, Wagoner et al1 supported the effective use of these varying fixation techniques in the appropriate clinical setting, without clear superiority of one method. The choice of surgical technique depends on many factors, including comorbid ocular conditions and anatomical considerations. For surgeons treating patients with history of trauma or complicated cataract surgery, vitrectomy is often required along with IOL placement. Herein, we describe an effective technique for ab externo scleral fixation of PCIOLs using GoreTex (W.L. Gore & Associates, Newark, DE) suture, initially described by Slade et al,2 modified to include concurrent 23-gauge pars plana vitrectomy.
Methods Between January 1, 2013 and June 30, 2013, 10 eyes of 10 patients (5 men, 5 women) underwent combined 23-gauge pars plana vitrectomy and scleralFrom the Retina Service, Wills Eye Hospital, Philadelphia, PA. None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.retinajournal.com). Design of study (M.J.S., O.P.G., M.L.D., A.T.G., M.A.K.), conduct of study (M.J.S., O.P.G., A.T.G., M.L.D.), data collection and analysis (M.A.K., M.L.D.), interpretation of data (M.J.S., O.P.G., M.L.D., A.T.G., M.A.K.), and manuscript preparation (M.J.S., O.P.G., M.L.D., A.T.G., M.A.K.). M. J. Spirn has had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Reprint requests: Marc J. Spirn, MD, Retina Service, Wills Eye Hospital, 840 Walnut Street, Suite 1020, Philadelphia, PA 19107; e-mail: [email protected]
1477
1478 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES
Fig. 1. A toric lens marker is used to mark the cornea at 2 points 180° apart.
opposite directions to balance tension on the IOL. The viscoelastic is removed using the vitrector through the original vitrectomy cannulas, which are then removed and sutured as needed. When vitrectomy is performed through the ciliary sulcus sclerotomies, viscoelastic is removed through the scleral tunnel incision. The conjunctival peritomy is then closed. Results Ten eyes in 10 patients (5 men, 5 women) were reviewed. Average age at the time of surgery was 66 years. Indications for surgery included dislocated IOL (six), traumatic cataract (two), and zonular weakness due to pseudoexfoliation syndrome (one) or previous ocular surgery (one). All 10 eyes in our series had successful scleral fixation of the IOL at 6 months. Overall, mean visual acuity was improved, with 70% of patients improving at least 3 lines of Snellen acuity at final follow-up (range, loss 2 lines to gain 9 lines). Anterior
Fig. 2. Four 23-gauge sclerotomies are made in the ciliary sulcus at a location 2 mm posterior to the limbus and 1.5 mm apart from each other, with 2 sclerotomies flanking each of the corneal marks.
2014 VOLUME 34 NUMBER 7
Fig. 3. Each end of the Gore-Tex suture is passed into the anterior chamber and pulled out of each corresponding sclerotomy using 25-gauge forceps.
segment complications included hyphema (six eyes), corneal edema (four eyes), and intraocular pressure spike (one eye), all of which were treated and resolved with topical therapy. Posterior segment complications included vitreous hemorrhage (one eye), serous choroidal detachment (one eye), cystoid macular edema (one eye), and epiretinal membrane (one eye). Infectious endophthalmitis, prolonged sterile ocular inflammation, retinal tear and/or detachment, suture erosion, or suture breakage were not observed in any patient.
Discussion Many options exist today for the surgical management of aphakia. The choice of surgical technique depends on many factors, including patient age, comorbid ocular conditions, and structural considerations (health of the iris, angle abnormalities). The anterior chamber IOL, iris-fixated PCIOL, and scleral-fixated PCIOL each offers a unique set of considerations.
Fig. 4. All four ends of the Gore-Tex suture are pulled and the IOL is centered.
1479
SURGICAL TECHNIQUE
Older closed-loop anterior chamber IOLs have been associated with higher rates of cystoid macular edema, endothelial cell loss, ocular hypertension, pupillary block, and uveitis–glaucoma–hyphema syndrome compared with PCIOLs.1,3 In patients with preexisting corneal pathology, uveitis, or glaucoma, or in younger patients who may incur these comorbidities over their lifetime, a PCIOL would be preferred. In addition, the PCIOL positions the IOL closer to the natural location of the crystalline lens, possibly offering refractive benefits. In regard to iris fixation versus scleral fixation, iris fixation has been associated with higher rates of iris atrophy, iris chafe, uveitis, pigment dispersion syndrome, and pseudophacodonesis as compared with scleral fixation.4 The trans-scleral–sutured PCIOL technique, however, is also not without complication. Retinal detachment, IOL tilt, vitreous or suprachoroidal hemorrhage, endophthalmitis, and suture erosion/breakage have all been reported with trans-scleral–sutured PCIOLs and may result in permanent vision loss.5–10 Concerns regarding suture erosion and breakage with scleral-sutured PCIOLs have received special attention. Concerns regarding the lifetime of the commonly used polypropylene (Prolene, Ethicon Endo-Surgery, Inc., Cincinnati, OH) suture have been raised. In one study, degradation of Prolene suture was believed to lead to spontaneous subluxation of scleralsutured PCIOLs in up to 27% of cases.11 In a retrospective study of patients undergoing combined pars plana vitrectomy and scleral-sutured PCIOL, suture breakage was observed in 27.9% of cases at a mean follow-up of 6 years.12 Refinement of the scleralsutured PCIOL surgical technique, with the use of an ab externo approach, a scleral flap, and rotation of suture knots, has reduced the rate of suture erosion/ breakage compared with earlier techniques.13 In response to these concerns, sutureless scleral fixation techniques have been published, with a recent revision of the sutureless technique offered by Prenner et al14 with outcomes available to 6 months. Gore-Tex suture is a nonabsorbable polytetrafluoroethylene (ePTFE) monofilament suture used in cardiac and vascular surgeries, among others. Ophthalmic surgeons have suggested and are currently using Gore-Tex suture, given a presumed decreased risk of suture breakage, but the safety and outcomes of the scleral-sutured IOL technique using this suture have not been evaluated to date. All 10 eyes in our series had successful scleral fixation of the IOL at 6 months. Overall, mean visual acuity was improved, and scleral fixation of IOLs with Gore-Tex suture was not associated with significant intraoperative or postoperative complications.
In summary, we describe a technique for ab externo scleral fixation of PCIOLs using Gore-Tex suture with concurrent 23-gauge pars plana vitrectomy. The technique may be an effective option for patients undergoing combined 23-gauge pars plana vitrectomy and IOL implantation for a variety of surgical indications. Ultimately, long-term evaluation of outcomes and complications will be necessary to determine the advantages and disadvantages of this technique. Key words: scleral fixation of posterior chamber intraocular lenses, Gore-tex suture, combined 23gauge pars plana vitrectomy, scleral sutured PCIOL placement. MOHAMMED A. KHAN, ADAM T. GERSTENBLITH, MICHAEL L. DOLLIN, OMESH P. GUPTA, MARC J. SPIRN,
MD MD MD MD MD
References 1. Wagoner MD, Cox TA, Ariyasu RG, et al. Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:840–859. 2. Slade DS, Hater MA, Cionni RJ, Crandall AS. Ab externo scleral fixation of intraocular lens. J Cataract Refract Surg 2012;38:1316–1321. 3. Nottage JM, Bhasin V, Nirankari VS. Long-term safety and visual outcomes of transscleral sutured posterior chamber IOLs and penetrating keratoplasty combined with transscleral sutured posterior chamber IOLs. Trans Am Ophthalmol Soc 2009;107:242–250. 4. Lane SS, Lubniewski AJ, Holland EJ. Transsclerally sutured posterior chamber lenses: improved lens designs and techniques to maximize lens stability and minimize suture erosion. Semin Ophthalmol 1992;7:245–252. 5. Lee JG, Lee JH, Chung H. Factors contributing to retinal detachment after transscleral fixation of posterior chamber intraocular lenses. J Cataract Refract Surg 1998;24:697–702. 6. Pavlin CJ, Rootman D, Arshinoff S, et al. Determination of haptic position of transsclerally fixated posterior chamber intraocular lenses by ultrasound biomicroscopy. J Cataract Refract Surg 1993;19:573–577. 7. Durak A, Oner HF, Koçak N, Kaynak S. Tilt and decentration after primary and secondary transsclerally sutured posterior chamber intraocular lens implantation. J Cataract Refract Surg 2001;27:227–232. 8. Cahane M, Chen V, Avni I. Dislocation of a scleral-fixated, posterior chamber intraocular lens after fixation suture removal. J Cataract Refract Surg 1994;20:186–187. 9. Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transscleral fixation of a posterior chamber intraocular lens. Arch Ophthalmol 1989;107:1427. 10. Kay MD, Epstein RJ, Torczynski E. Histopathology of acute intraoperative suprachoroidal hemorrhage associated with transscleral intraocular lens fixation. J Cataract Refract Surg 1993;19:83–87.
1480 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 11. Price MO, Price FW Jr, Werner L, et al. Late dislocation of scleral-sutured posterior chamber intraocular lenses. J Cataract Refract Surg 2005;31:1320–1326. 12. Vote BJ, Tranos P, Bunce C, et al. Long-term outcome of combined pars plana vitrectomy and scleral fixated sutured posterior chamber intraocular lens implantation. Am J Ophthalmol 2006;141:308–312.
2014 VOLUME 34 NUMBER 7
13. Walter KA, Wood TD, Ford JG, et al. Retrospective analysis of a novel method of transscleral suture fixation for posteriorchamber intraocular lens implantation in the absence of capsular support. Cornea 1998;17:262–266. 14. Prenner JL, Feiner L, Wheatley HM, Connors D. A novel approach for posterior chamber intraocular lens placement or rescue via a sutureless scleral fixation technique. Retina 2012;32:853–855.
Edited by George A. Williams
Scleral Fixation of Posterior Chamber Intraocular Lenses Using Gore-Tex Suture With Concurrent 23-Gauge Pars Plana Vitrectomy
I
sutured PCIOL placement using Gore-Tex suture at Wills Eye Hospital, Philadelphia, PA. The Supplemental Digital Content 1 (see Video, http://links.lww.com/IAE/A294) demonstrates the key steps to this procedure. In each case, a superior 270° conjunctival limbal peritomy is performed. A superior 7-mm scleral tunnel is created without entering the anterior chamber. A toric lens marker is used to mark the cornea at 2 points 180° apart (Figure 1). Four 23-gauge sclerotomies are made in the ciliary sulcus, located 2 mm posterior to the limbus and 1.5 mm apart from each other, with 2 sclerotomies flanking each of the corneal marks (Figure 2). Vitrectomy is then performed. A standard three-port pars plana vitrectomy may be performed with the superotemporal and superonasal trocars displaced superiorly. Alternatively, vitrectomy can be completed through two of the four ciliary sulcus sclerotomies described above. The anterior chamber is entered through the previously created scleral tunnel using a 2.75-mm phaco keratome. With the infusion clamped, the anterior chamber is then stabilized using viscoelastic. After being cut in half and removing the needle, the 8-0 Gore-Tex suture is then threaded through each eyelet of a CZ70BD (Alcon Laboratories, Fort Worth, TX) IOL at equal lengths. To minimize torsion, care is taken to ensure that the suture passed through the superior sclerotomy goes through the lens eyelet from anterior to posterior on one side of the IOL and is passed from posterior to anterior on the contralateral side. Each end of the Gore-Tex suture is then passed into the anterior chamber and pulled out of each corresponding sclerotomy using 25-gauge forceps (Figure 3). The internal lip of the scleral wound is enlarged to 7 mm, and the CZ70BD IOL is placed into the anterior chamber. All four ends of the Gore-Tex suture are pulled and the IOL is centered (Figure 4). The scleral wound is closed using interrupted 10-0 nylon sutures. The GoreTex sutures are tied using a 3-1-1 technique. The knots are trimmed and rotated into the eye using 25-gauge forceps, with nasal and temporal knots buried in
n the absence of capsular support, options for intraocular lens (IOL) placement include anterior chamber intraocular lenses, iris-fixated posterior chamber intraocular lenses (PCIOLs), and scleral-fixated PCIOLs. In a 2003 Ophthalmic Technology Assessment report for the American Academy of Ophthalmology, Wagoner et al1 supported the effective use of these varying fixation techniques in the appropriate clinical setting, without clear superiority of one method. The choice of surgical technique depends on many factors, including comorbid ocular conditions and anatomical considerations. For surgeons treating patients with history of trauma or complicated cataract surgery, vitrectomy is often required along with IOL placement. Herein, we describe an effective technique for ab externo scleral fixation of PCIOLs using GoreTex (W.L. Gore & Associates, Newark, DE) suture, initially described by Slade et al,2 modified to include concurrent 23-gauge pars plana vitrectomy.
Methods Between January 1, 2013 and June 30, 2013, 10 eyes of 10 patients (5 men, 5 women) underwent combined 23-gauge pars plana vitrectomy and scleralFrom the Retina Service, Wills Eye Hospital, Philadelphia, PA. None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.retinajournal.com). Design of study (M.J.S., O.P.G., M.L.D., A.T.G., M.A.K.), conduct of study (M.J.S., O.P.G., A.T.G., M.L.D.), data collection and analysis (M.A.K., M.L.D.), interpretation of data (M.J.S., O.P.G., M.L.D., A.T.G., M.A.K.), and manuscript preparation (M.J.S., O.P.G., M.L.D., A.T.G., M.A.K.). M. J. Spirn has had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Reprint requests: Marc J. Spirn, MD, Retina Service, Wills Eye Hospital, 840 Walnut Street, Suite 1020, Philadelphia, PA 19107; e-mail: [email protected]
1477
1478 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES
Fig. 1. A toric lens marker is used to mark the cornea at 2 points 180° apart.
opposite directions to balance tension on the IOL. The viscoelastic is removed using the vitrector through the original vitrectomy cannulas, which are then removed and sutured as needed. When vitrectomy is performed through the ciliary sulcus sclerotomies, viscoelastic is removed through the scleral tunnel incision. The conjunctival peritomy is then closed. Results Ten eyes in 10 patients (5 men, 5 women) were reviewed. Average age at the time of surgery was 66 years. Indications for surgery included dislocated IOL (six), traumatic cataract (two), and zonular weakness due to pseudoexfoliation syndrome (one) or previous ocular surgery (one). All 10 eyes in our series had successful scleral fixation of the IOL at 6 months. Overall, mean visual acuity was improved, with 70% of patients improving at least 3 lines of Snellen acuity at final follow-up (range, loss 2 lines to gain 9 lines). Anterior
Fig. 2. Four 23-gauge sclerotomies are made in the ciliary sulcus at a location 2 mm posterior to the limbus and 1.5 mm apart from each other, with 2 sclerotomies flanking each of the corneal marks.
2014 VOLUME 34 NUMBER 7
Fig. 3. Each end of the Gore-Tex suture is passed into the anterior chamber and pulled out of each corresponding sclerotomy using 25-gauge forceps.
segment complications included hyphema (six eyes), corneal edema (four eyes), and intraocular pressure spike (one eye), all of which were treated and resolved with topical therapy. Posterior segment complications included vitreous hemorrhage (one eye), serous choroidal detachment (one eye), cystoid macular edema (one eye), and epiretinal membrane (one eye). Infectious endophthalmitis, prolonged sterile ocular inflammation, retinal tear and/or detachment, suture erosion, or suture breakage were not observed in any patient.
Discussion Many options exist today for the surgical management of aphakia. The choice of surgical technique depends on many factors, including patient age, comorbid ocular conditions, and structural considerations (health of the iris, angle abnormalities). The anterior chamber IOL, iris-fixated PCIOL, and scleral-fixated PCIOL each offers a unique set of considerations.
Fig. 4. All four ends of the Gore-Tex suture are pulled and the IOL is centered.
1479
SURGICAL TECHNIQUE
Older closed-loop anterior chamber IOLs have been associated with higher rates of cystoid macular edema, endothelial cell loss, ocular hypertension, pupillary block, and uveitis–glaucoma–hyphema syndrome compared with PCIOLs.1,3 In patients with preexisting corneal pathology, uveitis, or glaucoma, or in younger patients who may incur these comorbidities over their lifetime, a PCIOL would be preferred. In addition, the PCIOL positions the IOL closer to the natural location of the crystalline lens, possibly offering refractive benefits. In regard to iris fixation versus scleral fixation, iris fixation has been associated with higher rates of iris atrophy, iris chafe, uveitis, pigment dispersion syndrome, and pseudophacodonesis as compared with scleral fixation.4 The trans-scleral–sutured PCIOL technique, however, is also not without complication. Retinal detachment, IOL tilt, vitreous or suprachoroidal hemorrhage, endophthalmitis, and suture erosion/breakage have all been reported with trans-scleral–sutured PCIOLs and may result in permanent vision loss.5–10 Concerns regarding suture erosion and breakage with scleral-sutured PCIOLs have received special attention. Concerns regarding the lifetime of the commonly used polypropylene (Prolene, Ethicon Endo-Surgery, Inc., Cincinnati, OH) suture have been raised. In one study, degradation of Prolene suture was believed to lead to spontaneous subluxation of scleralsutured PCIOLs in up to 27% of cases.11 In a retrospective study of patients undergoing combined pars plana vitrectomy and scleral-sutured PCIOL, suture breakage was observed in 27.9% of cases at a mean follow-up of 6 years.12 Refinement of the scleralsutured PCIOL surgical technique, with the use of an ab externo approach, a scleral flap, and rotation of suture knots, has reduced the rate of suture erosion/ breakage compared with earlier techniques.13 In response to these concerns, sutureless scleral fixation techniques have been published, with a recent revision of the sutureless technique offered by Prenner et al14 with outcomes available to 6 months. Gore-Tex suture is a nonabsorbable polytetrafluoroethylene (ePTFE) monofilament suture used in cardiac and vascular surgeries, among others. Ophthalmic surgeons have suggested and are currently using Gore-Tex suture, given a presumed decreased risk of suture breakage, but the safety and outcomes of the scleral-sutured IOL technique using this suture have not been evaluated to date. All 10 eyes in our series had successful scleral fixation of the IOL at 6 months. Overall, mean visual acuity was improved, and scleral fixation of IOLs with Gore-Tex suture was not associated with significant intraoperative or postoperative complications.
In summary, we describe a technique for ab externo scleral fixation of PCIOLs using Gore-Tex suture with concurrent 23-gauge pars plana vitrectomy. The technique may be an effective option for patients undergoing combined 23-gauge pars plana vitrectomy and IOL implantation for a variety of surgical indications. Ultimately, long-term evaluation of outcomes and complications will be necessary to determine the advantages and disadvantages of this technique. Key words: scleral fixation of posterior chamber intraocular lenses, Gore-tex suture, combined 23gauge pars plana vitrectomy, scleral sutured PCIOL placement. MOHAMMED A. KHAN, ADAM T. GERSTENBLITH, MICHAEL L. DOLLIN, OMESH P. GUPTA, MARC J. SPIRN,
MD MD MD MD MD
References 1. Wagoner MD, Cox TA, Ariyasu RG, et al. Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:840–859. 2. Slade DS, Hater MA, Cionni RJ, Crandall AS. Ab externo scleral fixation of intraocular lens. J Cataract Refract Surg 2012;38:1316–1321. 3. Nottage JM, Bhasin V, Nirankari VS. Long-term safety and visual outcomes of transscleral sutured posterior chamber IOLs and penetrating keratoplasty combined with transscleral sutured posterior chamber IOLs. Trans Am Ophthalmol Soc 2009;107:242–250. 4. Lane SS, Lubniewski AJ, Holland EJ. Transsclerally sutured posterior chamber lenses: improved lens designs and techniques to maximize lens stability and minimize suture erosion. Semin Ophthalmol 1992;7:245–252. 5. Lee JG, Lee JH, Chung H. Factors contributing to retinal detachment after transscleral fixation of posterior chamber intraocular lenses. J Cataract Refract Surg 1998;24:697–702. 6. Pavlin CJ, Rootman D, Arshinoff S, et al. Determination of haptic position of transsclerally fixated posterior chamber intraocular lenses by ultrasound biomicroscopy. J Cataract Refract Surg 1993;19:573–577. 7. Durak A, Oner HF, Koçak N, Kaynak S. Tilt and decentration after primary and secondary transsclerally sutured posterior chamber intraocular lens implantation. J Cataract Refract Surg 2001;27:227–232. 8. Cahane M, Chen V, Avni I. Dislocation of a scleral-fixated, posterior chamber intraocular lens after fixation suture removal. J Cataract Refract Surg 1994;20:186–187. 9. Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transscleral fixation of a posterior chamber intraocular lens. Arch Ophthalmol 1989;107:1427. 10. Kay MD, Epstein RJ, Torczynski E. Histopathology of acute intraoperative suprachoroidal hemorrhage associated with transscleral intraocular lens fixation. J Cataract Refract Surg 1993;19:83–87.
1480 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 11. Price MO, Price FW Jr, Werner L, et al. Late dislocation of scleral-sutured posterior chamber intraocular lenses. J Cataract Refract Surg 2005;31:1320–1326. 12. Vote BJ, Tranos P, Bunce C, et al. Long-term outcome of combined pars plana vitrectomy and scleral fixated sutured posterior chamber intraocular lens implantation. Am J Ophthalmol 2006;141:308–312.
2014 VOLUME 34 NUMBER 7
13. Walter KA, Wood TD, Ford JG, et al. Retrospective analysis of a novel method of transscleral suture fixation for posteriorchamber intraocular lens implantation in the absence of capsular support. Cornea 1998;17:262–266. 14. Prenner JL, Feiner L, Wheatley HM, Connors D. A novel approach for posterior chamber intraocular lens placement or rescue via a sutureless scleral fixation technique. Retina 2012;32:853–855.
