Many techniques1–4 for secondary intraocular lens (IOL) transscleral fixation through the ciliary sulcus or pars plana have been described. These techniques have to bury, cover, or rotate the fixation knots to avoid conjunctival erosion, decrease the risk for endophthalmitis, and reduce the intraocular manipulations.5–8 We developed an alternative technique that inserts a 10-0 polypropylene suture into the barrel of a 27-gauge sharp needle and creates scleral tunnels to bury the knots for transscleral IOL fixation. This technique requires fewer intraocular manipulations, and no special microsurgical tools or sutures are needed.
A 10-0 polypropylene suture is passed through the barrel of a 27-gauge sharp needle to fixate the IOL (Figure 1, bottom left). Scleral tunnels are prepared as described by Hoffman et al.9 Briefly, 2 scleral tunnels are created 180 degrees from each other, avoiding the long posterior ciliary arteries at the 3 o'clock and 9 o'clock meridians. After peritomy and scleral cautery are done, a 3.0 mm wide, half-thickness scleral incision is made 3.0 mm posterior to the limbus using a Beaver blade. The scleral tunnel extending to the limbus is dissected using a metal crescent blade. A 5.0 mm scleral tunnel IOL implantation incision is created at the superior location using a diamond step knife (Figure 1).
At the planned scleral fixation site, the 27-gauge needle with suture is passed through the roof of the scleral tunnel 1.0 mm posterior to the limbus and advanced until the beveled tip and the loop of the suture reach the pupil area. The loop of the suture is grabbed by a Sinskey hook. One suture end is kept in the needle cannula while the other end is pulled out of the IOL implantation incision by the Sinskey hook (Figure 1). The needle is withdrawn with the polypropylene suture still in the barrel. The needle is again passed through the roof of the scleral tunnel at the second planned fixation site, which is 1.0 mm posterior to the limbus and 1.0 to 2.0 mm adjacent to the first site. The suture is pulled out of the IOL implantation incision using the Sinskey hook to form a loop from the second fixation site (Figure 2, A and B). The needle is removed while the suture is left in the punctured track. At this point, there is a free suture end and an extraocular loop extending from the implantation incision (Figure 2, C).
The free end at the implantation incision is passed through the eyelet of the IOL haptic; a knot is tied and put through the loop (Figure 3, A). The suture at the second scleral fixation site is slowly and gently pulled (Figure 3, B). Finally, the free end, which is knotted at the haptic at the implantation incision, is pulled out of the roof of the scleral tunnel through the punctured track at the second scleral fixation site. The fixation suture is then passed through the entire sclera at the ciliary sulcus and forms an extraocular loop via the implantation incision (Figure 3, C).
If the haptics have no eyelets, the procedure above is used to form the extraocular loop via the implantation incision without making a knot. Then, a double loop is created at the tip of the extraocular loop by holding the suture with 1 forceps (lower) and pulling the tip of the loop back with another forceps (upper) (Figure 4, A), creating a double-loop knot around the haptic. The double-loop knot is set around the heptic and pulled to tighten (Figure 4, B).
Each end of the suture is then retrieved through the scleral tunnel opening by passing a Sinskey hook into the scleral tunnel and pulling the suture ends through the tunnel opening. Thus, the suture has been passed through the scleral incision, the floor of the tunnel, and finally into the eye through the ciliary sulcus. The IOL is placed in the eye with the haptics in the sulcus, and the implantation incision is closed with interrupted 10-0 nylon sutures. Tying the ends of the polypropylene suture results in 4-point scleral fixation of the IOL haptic and burying the knot under the roof of the scleral tunnel (Figure 5). Suturing the scleral tunnels may not be necessary. The conjunctival incisions are closed with an 8-0 polyglactin suture.
The technique for transscleral fixation of posterior chamber IOLs has been modified and improved in several ways, including less intraocular manipulation,10 lower incidence of IOL tilt11,12 and later IOL dislocation,13 and decreased risk for suturing erosion through the conjunctiva.14,15 The key element of the transscleral fixation procedure is the way to advance the suture through the sclera and pull it from the implantation incision to tie it to the IOL.
A commonly used method of introducing a suture into the vitreous cavity is to pass the long needle of a double-armed 10-0 polypropylene suture through the full-thickness sclera into the eye at a planned site and through the ciliary sulcus across the vitreous cavity and then pull it out at the opposite planned site. However, it is hard to ensure the exact exit site of the needle. This has been improved by using a 30-gauge needle as a guide wire introduced from the limbal incision at the opposite site; the long needle of the 10-0 polypropylene suture is then inserted into the barrel of the 30-gauge needle. The 30-gauge needle is removed from the eye carrying the long needle and the attached suture.16
Our method simplifies the intraocular manipulations using the suture-in-needle method. In this method, the needless suture is introduced into the vitreous cavity, and the loop at the tip of the needle is used as a lasso to pass the other end of the suture through the scleral wall. This method should ensure more safety because of less needle–transvitreous cavity manipulation.
Moreover, this method is flexible in several situations. We have developed a transscleral suture technique for fixation of a dislocated posterior chamber IOL using the same technique.17 With this technique, IOL tilt can be improved by creating 4-point fixation rather than the 2-point variation that results from a single pass through the sclera. However, this technique may require skillful bimanual manipulation and a customized hook might be required to facilitate pulling the loop from the incision.
Attempts to prevent suture erosion through the conjunctiva with subsequent endophthalmitis have included rotating the suture knot into the eye; suturing within a scleral groove; and covering the knot with a patch graft,14 fascia lata,15 or scleral flap.9 The advantages of scleral fixation using suture retrieval through a scleral tunnel have been described.9 In our experience, dissection of a scleral tunnel appears to be a simpler way of creating scleral coverage for the suture knot than the traditional triangular scleral flap. Tying the suture ends will fixate the haptic in the sulcus while the knot will slide under the tunnel roof.
Combining a scleral tunnel with the suture-in-needle technique can be used in any procedure requiring transscleral fixation; for example, implantation of secondary IOLs, repair of dislocated IOLs, repair of iridodialyses, and use of adjunctive surgical devices such as Ahmed capsular tension segments and Cionni capsular tension rings. Such modification of the traditional scleral fixation procedure simplifies the creation of a scleral covering and decreases the harmful manipulations of the needle passing through the vitreous cavity.
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