Intraocular lens (IOL) implantation in eyes with inadequate capsular support has undergone extensive modifications. Various surgical techniques, IOL types and management protocols have been studied and reported [1,2]. With growing surgical modifications and technological advances, operative complications have been reduced to a great extent in cataract surgery. However, lens implantation in the presence of a posterior capsular rupture (PCR) is still challenging.
The posterior capsule is an essential physical barrier to the normal lens. After cataract surgery, capsular support is crucial for maintaining the normal anatomical position and the ‘barrier’ effect for the IOL. Historically, either an anterior chamber/iris claw or a suture scleral fixated IOL has been implanted in eyes with deficient capsules [3–5]. Sutureless posterior chamber IOL implantation is another option under such circumstances [6–9]. In this manuscript, we have reviewed the technical modifications, results and surgical outcomes of glued IOL, which is the fibrin glue-assisted sutureless posterior chamber IOL implantation method in eyes with inadequate capsules .
SUTURELESS POSTERIOR CHAMBER INTRAOCULAR LENS
Maggi and Maggi  pioneered the initial sutureless IOL fixation in eyes with deficient posterior capsule in 1997. In their technique, pars plana fixation of a posterior chamber IOL was achieved by the transscleral passage of the haptics. The IOL they used had three equidistant supple loops, each attached to an armed suture, which served as haptics. In 2006, Gabor Scharioth introduced transscleral needle fixation of IOL in these eyes . Limbus parallel scleral tunnel insertion of haptics of a standard three-piece posterior chamber IOL was performed. The IOL with a haptic design, the same diameter as the ciliary sulcus, was implanted with an injector. He reported excellent results in the short and intermediate time duration [7,8]. In 2007, Agarwal et al.  introduced the glued IOL technique, which was Glued intrascleral haptic fixation of a posterior chamber IOL.
GLUED INTRAOCULAR LENS
In December 2007, we performed the first glued IOL surgery in a patient with a luxated single-piece PMMA (polymethylmethacrylate) IOL in the anterior vitreous. A pars plana vitrectomy was performed and the existing IOL was refixated by the glued IOL method. The intraoperative and postoperative period was uneventful.
Under peribulbar anaesthesia, localized peritomy at the site of exit of the IOL haptics is done. Two partial thickness limbal-based scleral flaps about 2.5 × 2.5 mm are created exactly 180° diagonally (use scleral marker) apart. Infusion cannula or anterior chamber maintainer is inserted. One can use 20G or 23G trocar cannula for infusion. Positioning of the infusion cannula should be in the pars plana about 3 mm from the limbus. Anterior segment surgeons can use an anterior chamber maintainer. Two straight sclerotomies with a 20G needle are made about 1–1.5 mm from the limbus under the existing scleral flaps. This is followed by vitrectomy via pars plana or anterior route to remove all vitreous traction. A corneo-scleral tunnel incision is then prepared for introducing the IOL in case of a three-piece nonfoldable IOL or corneal incision with keratome in case of an injectable three-piece foldable IOL.
Leading haptic externalization
The IOL cartridge is passed into the anterior chamber. The glued IOL forceps (Microsurgical Technology, MST, USA or Epsilon, India) is then passed through the sclerotomy and the tip of the haptic is grasped (Fig. 1a). The IOL is then gradually injected into the eye (Fig. 1b,c). In an injector with screwing mechanism, the assistant rotates the injector. One should not externalize the haptic until the optic totally unfolds inside the eye. Once the optic is unfolded, the glued IOL forceps is used to pull the haptic out and externalize it (Fig. 1d). The haptic is then held by an assistant.
Trailing haptic externalization
The surgeon now flexes the second haptic into the anterior chamber into the jaws of the glued IOL forceps introduced through the second sclerotomy using the handshake technique. This haptic is also thus externalized out (Fig. 2a–f). In a routine foldable glued IOL, the MST forceps can be introduced through the side port to grasp the trailing forceps and feed it into the jaws of the second forceps, which is passed through the opposite sclerotomy.
If the horizontal White to White is more than 11 mm, it would be better to do a ‘vertical glued IOL’, in which the scleral flaps are made at 12 and 6 o’ clock positions. The reason is that the vertical diameter of the cornea is shorter than the horizontal and one would get more haptic externalized to tuck and glue. A limbus parallel scleral tunnel is made with a 26G bent needle on either side at the point of haptic externalization. The haptic tips are then tucked into the intralamellar scleral tunnel.
Air is then injected into the anterior chamber and the fluid from the infusion cannula is turned off. This helps to prevent hypotony and also keeps the area of the glue application dry. The reconstituted fibrin glue (Tisseel, Baxter, California, USA) prepared is injected under the scleral flaps. Local pressure is given over the flaps for about 10–20 s. Corneo-scleral wound is closed with 10-0 monofilament nylon in nonfoldable three-piece IOL, and in case of foldable IOL, the corneal incision is sealed with fibrin glue. The conjunctiva is closed with the fibrin glue in all eyes irrespective of the type of IOL.
EVOLUTION OF GLUED INTRAOCULAR LENS
Initially, the IOL haptics were placed under the scleral flaps . In the following days, Agarwal et al. and Kumar et al.  started making scleral tunnels to insert the haptic tips, which provided more stability for the IOL. The surgical procedure though started with a single-piece, nonfoldable PMMA IOL, today it is performed with three-piece foldable and multifocal IOL [12▪▪]. The surgery was performed with 20G transscleral infusion cannula in the initial period; however, in the subsequent days, 23G transconjunctival trocar cannulas are used for intraoperative infusion . Anterior chamber maintainer has also been used nowadays to make the procedure even simpler.
‘Handshake’ technique as introduced by our group [12▪▪] reduces haptic externalization problems. In the ‘handshake’ technique, the end-opening forceps is passed through the opposite sclerotomy site, whereas another forceps is in the pupillary plane ready to receive the haptic. Any portion of the leading haptic is initially grasped with the forceps. Now, the other forceps starts grabbing the haptic like a handshake and this process is continued until the tip of the haptic is held by the forceps. The haptic is then pulled under the scleral flap. Similarly, the trailing haptic is externalized. Thus, both the haptics are externalized under the scleral flaps. In cases with screwing type injector and in eyes in which the leading haptic tip is not visualized in the pupillary plane or in a nondilating pupil, this manoeuver is useful.
Although the needle-guided scleral tunnel tucking of the haptics has been practiced by Gabor and Pavilidis , securing the tucked haptics under the scleral flaps has been introduced by Agarwal et al.[9,10]. The length of the tucking depends upon the overall diameter of the IOL. The longitudinal mobility and the transverse mobility are limited with tucking. Externalization of the greater part of the haptics into the intrascleral tunnel along its curvature stabilizes the axial positioning of the IOL and thereby prevents IOL tilt. Improper scleral tuck can lead to haptic complications such as haptic extrusion. The length of the haptic inside the scleral tunnel should be equal on both sides for proper IOL centration. Undue or excess pressure on the IOL haptic tip can lead to damaged or broken haptics. The depth of the tunnel is also an equivalent factor, which minimizes haptic erosion on a long term.
In our 1-year follow-up study of 53 eyes, there was a significant improvement in uncorrected visual acuity (UCVA) and spectacle best corrected visual acuity (BCVA) (P = 0.000) . In our earlier report on the interim results of rigid glued IOL (n = 152), there was a significant improvement in UCVA and BCVA [12▪▪]. Fifty-two per cent gained 20/20 BCVA postoperatively. We had reported the early results of multifocal glued IOL [12▪▪]. The mean preoperative BCVA was 0.60 ± 0.25 and the mean postoperative BCVA was 0.77 ± 0.34. The postoperative mean additional add for best near corrected vision was 0.5 ± 1.1D. There was a significant decrease in the near addition (P = 0.000). Good patient satisfaction was seen. Serial digital slit lamp images of the eye with full pupillary dilatation showed good IOL centration. In paediatric eyes, the mean postoperative BCVA was 0.43 ± 0.33, and there was a significant change noted (P < 0.001). Postoperatively, 20/20 and greater than 20/60 BCVA was obtained in 17.1 and 46.3% of eyes, respectively [14▪▪]. BCVA improvement more than one line was seen in 53.6% of eyes. Prakash et al. reported three eyes in which the same posterior chamber IOL was translocated from anterior to posterior chamber without complications. Sinha et al.[16▪] reported the outcomes after repositioning the decentred posterior chamber IOL in the posterior chamber using the same IOL by glued IOL method and showed good results. In a comparative study with scleral-fixated IOL by Ganekal et al.[17▪], BCVA was 20/40 or better in 88 and 84% of patients in the suture and glue groups, respectively.
Recent analysis of 735 eyes with glued intraocular lens
In the current retrospective analysis of visual outcomes of 735 eyes, there were 486 rigid glued IOL, 191 foldable IOL, 10 glued iris prosthesis, 16 glued IOL with pupilloplasty and 32 glued IOL with penetrating keratoplasty. The mean postoperative UCVA and BCVA were 0.19 ± 0.19 ± and 0.38 ± 0.27, respectively, (Fig. 3) in rigid IOL. Single-piece PMMA IOL (Appasamy Associates, Chennai, Tamil Nadu, India) with an optic diameter of 6.5 mm was used in all eyes. The most common indication was PCR and aphakia. There was a significant improvement in UCVA and BCVA (paired t-test, P = 0.000). In the 191 eyes with foldable IOL with a mean follow up of 16.6 ± 8.8 months (range 6–48 months), the mean postoperative BCVA and UCVA was 0.39 ± 0.29 and 0.22 ± 0.23, respectively. The lenses used were three-piece silicone foldable (Bausch &Lomb, Rochester, New York, USA) and three-piece acrylic foldable (AMO, Abbott Medical Optics, Chicago, Illinois, USA) IOL.
Results of surgical modifications
Glued IOL technique has undergone few modifications in the recent past.
Repositioning of the dislocated intraocular lens with sutureless 20-gauge vitrectomy
In this method, scleral flaps were made for the infusion cannula insertion and were closed with fibrin glue. The pars plana vitrectomy port made with the 20G needle during the glued IOL procedure was closed with glue instead of polyglactin sutures. Kumar et al. reported 1-year results of this method and showed no major vision threatening complications. The mean preoperative UCVA and BCVA was 0.08 ± 0.07 and 0.76 ± 0.22, respectively. Ultrasound biomicroscopy showed no vitreous traction or uveal incarceration in pars plana ports in the postoperative period.
Glued iris prosthesis
Glued IOL technique has been used for IOL implantation in eyes with aniridia with luxated cataract . We used a PMMA aniridia IOL (Intraocular care, Vadodara Gujarat, India). There were 10 eyes of nine patients who had glued iris prosthesis with a mean follow up of 5.2 months. The mean postoperative UCVA and BCVA was 0.27 ± 0.13 and 0.34 ± 0.22, respectively. There was a decrease in glare disability in all the eyes that had preoperative glare.
Glued intraocular lens scaffold
The IOL scaffold technique was described by us in 2011, and we used this to prevent nuclear fragment drop into the vitreous in the presence of a PCR [20▪]. In ‘Glued IOL Scaffold’, we combined the glued IOL technique and the IOL scaffold. Here, in case of intraoperative PCR, a three-piece foldable IOL is placed (by glued IOL method) behind the existing PCR and the phacoemulsification is completed above the IOL (Fig. 4). Thus, the IOL acts as an ‘artificial posterior capsule’. We have performed this method in three eyes. Except for the early postoperative corneal oedema (n = 1), there were no major complications encountered.
Glued intraocular lens with corneal surgeries
We showed the early results of combining glued IOL method with femtosecond laser-assisted keratoplasty . There was a significant improvement in vision and no episodes of keratoplasty or IOL-related problems. In our current analysis of 32 eyes with glued IOL with penetrating keratoplasty, the mean postoperative UCVA and BCVA at the last follow up was 0.09 ± 0.08 and 0.19 ± 0.13, respectively (Fig. 5). We also reported the early results of combining glued IOL with Descemet stripping automated endothelial keratoplasty (DSAEK) in three eyes . There was no donor graft dislocation reported. The average donor endothelial cell loss was 27.7% at 6 months. Sinha et al.[23▪] also combined glued IOL with DSAEK, and penetrating keratoplasty concluded that the IOL fixation was strong enough to sustain the manipulation required for corneal procedures.
In our recent combination surgeries of glued IOL, we have combined it with Descemet membrane endothelial keratoplasty (DMEK) procedure. The advantage of this is that the lenticule cannot fall into the vitreous cavity due to the glued IOL. There were two eyes of two patients with pseudophakic bullous keratopathy who underwent glued IOL with DMEK (Fig. 6).
Intraocular lens exchange
There have been many clinical indications in which the existing IOL has to be replaced with a new IOL. There were 41 eyes with IOL exchange, which included anterior chamber IOL (n = 6), postoperative decentred posterior chamber IOL(n = 23), post-traumatic luxated posterior chamber IOL (n = 11) and pseudophacocele (n = 1). The main indication for anterior chamber IOL removal was chronic uveitis. There was a significant improvement clinically (decrease in uveitis signs) as well as in symptoms after IOL exchange. Kumar et al.[12▪▪] showed early results of anterior chamber IOL exchange with glued posterior chamber IOL in eyes with uveitis. We also reported good IOL centration after foldable IOL exchange with glued IOL in eyes with bilateral spontaneous IOL dislocation .
NEWER COMBINATION PROCEDURES WITH GLUED INTRAOCULAR LENS
Glued IOL can be combined with iridoplasty in conditions with sectoral iris defect. We have performed this combination surgery in 16 eyes. The mean postoperative UCVA and BCVA was 0.54 ± 0.24 and 0.67 ± 0.19, respectively, at 6 months follow up. There was an improvement in symptoms such as glare and photosensitivity.
Jacob et al. combined glued IOL technique along with transplantation of cornea and sclera in eyes with congenital anterior staphyloma. Jacob et al. also reported fibrin glue-assisted endocapsular ring segment in eyes with deficient capsules.
We have combined corneal laceration repair with lens extraction and glued IOL implantation in traumatized eyes (n = 8). The mean postoperative BCVA was 0.45 ± 0.35 (mean follow up 19.2 months). The mean postoperative intraocular pressure (IOP) was 14.6 ± 4 mmHg. We recently reported the visual outcome of glued IOL in traumatic eyes and their potential indications . We also reported the results of management of traumatic phacocele by combining glued IOL and corneoscleral laceration repair .
Strabismus surgery can be performed along with glued IOL. In our analysis of six eyes with such combination, the mean postoperative UCVA was 0.28 ± 0.21. There was no intraoperative IOL decentration noted. Although four out of six eyes had pre-existing amblyopia, there was no loss of BCVA in any of the eyes.
In our analysis of eyes with glued IOL with trabeculectomy (n = 28), the mean postoperative BCVA was 0.35 ± 0.26 (mean follow up 18.8 months). The mean preoperative IOP of 20.3 mmHg decreased to 12.9 mmHg. The scleral flaps were 3 and 9 o’clock in 89% of the eyes. In 11% of the remaining eyes, the flaps position had been altered according to the surgical space. We have combined trabeculectomy with glued iris prosthesis in eight eyes. There has been a significant reduction (P = 0.018) in IOP.
There were 23 eyes with dislocated cataractous lens that had combined posterior vitrectomy and FAVIT  (Fall in vitreous) followed by glued IOL implantation . The mean BCVA was 0.38 ± 0.29. Complications included macular oedema (n = 1), optic capture (n = 1) and corneal oedema (n = 2).
The retrospective evaluation of complications at 1 year by Kumar et al. showed IOL decentration (5.6%) in the early postoperative period. The late complications were pigment dispersion (3.7%) and healed macular oedema (7.5%). The endothelial cell loss was 5.23 ± 3.4%. In the paediatric age group, the mean endothelial loss was 4.13% [14▪▪]. Postoperative complications included optic capture (2.4%), macular oedema (4.8%) and clinical decentration (4.8%). Prakash et al. reported an improvement in UCVA, with lowered IOP and no loss of BCVA after the translocation of malpositioned PC IOL from anterior to posterior chamber. Sinha et al.[16▪] reported no significant anterior or posterior segment inflammation, and normal IOP in their short-term follow up.
In the recent review of 191 eyes with foldable IOL, optic capture (5.7%) was the common complication in the early and late postoperative period. Others included IOL decentration (2.6%), uveitis (0.5%), fibrinous reaction (0.5%), scleral thinning (0.5%) and corneal oedema (0.5%). Haptic-related complications seen in the late postoperative period included haptic displacement (2%), haptic tip extrusion (0.5%) and subconjunctival haptic (1.5%) (Figs 7 and 8). Second surgical intervention was required in three eyes. The common reason for haptic-related complications was improper flap positioning and unequal intrascleral tunnel haptic tuck. The mean postoperative IOP was 12.9 ± 4.5 mmHg.
In the review of complications profile of 486 eyes with rigid IOL, the common early postoperative complications were optic capture (3.4%) and grade 2 anterior chamber reaction (3%). Transient raise in IOP was noted in two eyes (0.4%) and early postoperative corneal oedema that resolved with medical management was observed in four eyes (0.8%). The mean postoperative IOP was 14.8 mmHg. The late postoperative complications were IOL decentration (4.3%), optic capture (3.4%) and haptic displacement (4.1%). Posterior segment complications included macular oedema (1.4%), retinal detachment (1%) and chronic vitritis (0.4%) (Fig. 9).
Ganekal et al.[17▪] compared the complications profile after sutured scleral-fixated IOL and glued IOL. Postoperative inflammation and glaucoma were seen more frequently in eyes with sutures than in eyes with glue. A significantly higher number of complications were reported in suture fixation.
In a long-term review, McAllister and Hirst.  reported retinal detachment rate of 4.9% in eyes with scleral-fixated IOL at a mean of 53 weeks with no previous similar history. However, in our follow up of glued IOL, there seems to be lesser incidence (1%). The probable reason is the short intraoperative manipulation and less postoperative pseudophakodonesis. Ocular hypertension, which is the reported common complication in scleral-fixated IOL, is also less in the glued IOL method [5,10,11,12▪▪]. Samaresh Vasavada employed high-speed photography to study pseudophacodonesis following glued IOL implantation and observed a nondonetic IOL.
PAST AND FUTURE
Fibrin glue, which has been used for various indications in ophthalmology, has shown to provide airtight closure. By the time the fibrin starts degrading, surgical adhesions would have already occurred in the scleral bed. The glued IOL differed from other sutureless methods by the use of the fibrin glue, which enhances the rate of adhesion with haemostasis and also by the use of available IOLs unlike other techniques, which require newly designed IOLs [6,7]. The other advantage of this technique is the rapidity and ease, as all the time taken in suture scleral-fixated IOL for passing suture is significantly reduced. The risk of retinal photic injury, which is known to occur in scleral-fixated IOL, would also be reduced due to the short surgical time . The frequent complications of secondary IOL implantation such as secondary glaucoma, cystoid macular oedema, uveitis, glaucoma and hyphema syndrome or bullous keratopathy are less . Especially suture-related complications of scleral-fixated IOL such as suture erosion, knot exposure or dislocation of IOL after suture disintegration or broken suture are prevented [5,32,33]. As compared with sutured scleral-fixated IOL, posterior segment complications due to pseudophakodonesis are extremely reduced. However, haptic-related complications have been noted in few cases. The chance of endophthalmitis is less as the haptics are well enclosed in the sclera.
Managing complications with ease is the main objective of any new technique. Glued IOL has shown satisfactory results in the current review. We know that many clinical circumstances have difficulty for ‘in-the-bag PC IOL’ fixation and multiple options do exist in the setting of inadequate capsular support . We aim in making the technique more refined and simple for all complicated eyes, so that there would not be any clinical condition that hinders IOL implantation. We believe that glued IOL in inadequate capsular support would stand as a good alternative.
Conflicts of interest
No funding or support was provided for this study.
Dhivya Ashok Kumar has no financial or proprietary interest in any product, instrument or piece of instrument described in this manuscript.
Amar Agarwal is a paid consultant for Bausch & Lomb, Staar Surgicals and AMO (Abbott Medical Optics).
Design of the study was carried out by D.A., conduct of the study by A.A. and D.A., collection by D.A., management by A.A., analysis and interpretation of data by D.A., preparation of the study by D.A., review by both A.A. and D.A., provision of material, patients and resources by A.A. and D.A., and administrative, technical and logistic support was provided by D.A. and A.A. The authors would like to acknowledge the study coordinator Ms Sathya for helping in data collection.
The authors performed a Medline search with Pubmed. The search was restricted to publications related to humans, in English and other language publications with English abstracts. Articles and book chapters obtained from the reference lists of other articles were reviewed and included when considered appropriate.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 80).
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