IOL Fixation Techniques

A European surgeon offers his views on the treatment of luxated intraocular lenses

GÁBOR B. SCHARIOTH, MD

Fixation of intraocular lenses in cases of insufficient or no capsular support is challenging and requires a large armamentarium of techniques to resolve different situations.^1–22

A vitreoretinal surgeon could be faced with three scenarios. First, the patient could be aphakic after complicated phacoemuslification, trauma or vitreoretinal surgery or years after intracapsular cataract extraction. Second, the patient could be pseudophakic, with dislocated intraocular lens or even dislocated capsular bag/intraocular lens complex, sometimes with a capsular tension ring in place. This is even more complicated if the previous secondary implantation with intraocular suturing (transiridal or trans-scleral) was performed. Third, the vitreoretinal surgeon could recognize the dislocation during standard pars plana vitrectomy (pre-existing or caused by the surgeon), complicating the surgery and perhaps requiring intraoperative repair.

The introduction of IOLs in cataract surgery was first performed by Sir Harold Ridley in 1949. It became standard of care in the late 1980s. Whenever possible, in-the-bag implantation with overlapping continuous curvilinear capsulorhexis is preferable. However, various models, fixation sites and techniques are recommended for difficult situations.

Anterior-chamber lenses were used for many years because of relatively easy implantation technique, even in the total absence of capsular support. However, the fixation in the anterior-chamber angle may cause glaucoma and chronic irritation to the iris. Furthermore, long-term endothelial cell loss with corneal decompensation is reported for angle-fixated intraocular lenses, as well as for iris claw lenses fixed to the anterior surface, a technique introduced by Jan Worst almost 30 years ago.

Figure 1. Intraoperative appearance of luxated capsular bag-intraocular lens-capsular tension ring complex.

Both techniques require relatively large incisions of up to 6.5 mm. For iris claw lenses, uveitis–glaucoma–hemorrhage syndrome has been reported and late dislocations may occur. Should vitreoretinal surgeons choose to use this type of lens, I would recommend the retropupillary reverse implantation technique.²¹ This technique is much more convenient because it prevents contact with the corneal endothelium intraoperatively, ie, during fluid-air exchange and postoperatively due to eye rubbing, blinking, etc.

Some surgeons prefer iris-sutured intraocular lenses. These can cause cat-like pupil and iris chafing, with uveitis and/or pigment dispersion and secondary complications such as chronic inflammation and secondary glaucoma. These techniques need sufficient iris stroma for fixation. Furthermore, there could be a need for special intraocular lenses, which may not be available everywhere. In addition, urgency, extra cost, logistics, and adapted biometry are all possible complicating factors.

I am convinced that the best place for fixation of intraocular lenses in the absence of sufficient zonular/capsular support is the sclera. It is the strongest intraocular tissue, mainly avascular, and does not have a tendency toward inflammation.

As vitreoretinal surgeons, we have known for decades that implants and explants for retinal procedures are well tolerated over a long period. In moderately damaged zonular apparatus, I have been using for many years capsular bag refixation techniques with modified capsular tension rings such as the Cionni ring or Ahmed segments. These implants can be positioned in the capsular bag and have an extra eyelet that is positioned on the anterior surface of the anterior capsule and fixed with a 10x0 or 9x0 Prolene suture trans-sclerally into the ciliary sulcus. This technique is difficult and needs an intact capsulorhexis.

Figure 2. Intrascleral haptic fixation. Both haptics are externalized through the ciliary sulcus sclerotomy, 25-g pars plana infusion for intraoperative tonization.

For more severe luxated capsular bags or for fixation of intraocular lenses in the absence of sufficient support, the haptic of the intraocular lens can be knotted to a 10x0 or 9x0 Prolene suture and fixed to the scleral wall. Many variations of trans-scleral suture fixation have been reported and these techniques are used worldwide because small-incision techniques can be used, intraocular lenses are positioned more physiologically in the posterior chamber, and standard lenses can be used. In cases of dislocated intraocular lenses, this could be refixated by intraoperative haptic externalization for knot fixation to the haptic and trans-scleral suture fixation without need for intraocular lens explantation.

A fibrosed capsular bag — especially with a capsular tension ring — can be easily refixated with double-armed 10x0 or 9x0 Prolene suture to the ciliary sulcus. The first needle is passed through the capsule catching the haptic and/or capsular tension ring and passed through the sclera, while the second needle is just placed above the bag through the sclera. The created suture loop will hold the bag after knotting to the sclera. Usually more than one sclerafixation is necessary to stabilize the whole bag.

Recently, Richard Hoffmann reported a technique for trans-scleral suture fixation without opening of the conjunctiva. Here, the pockets for suture knots are prepared from the limbus intrasclerally toward the sclera, a doublearmed suture is used and stitched 1.5 mm postlimbally through the scleral pockets and conjunctiva, needles are cut off, and the sutures are caught with a hook from the limbus. Then, the suture is knotted and the ends are buried into the scleral pocket. I use this technique today in cases of dislocated single-piece intraocular lenses. The suture is passed through the haptic or knotted if the haptic seems too thin.

Figure 3. Intrascleral haptic fixation. Insertion of haptic into limbus, parallel intrascleral tunnel with a 25-g end-gripping forceps.

However, centration of suture-fixated intraocular lenses is difficult and lens tilt is a common problem. Fixation into the ciliary sulcus without capsular and zonular support is difficult, and malpositioning may result in chronic irritation to ciliary bodies and/or the iris with secondary complications. Good long-term stability has been reported, but late dislocations due to suture biodegradation may occur.^22-26

For these reasons, I was searching for a technique for intraocular lens fixation in the absence of sufficient capsular support that uses a standard foldable intraocular lens, employs sclerafixation, is independent from iris changes and the amount of zonular/capsular damage, is sutureless, reduces the contact to uveal tissue, and could be standardized.

In 2006, we performed the first intrascleral haptic fixation of a standard three-piece intraocular lens and reported the surgical technique in 2007.²⁷ This sutureless technique for fixation of a posterior-chamber intraocular lens used permanent incarceration of the haptics in a scleral tunnel parallel to the limbus. After peritomy, the eye is stabilized either by pars plana infusion (ie, 25-g) or by anterior-chamber maintainer. We try to prevent any diathermy of episcleral vessels to reduce the risk for scleral atrophy. Two straight sclerotomies ab externo are prepared with a sharp 24-g cannula (Neopoint Luer Nr. 17) 1.5 mm postlimbally, exactly 180° from each other and directed toward the center of the globe. These cannulas are then used to create a limbus-parallel tunnel at about 50% of scleral thickness, starting from the ciliary sulcus sclerotomies and ending with externalization of the cannula after 2.0 to 3.0 mm.

A standard three-piece intraocular lens with a haptic design fitting to the diameter of ciliary sulcus is implanted with an injector, and the trailing haptic is fixated in the corneal incision. The leading haptic is then grasped at its tip with an end-gripping 25-g forceps and pulled through the sclerotomy and left externalized. With the same forceps, the haptic is then introduced into the intrascleral tunnel. The same maneuvers are performed with the trailing haptic. The ends of the haptic are left in the tunnel to prevent foreign body sensation and erosion of the conjuctiva and to reduce the risk of inflammation. The sclerotomies are checked for leakage and, if necessary, sutured.

We have used this technique in more than 60 eyes over the past three years. Our standard intraocular lenses were Sensar AR40e (AMO, Santa Ana, CA) and Acrysof (Alcon, Fort Worth, TX), but we have also used multifocal intraocular lenses (ReZoom, AMO). We had four haptic dislocations that could be reimplanted and one transient vitreous hemorrhage. These complications all occurred in the first 10 cases and in first four postoperative weeks. Meanwhile, a variation of this technique with under scleral flap intrascleral hapitic fixation with use of fibrin glue has been published by Amar Agarwal.²⁸

Management of secondary implantation or reflxation of dislocated intraocular lenses with the use of scleral tunnel fixation of the haptic is less technically demanding because it stabilizes the intraocular lens in the posterior chamber without difficult suturing procedures and because it uses a real microsurgical approach if used in combination with 25-g vitrectomy system. Incarcerating a longer part of the haptic stabilizes the axial position of the posterior-chamber intraocular lens, which should decrease the incidence of IOL tilt. Up to three years of follow-up with no complications after the early postoperative period and a learning period for this procedure seem to indicate the long-term stability of intraocular lenses fixated with this technique.

However, vitreoretinal surgeons should be familiar with different techniques for fixation of intraocular lenses because we will be faced with situations where an intraocular lens is already implanted and requires secondary intervention. In the future, urgent phacoemulsification problems, such as dropped nucleus, will need revision less often. More often, we will see eyes with late dislocation of the entire capsular bag after primary uneventful cataract surgery because of chronic ongoing disease such as Pseudoexfoliation syndrome. We should be able to select a less demanding and traumatizing technique that gives a great chance that no further intervention will be necessary. RP

REFERENCES

1. Anand R, Bowman RW. Simplified technique for suturing dislocated posterior chamber Intraocular lens to the ciliary sulcus [letter]. Arch Ophthalmol. 1990;108:1205–1206.
2. Azar DT, Wiley WF. Double-knot transscleral suture fixation technique for displaced intraocular lenses. Am J Ophthalmol. 1999;128:644–646.
3. Bloom SM, Wyszynskl RE, Brucker AJ. Scleral fixation suture for dislocated posterior chamber intraocular lens. Ophthalmic Surg. 1990;21:851–854.
4. Chan CK. An Improved technique for management of dislocated posterior chamber implants. Ophthalmology. 1992;99:51–57.
5. Chang S. Perfluorocarbon liquids In vitreoretinal surgery. Int Ophthalmol Clin. 1992;32:153–163.
6. Chang S, Coll GE. Surgical techniques for repositioning a dislocated Intraocular lens, repair of iridodlalysls, and secondary Intraocular lens implantation using Innovative 25-gauge forceps. Am J Ophthalmol. 1995;119:165–174.
7. Fanous MM, Friedman SM. Ciliary sulcus fixation of a dislocated posterior chamber intraocular lens using liquid perfluorophenanthrene. Ophthalmic Surg. 1992;23:551–552.
8. Friedberg MA, Pllkerton AR. A new technique for repositioning and fixating a dislocated Intraocular lens. Arch Ophthalmol. 1992;110:413–415.
9. Kokame GT, Yamamoto I, Mandel H. Scleral fixation of dislocated posterior chamber Intraocular lenses; temporary haptic externalizatlon through a clear corneal Incision. J Cataract Refract Surg. 2004;30:1049–1056.
10. Little BC, Rosen PH, Orr G, Aylward GW. Trans-scleral fixation of dislocated posterior chamber intraocular lenses using a 9/0 microsurgical polypropylene snare. Eye. 1993;7:740–743.
11. Maguire AM, Blumenkranz MS, Ward TG, Winkelman JZ. Scleral loop fixation for posteriorly dislocated Intraocular lenses; operative technique and long-term results. Arch Ophthalmol. 1991;109:1754–1758.
12. Nabors G, Varley MP, Charles S. Ciliary sulcus suturing of a posterior chamber intraocular lens. Ophthalmic Surg. 1990;21:263–265.
13. Schnelderman TE, Johnson MW, Smlddy WE, et al. Surgical management of posteriorly dislocated silicone plate haptic Intraocular lenses. Am J Ophthalmol 1997;123:629–635.
14. Shin DH, Hu BV, Hong YJ, Glbbs KA. Posterior chamber lens implantation In the absence of posterior capsular support [letter and reply by WJ Stark, GL Goodman, JD Gottsch]. Ophthalmic Surg. 1988;19:606–607.
15. Smiddy WE. Dislocated posterior chamber intraocular lens; a new technique of management. Arch Ophthalmol. 1989;107:1678–1680.
16. Smlddy WE, Flynn HW Jr. Needle-assisted scleral fixation suture technique for relocating posteriorly dislocated IOLs [letter]. Arch Ophthalmol. 1993;111:161–162.
17. Smlddy WE, Ibanez GV, Alfonso E, Flynn HW Jr. Surgical management of dislocated Intraocular lenses. J Cataract Refract Surg. 1995;21:64–6.
18. Thach AB, Dugel PU, Slpperley JO, et al. Outcome of sulcus fixation of dislocated posterior chamber Intraocular lenses using temporary externalizatlon of the haptlcs. Ophthalmology. 2000;107:480–484; discussion by WF Mleler 485.
19. Koh HJ, Kim CY, Llm SJ, Kwon OW. Scleral fixation technique using 2 corneal tunnels for a dislocated intraocular lens. J Cataract Refract Surg. 2000: 26:1439–1441.
20. Lewis JS. Ab externo sulcus fixation. Ophthalmic Surg. 1991;22:692–695.
21. Mohr A, Hengerer F, Eckardt C Retropuplllare Fixation der Irisklauenlinse bel Aphakie; Elnjahresergebnisse einer neuen Implantationstechnik. [Retropupillary fixation of the Iris claw lens In aphakia; 1 year outcome of a new Implantation technique.] Ophthalmologe. 2002;99:580–583.
22. Teichmann KD, Teichmann IAM. The torque and tilt gamble. J Cataract Refract Surg. 1997;23:413–418.
23. Por YM, Lavln MJ. Techniques of Intraocular lens suspension In the absence of capsular/zonular support. Sun Ophthalmol. 2005;50:429–462.
24. 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. (Ophthalmic Technology Assessment) Ophthalmology. 2003;110:840–859.
25. Gross JG, Kokame GT, Weinberg DV. In-the-bag intraocular lens dislocation; the Dislocated In-the-Bag Intraocular Len Study. Am J Ophthalmol. 2004;137:630–635.
26. Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of Intraocular lens within the capsular bag in Pseudoexfoliation patients. Ophthalmology 2001;108:1727–1731.
27. Gabor SG, Pavlidls MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2007;33:1851–1854.
28. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinlvasan. Fibrin glue-assisted sutureless posterior chamber Intraocular lens implantation In eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34:1433–1438.