TECHNIQUE
Simplified and safe method of sutureless intrascleral posterior chamber intraocular lens fixation: Y-fixation technique Toshihiko Ohta, MD, PhD, Hiroshi Toshida, MD, PhD, Akira Murakami, MD, PhD
We report a new surgical technique that allows intrascleral fixation of a posterior chamber intraocular lens (IOL) without sutures. The Y-fixation technique does not involve complicated intraocular manipulation and achieves safe sutureless fixation. A Y-shaped incision is made in the sclera and a 24-gauge microvitreoretinal (MVR) knife is used to create the sclerotomy instead of a needle. The Y-shaped incision eliminates the need to raise a large lamellar scleral flap and to use fibrin glue because the haptic can be fixed both inside the tunnel and in the groove, and performing the sclerotomy with the 24-gauge MVR knife simplifies extraction of the haptic and improves wound closure. There is no risk of infection from exposure of the haptic on the sclera and no use of fibrin glue. There was significantly less IOL decentration and tilt than with suture fixation. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:2–7 Q 2013 ASCRS and ESCRS Online Video
Intraocular lens (IOL) implantation in eyes that lack or have insufficient capsular support has been accomplished with transscleral IOL fixation through the ciliary sulcus or pars plana, an iris-fixed IOL, and an anterior chamber IOL. However, each of these techniques has problems.1 Transscleral IOL fixation is associated with several suture-related complications such as IOL decentration, tilt,2 suture breakage,3 vitreous hemorrhage,4 and endophthalmitis due to suture exposure.5
Submitted: March 1, 2013. Final revision submitted: June 22, 2013. Accepted: June 26, 2013. From the Department of Ophthalmology (Ohta, Toshida), Juntendo University Shizuoka Hospital, Shizuoka and the Department of Ophthalmology (Murakami), Juntendo University School of Medicine, Tokyo, Japan. Presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Chicago, Illinois, USA, April 2012. Corresponding author: Toshihiko Ohta, MD, PhD, Department of Ophthalmology, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni-shi, Shizuoka 410-2295, Japan. E-mail: [email protected].
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Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
In recent years, IOL implantation by sutureless intrascleral fixation has become more popular.6–13 We describe a new intrascleral fixation technique that does not require large lamellar scleral flaps and fibrin glue. The Y-fixation technique14,15,A is simpler and safer than other intrascleral IOL fixation techniques. SURGICAL TECHNIQUE Under peribulbar anesthesia, a 5.0 mm conjunctival peritomy is done at the 2 o'clock and 8 o'clock positions. A reference marker and Y marker (Duckworth & Kent Ltd.) are used for marking (Figures 1, A, and 2, A and B). Then, 2 Y-shaped incisions are made 2.0 mm from the limbus exactly 180 degrees apart diagonally (Figure 1, B). An infusion cannula or anterior chamber maintainer is inserted. To prevent interference with creation of the Y-shaped incision, the infusion cannula should be positioned at 4 o'clock. Anterior vitrectomy is performed, if necessary. Sclerotomy is done parallel to the iris at the Y-shaped incision with a 24-gauge angled microvitreoretinal (MVR) knife (Figure 1, C), and a scleral tunnel is made parallel to the limbus at the branching point of the Y-shaped incision (Figure 1, D). Next, a 2.4 to 3.0 mm keratome is used to make a corneal incision at 10 o'clock through which a 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.11.003
TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
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Figure 1. The Y-fixation technique. A: A 5.0 mm conjunctival peritomy is made at the 2 o'clock and 8 o'clock positions using a reference marker and Y-marker. B: A Y-shaped incision is made 2.0 mm from the limbus. C: A 24-gauge angled MVR knife is used to perform a sclerotomy parallel to the iris. D: The 24-gauge angled MVR knife is used to create a scleral tunnel parallel to the limbus at the branching point of the Y-shaped incision. E: The leading haptic is grasped at the tip with a 25-gauge forceps and pulled through the sclerotomy. F: The trailing haptic is inserted into the anterior chamber with a Gaskin forceps held in the right hand. G: The IOL may rotate clockwise with the leading haptic slipping back into the eye. H: The IOL is pushed to the back of the iris and moved to the 2 o'clock position using a push-and-pull hook (push-and-pull hook technique). I: A U-hook is used to guide the IOL haptic to the center of the pupil. Then the tip of the IOL haptic is grasped with a 25-gauge forceps and pulled through the second sclerotomy. J: The tip of the IOL haptic is inserted into the limbus–parallel scleral tunnel with a Gaskin forceps. K: An 8-0 nylon suture is placed in the scleral bed to prevent the IOL shifting immediately after surgery. L: The sclera is sutured with 8-0 polyglactin 901, the incision is completely closed, and the haptic is embedded into the sclera.
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TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
Figure 2. Instruments for the intrascleral IOL fixation technique: reference marker (A), Y-marker (B), U-hook (C), haptic gripping forceps (25-gauge) (D).
standard 3-piece IOL is implanted with an injector; the trailing haptic is left outside the incision. The tip of the haptic is then grasped with a 25-gauge IOL haptic gripping forceps (Eye Technology Ltd.) (Figure 2, D), pulled through the sclerotomy, and externalized on the left side (Figure 1, E). After the trailing haptic is inserted into the anterior chamber with Gaskin forceps held in the right hand (Figure 1, F), a U-hook (Duckworth & Kent Ltd.) (Figure 2, C) is used to guide the haptic to the center of the pupil at the 8 o'clock position (the Uhook technique). Then, the haptic tip is grasped with a 25-gauge forceps, pulled through the second sclerotomy, and externalized on the right side (Figure 1, I). However, the haptic insertion into the anterior chamber may be difficult depending on the material or shape of the haptics, which can cause the IOL to rotate clockwise and the leading haptic to slip back into the eye (Figure 1, G). To prevent such risks, the IOL optic is pushed to the back of the iris and moved to the 2 o'clock position with a push-and-pull hook inserted through the side port at the 1 o'clock position (push-and-pull hook technique, Video 1, available at www.jcrsjournal.org) (Figure 1, H). The tip of the haptic is subsequently inserted into the limbus–parallel scleral
tunnel with a Gaskin forceps (Figure 1, J), after which the IOL is positioned and centered. A single 8-0 nylon suture is used to fixate the haptic to the scleral bed to prevent it from shifting immediately after surgery (Figure 1, K), and the incision is closed with 8-0 polyglactin 910 (Vicryl) (Figure 1, L). If there is no leakage from the sclerotomy position, no wound suture is needed. After the incision is completely closed and the haptic is embedded in the sclera, the anterior chamber maintainer or infusion cannula is removed. The conjunctiva is closed with 8-0 polyglactin (surgical technique, Video 2, available at www.jcrsjournal.org). Results A retrospective nonrandomized interventional clinical study was conducted from November 2007 to May 2011 at Juntendo University Shizuoka Hospital in Japan in which the Y-fixation technique was used in 44 eyes of 40 patients. Transscleral IOL fixation was performed in 40 eyes of 36 patients, and no intraoperative complication occurred in the cases with the Y-fixation technique. All IOLs were stable and centered at the end of surgery. Intraocular lens decentration due to ocular contusion was
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TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
Table 1. Postoperative complications.*
Complication IOL dislocation, tilt Temporary IOP increase Vitreous hemorrhage CME Retinal detachment
IOL Intrascleral Fixation (44 Eyes)
Number (%)
2† (5) 4 (9) 3 (6) 0 1 (2)
IOL Sutured Fixation (40 Eyes) 7† (18) 5 (13) 7 (18) 1 (3) 1 (3)
CME Z cystoid macular edema; IOL Z intraocular lens *6 eyes with complications in intrascleral fixation group; 19 eyes with complications in sutured fixation group † P!.01, Fisher exact test
subsequently observed in 2 eyes but was corrected without difficulty. There was no decline in corrected visual acuity except in 1 eye with a postoperative retinal detachment. In 5 eyes with a dislocated IOL, the same IOL was used again. There was significantly less IOL decentration and tilt than with suture fixation (Table 1). Astigmatism was also significantly less marked than with suture fixation, showing virtually no difference from intracapsular fixation (Figure 3). There was no significant difference in the percent reduction of corneal endothelial cells at 6 months after surgery. The decrease was 10.1% G 3.9% (SD) following intrascleral fixation and 11.7% G 5.3% with suture fixation. DISCUSSION Transscleral IOL fixation has several potential risks such as endophthalmitis related to erosion of the fixation sutures through the conjunctiva, IOL dislocation related to suture degradation or breakage, vitreous hemorrhage, and IOL tilt associated with inaccurate placement of the fixation sutures. To overcome such suture-related problems, sutureless intrascleral fixation was recently described in eyes with deficient capsular support. Gabor et al.7 described a technique for intrascleral fixation of both haptics in the ciliary sulcus using a parallel scleral tunnel, with a 24gauge needle used to create a straight sclerotomy. However, extracting the haptic is difficult and closure is problematic. There is also a risk of infection because of exposure of the haptic on the sclera. Agarwal et al.8 used a 22-gauge needle to create a straight sclerotomy and bioadhesive to attach the haptics and to glue the scleral flaps and overlying conjunctiva. However, their technique has problems related to closure and postoperative hypotony, uses fibrin glue, and requires the creation of a large lamellar scleral flap. Fibrin glue has a theoretical possibility of viral infections, and it is therefore mandatory to have informed consent from the patient before the surgery.
The Y-fixation technique does not involve complicated manipulation and achieves safe sutureless fixation. A Y-shaped incision is made in the sclera, and a 24-gauge MVR knife is used to create the sclerotomy instead of a needle. This incision eliminates the need to raise a large lamellar scleral flap and to use fibrin glue because the haptic can be fixated both inside the tunnel and in the groove at the Y-shaped incision, and performing sclerotomy with the 24-gauge MVR knife simplifies extraction of the haptic and improves wound closure. Choosing an appropriate forceps to extract the IOL haptic is important in performing surgery safely and without failure. Gabor et al.7 extracted the IOL haptic using an end-gripping 25-gauge forceps. This forceps has rounded tips, which may break the haptic during extraction depending on the type of the IOL. In contrast, the tips of the 25-gauge IOL haptic gripping forceps (Figure 2, D) developed for this procedure (the Y-fixation technique) have a flat inner surface so the haptic will not break when it is grasped regardless of its composition or shape. In addition, the short and curved shaft of the forceps makes intraocular manipulation easier at the iris level. Insertion of the trailing haptic into the anterior chamber may prove difficult, depending on its material or shape, and there is a risk for the IOL to rotate clockwise with the leading haptic slipping back into the eye. To avoid such problems, the IOL is pushed to the back of the iris and moved to the 2 o'clock position using a push-and-pull hook inserted through the side port at the 1 o'clock position (push-and-pull hook technique). Beiko et al.16 reported a technique in which the externalized haptic is maintained by a silicone tire without the aid of an assistant. With the push-and-pull hook technique, no special instrument is needed. Extracting the IOL haptic is an important part of this surgical procedure. Extracting the haptic at the 2 o'clock position is relatively easy, but it is difficult
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TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
Figure 3. Intraocular lens astigmatism.
at the 8 o'clock position. Agarwal et al.17 reported a method known as the handshake technique in which the trailing haptic is extracted using 2 vitreous forceps. While the handshake technique needs 2 vitreous forceps, the haptic can be pulled out with 1 vitreous forceps in the U-hook technique. The biggest advantage of using intrascleral fixation is that stronger fixation of the IOL is achieved because the haptic sits in a scleral tunnel, which reduces the possibility of IOL decentration or tilt (Figure 4, A and B) (Table 1). Using anterior segment optical coherence tomography, we examined eyes that had intrascleral fixation and found no decentrationl the IOL was well placed in all eyes (Figure 5, A and B). Anatomical stability of the IOL leads to optical stability and better postoperative refraction. Another advantage of intrascleral fixation is that IOL decentration due to contusion after surgery can be easily corrected. Postoperative repositioning of
the IOL is difficult after suture fixation. With intrascleral fixation, repositioning is easily performed by reopening the incision in the conjunctiva and sclera and adjusting the position of the IOL haptic. Additional merits of intrascleral fixation include the avoidance of complicated manipulation for suturing and no need of a special IOL for suture fixation. Moreover, a small incision is adequate for surgery, the learning curve is short, and the operating time can be reduced. Our technique also simplifies the scleral fixation of a dislocated posterior chamber IOL (PC IOL) and allows successful repositioning of dislocated and subluxated PC IOLs. The Y-fixation technique that we devised is simpler and safer than the other intrascleral IOL fixation techniques. This technique is a new-generation secondary IOL implantation method that achieves both anatomical and optical stability. Further development of this technique can be expected.
Figure 4. A: Postoperative view of the anterior chamber. Stable fixation is confirmed without IOL decentration or tilt at 16 months after surgery in a 72-year-old woman. B: Site of fixation in the sclera. The IOL haptics can be observed in the sclera.
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Figure 5. A: Anterior segment optical coherence tomography (OCT) images. Stable fixation is confirmed without IOL decentration or tilt. B: Anterior segment OCT images. The IOL haptics can be observed in the sclera.
WHAT WAS KNOWN Several surgical techniques have been reported of intrascleral haptic fixation of posterior chamber IOLs in the absence of capsule support for visual rehabilitation in aphakia. Those techniques have problems in wound closure, postoperative hypotony, the use of fibrin glue, and the creation of a large lamellar scleral flap. WHAT THIS PAPER ADDS The Y-fixation technique does not need large lamellar scleral flaps, does not use fibrin glue, simplifies haptic externalization, and greatly improves wound closure. The technique is achieves both anatomical and optical stability.
REFERENCES 1. Por YM, Lavin MJ. Techniques of intraocular lens suspension in the absence of capsular /zonular support. Surv Ophthalmol 2005; 50:429–462 2. Teichmann KD, Teichmann IAM. The torque and tilt gamble. J Cataract Refract Surg 1997; 34:413–418 3. McAllister AS, Hirst LW. Visual outcomes and complications of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2011; 37:1263–1269 4. Solomon K, Gussler JR, Gussler C, Van Meter WS. Incidence and management of complications of transsclerally sutured posterior chamber lenses. J Cataract Refract Surg 1993; 19:488–493 5. Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transscleral fixation of a posterior chamber intraocular lens. Arch Ophthalmol 1989; 107:1427 6. Maggi R, Maggi C. Sutureless scleral fixation of intraocular lenses. J Cataract Refract Surg 1997; 23:1289–1294 7. Gabor SGB, Pavilidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2007; 33:1851–1854 8. 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; 34:1433–1438
9. Rodrıguez-Agirretxe I, Acera-Osa A, Ubeda-Erviti M. Needleguided intrascleral fixation of posterior chamber intraocular lens for aphakia correction. J Cataract Refract Surg 2009; 35:2051–2053 10. Prakash G, Jacob S, Kumar DA, Narsimhan S, Agarwal A, Agarwal A. Femtosecond-assisted keratoplasty with fibrin glue-assisted sutureless posterior chamber lens implantation: new triple procedure. J Cataract Refract Surg 2009; 35:973–979 11. 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 12. Kumar DA, Agarwal A, Jacob S, Prakash G, Agarwal A, Gabor SGB, Prasad S. Sutureless scleral-fixated posterior chamber intraocular lens [letter]. J Cataract Refract Surg 2011; 37:2089–2090 13. Kumar DA, Agarwal A, Prakash D, Prakash G, Jacob S, Agarwal A. Glued intrascleral fixation of posterior chamber intraocular lens in children. Am J Ophthalmol 2012; 153:594–601 14. Narang P, Beiko G, Ohta T, Agarwal A. Modifications in the glued IOL technique. In: Agarwal A, ed, Glued IOL: Glued Intrascleral Haptic Fixation of a PC IOL. New Delhi, India, Jaypee Brothers, 2013; 88–96 15. Ohta T. [Y-fixation technique used for intrascleral haptic fixation of posterior chamber intraocular lens]. [Japanese]. IOL&RS 2013; 27:13–19 16. Beiko G, Steinert R. Modification of externalized haptic support of glued intraocular lens technique. J Cataract Refract Surg 2013; 39:323–325 17. Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S, Agarwal A. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg 2013; 39:317–322
OTHER CITED MATERIAL A. Ohta T, “Y-fixation technique used for intrascleral haptic fixation of posterior chamber intraocular lens,” Ocular Surgery News October 10, 2012, page 41
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First author: Toshihiko Ohta, MD, PhD Department of Ophthalmology, Juntendo University Shizuoka Hospital, Shizuoka Japan
Simplified and safe method of sutureless intrascleral posterior chamber intraocular lens fixation: Y-fixation technique Toshihiko Ohta, MD, PhD, Hiroshi Toshida, MD, PhD, Akira Murakami, MD, PhD
We report a new surgical technique that allows intrascleral fixation of a posterior chamber intraocular lens (IOL) without sutures. The Y-fixation technique does not involve complicated intraocular manipulation and achieves safe sutureless fixation. A Y-shaped incision is made in the sclera and a 24-gauge microvitreoretinal (MVR) knife is used to create the sclerotomy instead of a needle. The Y-shaped incision eliminates the need to raise a large lamellar scleral flap and to use fibrin glue because the haptic can be fixed both inside the tunnel and in the groove, and performing the sclerotomy with the 24-gauge MVR knife simplifies extraction of the haptic and improves wound closure. There is no risk of infection from exposure of the haptic on the sclera and no use of fibrin glue. There was significantly less IOL decentration and tilt than with suture fixation. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:2–7 Q 2013 ASCRS and ESCRS Online Video
Intraocular lens (IOL) implantation in eyes that lack or have insufficient capsular support has been accomplished with transscleral IOL fixation through the ciliary sulcus or pars plana, an iris-fixed IOL, and an anterior chamber IOL. However, each of these techniques has problems.1 Transscleral IOL fixation is associated with several suture-related complications such as IOL decentration, tilt,2 suture breakage,3 vitreous hemorrhage,4 and endophthalmitis due to suture exposure.5
Submitted: March 1, 2013. Final revision submitted: June 22, 2013. Accepted: June 26, 2013. From the Department of Ophthalmology (Ohta, Toshida), Juntendo University Shizuoka Hospital, Shizuoka and the Department of Ophthalmology (Murakami), Juntendo University School of Medicine, Tokyo, Japan. Presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Chicago, Illinois, USA, April 2012. Corresponding author: Toshihiko Ohta, MD, PhD, Department of Ophthalmology, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni-shi, Shizuoka 410-2295, Japan. E-mail: [email protected].
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Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
In recent years, IOL implantation by sutureless intrascleral fixation has become more popular.6–13 We describe a new intrascleral fixation technique that does not require large lamellar scleral flaps and fibrin glue. The Y-fixation technique14,15,A is simpler and safer than other intrascleral IOL fixation techniques. SURGICAL TECHNIQUE Under peribulbar anesthesia, a 5.0 mm conjunctival peritomy is done at the 2 o'clock and 8 o'clock positions. A reference marker and Y marker (Duckworth & Kent Ltd.) are used for marking (Figures 1, A, and 2, A and B). Then, 2 Y-shaped incisions are made 2.0 mm from the limbus exactly 180 degrees apart diagonally (Figure 1, B). An infusion cannula or anterior chamber maintainer is inserted. To prevent interference with creation of the Y-shaped incision, the infusion cannula should be positioned at 4 o'clock. Anterior vitrectomy is performed, if necessary. Sclerotomy is done parallel to the iris at the Y-shaped incision with a 24-gauge angled microvitreoretinal (MVR) knife (Figure 1, C), and a scleral tunnel is made parallel to the limbus at the branching point of the Y-shaped incision (Figure 1, D). Next, a 2.4 to 3.0 mm keratome is used to make a corneal incision at 10 o'clock through which a 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.11.003
TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
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Figure 1. The Y-fixation technique. A: A 5.0 mm conjunctival peritomy is made at the 2 o'clock and 8 o'clock positions using a reference marker and Y-marker. B: A Y-shaped incision is made 2.0 mm from the limbus. C: A 24-gauge angled MVR knife is used to perform a sclerotomy parallel to the iris. D: The 24-gauge angled MVR knife is used to create a scleral tunnel parallel to the limbus at the branching point of the Y-shaped incision. E: The leading haptic is grasped at the tip with a 25-gauge forceps and pulled through the sclerotomy. F: The trailing haptic is inserted into the anterior chamber with a Gaskin forceps held in the right hand. G: The IOL may rotate clockwise with the leading haptic slipping back into the eye. H: The IOL is pushed to the back of the iris and moved to the 2 o'clock position using a push-and-pull hook (push-and-pull hook technique). I: A U-hook is used to guide the IOL haptic to the center of the pupil. Then the tip of the IOL haptic is grasped with a 25-gauge forceps and pulled through the second sclerotomy. J: The tip of the IOL haptic is inserted into the limbus–parallel scleral tunnel with a Gaskin forceps. K: An 8-0 nylon suture is placed in the scleral bed to prevent the IOL shifting immediately after surgery. L: The sclera is sutured with 8-0 polyglactin 901, the incision is completely closed, and the haptic is embedded into the sclera.
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TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
Figure 2. Instruments for the intrascleral IOL fixation technique: reference marker (A), Y-marker (B), U-hook (C), haptic gripping forceps (25-gauge) (D).
standard 3-piece IOL is implanted with an injector; the trailing haptic is left outside the incision. The tip of the haptic is then grasped with a 25-gauge IOL haptic gripping forceps (Eye Technology Ltd.) (Figure 2, D), pulled through the sclerotomy, and externalized on the left side (Figure 1, E). After the trailing haptic is inserted into the anterior chamber with Gaskin forceps held in the right hand (Figure 1, F), a U-hook (Duckworth & Kent Ltd.) (Figure 2, C) is used to guide the haptic to the center of the pupil at the 8 o'clock position (the Uhook technique). Then, the haptic tip is grasped with a 25-gauge forceps, pulled through the second sclerotomy, and externalized on the right side (Figure 1, I). However, the haptic insertion into the anterior chamber may be difficult depending on the material or shape of the haptics, which can cause the IOL to rotate clockwise and the leading haptic to slip back into the eye (Figure 1, G). To prevent such risks, the IOL optic is pushed to the back of the iris and moved to the 2 o'clock position with a push-and-pull hook inserted through the side port at the 1 o'clock position (push-and-pull hook technique, Video 1, available at www.jcrsjournal.org) (Figure 1, H). The tip of the haptic is subsequently inserted into the limbus–parallel scleral
tunnel with a Gaskin forceps (Figure 1, J), after which the IOL is positioned and centered. A single 8-0 nylon suture is used to fixate the haptic to the scleral bed to prevent it from shifting immediately after surgery (Figure 1, K), and the incision is closed with 8-0 polyglactin 910 (Vicryl) (Figure 1, L). If there is no leakage from the sclerotomy position, no wound suture is needed. After the incision is completely closed and the haptic is embedded in the sclera, the anterior chamber maintainer or infusion cannula is removed. The conjunctiva is closed with 8-0 polyglactin (surgical technique, Video 2, available at www.jcrsjournal.org). Results A retrospective nonrandomized interventional clinical study was conducted from November 2007 to May 2011 at Juntendo University Shizuoka Hospital in Japan in which the Y-fixation technique was used in 44 eyes of 40 patients. Transscleral IOL fixation was performed in 40 eyes of 36 patients, and no intraoperative complication occurred in the cases with the Y-fixation technique. All IOLs were stable and centered at the end of surgery. Intraocular lens decentration due to ocular contusion was
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TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
Table 1. Postoperative complications.*
Complication IOL dislocation, tilt Temporary IOP increase Vitreous hemorrhage CME Retinal detachment
IOL Intrascleral Fixation (44 Eyes)
Number (%)
2† (5) 4 (9) 3 (6) 0 1 (2)
IOL Sutured Fixation (40 Eyes) 7† (18) 5 (13) 7 (18) 1 (3) 1 (3)
CME Z cystoid macular edema; IOL Z intraocular lens *6 eyes with complications in intrascleral fixation group; 19 eyes with complications in sutured fixation group † P!.01, Fisher exact test
subsequently observed in 2 eyes but was corrected without difficulty. There was no decline in corrected visual acuity except in 1 eye with a postoperative retinal detachment. In 5 eyes with a dislocated IOL, the same IOL was used again. There was significantly less IOL decentration and tilt than with suture fixation (Table 1). Astigmatism was also significantly less marked than with suture fixation, showing virtually no difference from intracapsular fixation (Figure 3). There was no significant difference in the percent reduction of corneal endothelial cells at 6 months after surgery. The decrease was 10.1% G 3.9% (SD) following intrascleral fixation and 11.7% G 5.3% with suture fixation. DISCUSSION Transscleral IOL fixation has several potential risks such as endophthalmitis related to erosion of the fixation sutures through the conjunctiva, IOL dislocation related to suture degradation or breakage, vitreous hemorrhage, and IOL tilt associated with inaccurate placement of the fixation sutures. To overcome such suture-related problems, sutureless intrascleral fixation was recently described in eyes with deficient capsular support. Gabor et al.7 described a technique for intrascleral fixation of both haptics in the ciliary sulcus using a parallel scleral tunnel, with a 24gauge needle used to create a straight sclerotomy. However, extracting the haptic is difficult and closure is problematic. There is also a risk of infection because of exposure of the haptic on the sclera. Agarwal et al.8 used a 22-gauge needle to create a straight sclerotomy and bioadhesive to attach the haptics and to glue the scleral flaps and overlying conjunctiva. However, their technique has problems related to closure and postoperative hypotony, uses fibrin glue, and requires the creation of a large lamellar scleral flap. Fibrin glue has a theoretical possibility of viral infections, and it is therefore mandatory to have informed consent from the patient before the surgery.
The Y-fixation technique does not involve complicated manipulation and achieves safe sutureless fixation. A Y-shaped incision is made in the sclera, and a 24-gauge MVR knife is used to create the sclerotomy instead of a needle. This incision eliminates the need to raise a large lamellar scleral flap and to use fibrin glue because the haptic can be fixated both inside the tunnel and in the groove at the Y-shaped incision, and performing sclerotomy with the 24-gauge MVR knife simplifies extraction of the haptic and improves wound closure. Choosing an appropriate forceps to extract the IOL haptic is important in performing surgery safely and without failure. Gabor et al.7 extracted the IOL haptic using an end-gripping 25-gauge forceps. This forceps has rounded tips, which may break the haptic during extraction depending on the type of the IOL. In contrast, the tips of the 25-gauge IOL haptic gripping forceps (Figure 2, D) developed for this procedure (the Y-fixation technique) have a flat inner surface so the haptic will not break when it is grasped regardless of its composition or shape. In addition, the short and curved shaft of the forceps makes intraocular manipulation easier at the iris level. Insertion of the trailing haptic into the anterior chamber may prove difficult, depending on its material or shape, and there is a risk for the IOL to rotate clockwise with the leading haptic slipping back into the eye. To avoid such problems, the IOL is pushed to the back of the iris and moved to the 2 o'clock position using a push-and-pull hook inserted through the side port at the 1 o'clock position (push-and-pull hook technique). Beiko et al.16 reported a technique in which the externalized haptic is maintained by a silicone tire without the aid of an assistant. With the push-and-pull hook technique, no special instrument is needed. Extracting the IOL haptic is an important part of this surgical procedure. Extracting the haptic at the 2 o'clock position is relatively easy, but it is difficult
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TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
Figure 3. Intraocular lens astigmatism.
at the 8 o'clock position. Agarwal et al.17 reported a method known as the handshake technique in which the trailing haptic is extracted using 2 vitreous forceps. While the handshake technique needs 2 vitreous forceps, the haptic can be pulled out with 1 vitreous forceps in the U-hook technique. The biggest advantage of using intrascleral fixation is that stronger fixation of the IOL is achieved because the haptic sits in a scleral tunnel, which reduces the possibility of IOL decentration or tilt (Figure 4, A and B) (Table 1). Using anterior segment optical coherence tomography, we examined eyes that had intrascleral fixation and found no decentrationl the IOL was well placed in all eyes (Figure 5, A and B). Anatomical stability of the IOL leads to optical stability and better postoperative refraction. Another advantage of intrascleral fixation is that IOL decentration due to contusion after surgery can be easily corrected. Postoperative repositioning of
the IOL is difficult after suture fixation. With intrascleral fixation, repositioning is easily performed by reopening the incision in the conjunctiva and sclera and adjusting the position of the IOL haptic. Additional merits of intrascleral fixation include the avoidance of complicated manipulation for suturing and no need of a special IOL for suture fixation. Moreover, a small incision is adequate for surgery, the learning curve is short, and the operating time can be reduced. Our technique also simplifies the scleral fixation of a dislocated posterior chamber IOL (PC IOL) and allows successful repositioning of dislocated and subluxated PC IOLs. The Y-fixation technique that we devised is simpler and safer than the other intrascleral IOL fixation techniques. This technique is a new-generation secondary IOL implantation method that achieves both anatomical and optical stability. Further development of this technique can be expected.
Figure 4. A: Postoperative view of the anterior chamber. Stable fixation is confirmed without IOL decentration or tilt at 16 months after surgery in a 72-year-old woman. B: Site of fixation in the sclera. The IOL haptics can be observed in the sclera.
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TECHNIQUE: SUTURELESS INTRASCLERAL PC IOL FIXATION
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Figure 5. A: Anterior segment optical coherence tomography (OCT) images. Stable fixation is confirmed without IOL decentration or tilt. B: Anterior segment OCT images. The IOL haptics can be observed in the sclera.
WHAT WAS KNOWN Several surgical techniques have been reported of intrascleral haptic fixation of posterior chamber IOLs in the absence of capsule support for visual rehabilitation in aphakia. Those techniques have problems in wound closure, postoperative hypotony, the use of fibrin glue, and the creation of a large lamellar scleral flap. WHAT THIS PAPER ADDS The Y-fixation technique does not need large lamellar scleral flaps, does not use fibrin glue, simplifies haptic externalization, and greatly improves wound closure. The technique is achieves both anatomical and optical stability.
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9. Rodrıguez-Agirretxe I, Acera-Osa A, Ubeda-Erviti M. Needleguided intrascleral fixation of posterior chamber intraocular lens for aphakia correction. J Cataract Refract Surg 2009; 35:2051–2053 10. Prakash G, Jacob S, Kumar DA, Narsimhan S, Agarwal A, Agarwal A. Femtosecond-assisted keratoplasty with fibrin glue-assisted sutureless posterior chamber lens implantation: new triple procedure. J Cataract Refract Surg 2009; 35:973–979 11. 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 12. Kumar DA, Agarwal A, Jacob S, Prakash G, Agarwal A, Gabor SGB, Prasad S. Sutureless scleral-fixated posterior chamber intraocular lens [letter]. J Cataract Refract Surg 2011; 37:2089–2090 13. Kumar DA, Agarwal A, Prakash D, Prakash G, Jacob S, Agarwal A. Glued intrascleral fixation of posterior chamber intraocular lens in children. Am J Ophthalmol 2012; 153:594–601 14. Narang P, Beiko G, Ohta T, Agarwal A. Modifications in the glued IOL technique. In: Agarwal A, ed, Glued IOL: Glued Intrascleral Haptic Fixation of a PC IOL. New Delhi, India, Jaypee Brothers, 2013; 88–96 15. Ohta T. [Y-fixation technique used for intrascleral haptic fixation of posterior chamber intraocular lens]. [Japanese]. IOL&RS 2013; 27:13–19 16. Beiko G, Steinert R. Modification of externalized haptic support of glued intraocular lens technique. J Cataract Refract Surg 2013; 39:323–325 17. Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S, Agarwal A. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg 2013; 39:317–322
OTHER CITED MATERIAL A. Ohta T, “Y-fixation technique used for intrascleral haptic fixation of posterior chamber intraocular lens,” Ocular Surgery News October 10, 2012, page 41
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First author: Toshihiko Ohta, MD, PhD Department of Ophthalmology, Juntendo University Shizuoka Hospital, Shizuoka Japan
