Many techniques for managing a dislocated intraocular lens (IOL) are available,1–6 but many of them have difficulty tying the haptic of an IOL without removing an IOL from the anterior chamber. A technique without knotting the haptic of an IOL has been introduced.7 Others have used an IOL with a hole in the haptic. Although the technique of suturing in the anterior chamber without removing the dislocated IOL has also been introduced, it is very difficult, needs many instruments, and has a high risk for complications such as intraocular hemorrhage and tissue damage because of multiple traumatic needlings.8 If the haptic of an IOL is not fixated firmly, positioning the IOL in the center is difficult and the risk for redislocation increased. We describe a technique for knotting a suture to the haptic of a dislocated IOL through the sclerotomy site without removing the IOL and burying the knots in the sclerotomy site without exposure.
After vitrectomy, sclerotomy 1 mm posterior to the surgical limbus is made using the MVR blade at 2 and 8 o'clock for transscleral fixation of the dislocated IOL (Figure 1). Then a 27-gauge blunt needle with a 10-0 polypropylene (Prolene®) loop passes through the sclerotomy site. The loop hooks to the haptic of the dislocated IOL (Figure 2). After the haptic is pulled close to the sclerotomy site, a suture is tied to the haptic of a dislocated IOL from outside through the sclerotomy site (Figure 3). After 3 knots are made on the haptic, the knots are exposed by pulling the IOL with a Sinskey hook from the opposite side of the chamber to confirm the tightness of the knots. The remaining suture material are tied together into the sclera with a mattress suture that closes the sclerotomy site simultaneously (Figure 4). The knot is buried and fixed in the sclerotomy site without making a scleral flap. Postoperative complications and final visual acuities are recorded.
In an experiment with 4 scleral shells, the procedure for transscleral fixation of an IOL was done with the same technique (Figures 5 through 7). Two Acrysof® IOLs (Alcon) and 2 Sensar® IOLs (Allergan) were used. The knots are then checked to be sure they are tight and there are no signs of slippage.
Best-corrected visual acuity improved in all 4 cases (Table 1). Poly(methyl methacrylate) (PMMA) IOLs were used in 3 cases, and an acrylic IOL was used in the other. Postoperative complications such as decentering of the IOL, redislocation, retinal detachment, vitreous hemorrhage, corneal edema, iris damage, and cystoid macular edema were absent. Complications associated with the exposure of knots that were made in the sclerotomy site were also absent.
In the experiment with the scleral shells, the transscleral fixation using 2 types of acrylic IOL was done. If the knots can pass through the scleral wall without biting into tissue, the knot will be located exactly on the haptic of the IOL in both types (Figure 7). After 3 true ties were made, the 10-0 Prolene® was pulled toward the end of haptic, but the knots were tight and safe without slipping in all 4 experimental cases. After the IOL was fixated in the sclera shell, the opposite haptic was pulled with forceps to check the tension; no movement of the knot was found (Figure 8).
When the dislocation of an IOL occurs, the options are observation, removal of the IOL, and exchanging or repositioning the IOL. Among these choices, when an operation is needed, repositioning a dislocated IOL is commonly used because it is safer and less traumatic than other methods.9,10 After pars plana vitrectomy, the IOL can be held by intraocular forceps before a 30-gauge needle with the loop of a suture material is passed and the haptic of the IOL is hooked.1–3 In the other technique, while the IOL is held with intraocular forceps, the suture material can be passed above and below the haptic portion to make a loop.4,5 Liquid perfluorocarbon can also be used in sulcus fixation of a dislocated IOL.6,11
The operative methods belong to 2 categories, with or without knotting the haptic portion. In the knotting method, more time and instruments are needed, because the haptic of the IOL needs to be removed or exposed, and the method is difficult to learn. In the method without knotting, the IOL is not stable, the risk for redislocation is high, and complications such as intraocular hemorrhage and ocular tissue damage are common because of multiple traumatic needle passes through ocular tissues. In our method, a suture is knotted to the haptic of a dislocated IOL without removal or exposure of the IOL so that transscleral fixation is stable in the closed chamber condition during the operation. The operation time can be reduced by burying the suture material in the sclerotomy site from the outside without exposure of knots. Only 1 end of the suture cannot be tied into the sclera during transscleral fixation of a dislocated IOL because both ends need balance with the same tension on both haptics. Both haptics must therefore be inserted in the ciliary sulcus before fixation to the sclera. At this time, if the haptic is not tied and fixed, the risk for decentration or redislocation is high during the procedure of centering the IOL. In our method, the IOL can be centered safely because a suture is knotted to the haptic of the IOL before transscleral fixation.
There is a little gap between the haptic and outer scleral wall. A 10-0 Prolene suture has elastic features, and the space of the sclerotomy incision parallel to the limbus is enough. Therefore, the knots can be tied tightly to the haptic through the sclerotomy site. In the outer sclera, the remaining 10-0 Prolene is tied to the scleral wall and outer scleral knots are buried in the sclerotomy site.
In the experiment with the scleral shells, the knot can be passed through the scleral wall without engaging a tissue through the sclerotomy site, and the knot is located exactly on the haptic of the IOL (Figure 7). Commonly used acrylic lenses such as the Acrysof and Sensar have a PMMA haptic so that the knots on the haptic can be done tightly and do not slide to the end of haptic when the haptic is pulled in the opposite direction (Figure 8). The haptic is tied successfully in the experiments, so our knotting technique could be applied in both types.
In conclusion, our technique of transscleral fixation through the sclerotomy site without removing an IOL is safe and effective. We have not had any complications such as redislocation, intraocular hemorrhage, or decentration. The suture is tied together and buried in the sclerotomy site so problems associated with the exposure of knots do not occur.
1. 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
2. Chang S, Coll GE. Surgical techniques for repositioning a dislocated intraocular lens, repair of iridodialysis, and secondary intraocular lens implantation using innovative 25-gauge forceps. Am J Ophthalmol 1995; 119:165-174
3. Marcil G, Lesk MR. A modified ring forceps for retrieval and scleral fixation of dislocated posterior chamber intraocular lenses [Letter]. Retina 1994; 14:282-283
4. Kwok AKH, Cheng ACK, Lam DSC. Surgical technique for transscleral-fixation of a dislocated posterior chamber intraocular lens. Am J Ophthalmol 2001; 132:406-408
5. Koh HJ, Kim CY, Lim SJ, Kwon OW. Scleral fixation technique using 2 corneal tunnels for a dislocated intraocular lens. J Cataract Refract Surg 2000; 26:1439-1441
6. Tognetto D, Agolini G, Ravalico G. Spontaneous dislocation into the vitreous of a poly(methyl methacrylate) disc lens 9 years after surgery. J Cataract Refract Surg 1999; 25:289-292
7. Azar DT, Wiley WF. Double-knot transscleral suture fixation technique for displaced intraocular lenses. Am J Ophthalmol 1999; 128:644-646
8. Navia-Aray EA. A technique for knotting a suture around the loops of a dislocated intraocular lens, within the eye, for fixation in the ciliary sulcus. Ophthalmic Surg 1993; 24:702-707
9. Smiddy WE, Ibanez GV, Alfonso E, Flynn HW Jr. Surgical management of dislocated intraocular lenses. J Cataract Refract Surg 1995; 21:64-69
10. Smiddy WE, Flynn HW Jr. Management of dislocated posterior chamber lenses. Ophthalmology 1991; 98:889-894
11. Fanous MM, Friedman SM. Ciliary sulcus fixation of a dislocated posterior chamber intraocular lens using liquid perfluorophenanthrene. Ophthalmic Surg 1992; 23:551-552