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Ohta, Toshihiko MD, PhD

Journal of Cataract & Refractive Surgery: May 2014 - Volume 40 - Issue 5 - p 851-852
doi: 10.1016/j.jcrs.2014.02.029
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Kobayakawa et al.1 reported trocar-assisted sutureless intrascleral posterior chamber IOL fixation in 2010 before Totan et al.,2 and they noted a high incidence of vitreous hemorrhage (3 of 5 eyes [60%]). They concluded that bleeding was likely to have been caused by erroneous insertion of the 25-gauge trocar into the pars plicata because of the thickness of the instrument. Totan et al. reported similar complications. In addition, a scleral hole made with a 25-gauge trocar is less likely to close than one made with a 24-gauge microvitreoretinal (MVR) knife, so it is difficult to close the wound. Our 24-gauge MVR knife for performing a sclerotomy is thinner than the 25-gauge trocar, which means that erroneous insertion into the pars plicata is less likely. Haptic extraction is also easier than extraction through a scleral hole made by needle puncture. For these reasons, trocar-assisted sutureless intrascleral posterior chamber IOL fixation is not currently performed in Japan.

We use a single 8-0 nylon suture to fixate the haptic to the scleral bed to prevent it from shifting immediately after surgery. For this purpose, Totan et al.2 also placed a nonabsorbable suture transconjunctivally after placing the haptics in the scleral groove for stabilization during the early postoperative period and removing it 1 week later in their trocar-assisted technique. However, permanent fixation cannot be expected with a nylon suture because it rapidly becomes loose due to hydrolysis. We believe that short-term stability of the haptic is achieved by a nylon suture, whereas permanent stability is achieved by a scleral tunnel compression. The short-term stability obtained with a nylon suture is similar to that achieved by fibrin glue in the fibrin glue–assisted technique of Agarwal et al.,3 while nylon thread has no risk for infection.

Postoperative IOL decentration was observed in both eyes of an 84-year-old woman who was prone to falls. She was referred to our clinic because of luxation of the right lens and subluxation of the left lens. Intrascleral fixation was performed in both eyes, but the patient fell again after discharge. Although ocular blunt trauma caused IOL decentration in both eyes, it was slight due to fixation and was corrected without difficulty. No other severe complications have occurred during my 5-year experience using intrascleral fixation in 230 eyes.

References

1. Kobayakawa S, Matsumoto T, Gonda Y, Tochikubo T. [The new technique for secondary foldable PC-IOL implantation: intrascleral fixated IOL], [Japanese] Ganka Shujutsu 2010;23:125-130.
2. Totan Y, Karadag R. Trocar-assisted sutureless intrascleral posterior chamber foldable intra-ocular lens fixation. Eye. 26, 2012, p. 788-791, Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3376277/pdf/eye201219a.pdf. Accessed February 20, 2014.
3. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34:1433-1438.
© 2014 by Lippincott Williams & Wilkins, Inc.