We agree with the concern that we did not mention the increasingly popular techniques of secondary intraocular lens (IOL) implantation in aphakia management, namely intrascleral sutureless haptic fixation and iris-claw lenses and it would be better to concern about those techniques in the article. However, we believe that intrascleral sutureless haptic fixation techniques are so cumbersome that no one, but a veteran ophthalmic surgeon can succeed it and they are not as popular as the reviewer suppose. This can be more understood after trying a few attempts. Today, scleral fixation of a foldable IOL seems to be the most popular method for aphakia in the world.
In our case series, we used one-piece IOLs, and it is true that transscleral IOL fixation has some risks and complications such as IOL decentration, tilt, suture breakage, vitreous hemorrhage, and endophthalmitis. Except IOL decentration and tilt, our procedure has the same risk factors that can be seen in all sutured sclera fixated IOL surgeries, and these are the limitation of our procedure. It would be better to prefer a three-piece hydrophobic IOL to decrease the likelihood of such complications.
In a scleral-fixated IOL, the haptics are stacked in the ciliary sulcus, and the IOL is not suspended. Hence, we do not agree with the concern that there is more pseudophacodonesis, and this may lead to posterior segment complications in the long-term.
Late suture breakage and other complications of scleral fixated posterior chamber IOLs are possible to occur, but they were reported in the literature as case reports. Their very low ratio is not an obstacle to do this method. The likelihood of having a complication in a normal phacoemulsification surgery is much more and this situation is not an obstacle to perform phacoemulsification surgery.
We left suture knots were long, extended and buried under the conjunctiva in order to prevent suture exposure and external suture erosion. We did not leave the sutures short in length. It is the choice of the surgeon to make a scleral flap, scleral pocket or patch graft to cover the external suture.
1. Can E, Basaran R, Gul A, Birinci H. Scleral fixation of one piece intraocular lens by injector implantation Indian J Ophthalmol. 2014;62:857–60