The greatest disadvantage of existing techniques for ciliary sulcus suture fixation of intraocular lenses (IOLs),1–13 including ab interno ciliary sulcus suture fixation in which the needle is inserted from inside the eye4,8,10,13 and ab externo ciliary sulcus suture fixation in which the needle is inserted from outside the eye,1–3,5–7,9–12 is that the needle is inserted blindly, making it impossible to directly observe the ciliary sulcus on microscopy (Figure 1a). With the latter technique, the point at which the needle exits varies greatly depending on its angle (Figure 1b). The ciliary processes, which form the lower surface of the ciliary sulcus, contain a capillary network originating from the major arterial circle of the iris.14,15 Thus, piercing the needle into this area can cause considerable bleeding. In addition, piercing the needle into the wrong area can cause complications, such as dislocation of the IOL, corectopia, and secondary glaucoma.
We therefore developed the Ciliary Sulcus Pad, whose shape matches the shape of the ciliary sulcus, allowing the surgeon to correctly pierce the ciliary sulcus and minimize complications arising from the lack of direct observation. We previously proposed a method in which this auxiliary device is used for ciliary sulcus suture fixation of an IOLA (Video 1, available at http://jcrsjournal.org). The device was developed based on the shape of the ciliary sulcus obtained from ultrasound biomicroscopy observation of 16 aphakic eyes of patients after intracapsular cataract extraction13 (Figure 2).
Moreover, we improved the Ciliary Sulcus Pad, developing the Ciliary Sulcus Pad Injector (Duckworth & Kent Ltd.),13 which is a safer and simpler instrument for piercing the ciliary sulcusB–D (Videos 2 to 4, available at http://jcrsjournal.org). The tip of the injector matches the shape of the ciliary sulcus and has an angle of 66 degrees and a width of 2.0 mm. A hole in the injector is loaded with a straight needle. The hole is 0.45 mm below the upper surface of the tip and continues to the tube of the injector. In addition, the radius of curvature of the tip coincides with the radius of curvature of the ciliary sulcus (Figure 3).
We describe the technique of ciliary sulcus suture fixation of an IOL using the Ciliary Sulcus Pad Injector and present other details for performing the surgery successfully. An endoscope was used to confirm the success rate of using the injector to pierce the ciliary sulcus. We also studied the difference between the preoperative expected refractive power and the postoperative spherical equivalent power in 128 cases.
The 2 suture points must be symmetric with respect to the center point of the cornea because misalignment can lead to dislocation of the IOL. The direction of the incision for inserting the IOL should be at right angles to the suture direction to facilitate fixation of the IOL haptics to the ciliary sulcus. Therefore, the suture directions perpendicular to the direction of the incision for IOL insertion are marked at the beginning of surgery. A suture placement marker (AE-2759, ASICO LLC) can be used for this purpose (Figure 4).
Figure 5 shows the steps for corneal or scleral incision creation and irrigation port creation. Steps are shown for the right eye and the left eye. The irrigation ports are placed to maintain intraocular pressure.
The surgery is performed as follows: First, an irrigation port is made after crisscross marking. Second, marks are placed on the sclera 2.5 mm from the posterior surgical limbus after an incision is made in the conjunctiva. Third, two 2.65 mm corneal incisions are made for insertion of the Ciliary Sulcus Pad Injector and a vitrector (Figure 5). Fourth, the vitrector is inserted through the corneal incision to perform vitrectomy. This vitrectomy is performed to the equator. Careful vitrectomy is required under the iris of the opposite side of the 2.65 mm incision through which the injector is inserted to prevent vitreous body traction when the needle or IOL is inserted.
The injector is loaded with a straight suture needle with loop thread (1486L, Mani Co., Ltd) by inserting the rear of the needle while firmly pressing the plunger. The tip of the plunger that pushes the needle out has a dimple into which the rear tip of the needle fits. Pushing the end of the needle into the dimple holds the needle. The needle is drawn in by the spring when the plunger is releasedB,C (Figure 6) (Videos 2 and 3, available at http://jcrsjournal.org).
The injector is inserted through the 2.65 mm corneal incision at the opposite side of the suture fixation point and is slid along the posterior surface of the iris to the opposite side until it fits in the ciliary sulcus (Figure 7). The tip of injector is moved up and down slightly. The tip of the ciliary sulcus pad injector cannot be moved if it is fitted correctly in the ciliary sulcus. At this point, the plunger is pushed forward. If the straight needle pierces the deepest point of the ciliary sulcus, the needle emerges at the mark 2.5 mm away from the posterior surgical limbus. The straight needle is withdrawn using a forceps at the same time the injector is withdrawn from the incision (Figure 8). The loop thread is pulled out from the incision for IOL insertion with a hook (Figure 9). Next, the piercing point is observed using an endoscope to determine whether the needle is pierced correctly (Figure 10). If the suture thread does not correctly pass through the deepest part of the ciliary sulcus, the suture thread is removed and the process repeated after the injector is loaded with a straight needle.
Next, the loop thread is fixed to the haptics of the IOL (NR-81K, NIDEK Co., Ltd) using a cow-hitch suture. The IOL is inserted through the 6.0 mm incision parallel to the surface of the iris. The haptics then are fixated to the ciliary sulcus while the loop thread is being pulled (Figure 11). At this point, an endoscope is used to check that the haptics are correctly fixated parallel to the ciliary sulcus (Figure 12). If the haptics are fixated at an angle, a hook is used to lift the IOL into the correct position.
The needle is passed through one half of the sclera, and 1 thread of the loop thread is cut before it is tied on the surface of the sclera. Approximately 5.0 mm of the cut end of the suture thread is left. If it is too short, the cut end of the suture thread protrudes and might cause a postoperative infection by tearing the conjunctiva. Leaving a longer suture thread prevents tearing of the conjunctiva, and the thread remains under the conjunctiva for a long period after surgery.
The incision used to insert the IOL is sutured using 10-0 nylon. Next, the conjunctiva of the suture-fixation location is sutured using 8-0 silk. Finally, the irrigation port is sutured using an absorbable thread, and the conjunctiva through which the port was placed is sutured with 8-0 silk, completing the procedureB–D (Figure 13) (Video 2 to 4, available at http://jcrsjournal.org).
In 128 cases performed by the same surgeon (T.S.), an NR-81K IOL was implanted. During surgery, endoscopy was performed to confirm the position of the piercing. The ciliary sulcus was pierced correctly on the first attempt in 117 cases (91.4%); however, the piercing procedure was repeated in 11 cases (8.6%). The difference between the expected preoperative refractive power and the spherical equivalent power was −0.63 diopter (D) 6 months after surgery.
There are many reports of ab externo ciliary sulcus suture fixation in the literature.1–3,5–7,9–12 However, there has been dispute regarding whether the haptics were actually fixated in the ciliary sulcus. This is because the shape of the ciliary sulcus and its position were not entirely clear. Moreover, insertion of the needle from outside the eye is easier in a practical surgical technique. Previously, we clarified the shape of the ciliary sulcus of the living eye using an ultrasound biomicroscope and an endoscope.13 We developed the Ciliary Sulcus Pad Injector based on these results. We found that with the injector, the success rate for correctly piercing the ciliary sulcus improved significantly and that it was possible to maintain a stable eye for a long period after surgery (Figure 14). In a study by Kamal et al.,16 the success rate of correct haptic fixation in the ciliary sulcus was 31% with ab externo fixation and 29% with ab interno fixation.
Using the Ciliary Sulcus Pad Injector improves the accuracy of successful ciliary sulcus piercing and makes ciliary sulcus suture fixation easier. However, the use of the injector alone does not guarantee successful suture IOL fixation. Several other important factors exist.
It is important to mark the sclera 2.5 mm from the posterior surgical limbus. In our previous study,13 ultrasound biomicroscopy measurements of the shape of the ciliary sulcus in aphakic eyes showed that if a straight needle correctly pierces the deepest part of the ciliary sulcus from the opposite side of a corneal incision, the needle emerges from the sclera at 2.5 mm from the posterior surgical limbus.13 If there is a significant deviation that point, it is likely the needle has not correctly pierced the ciliary sulcus and the piercing procedure must be repeated. In the 11 cases in which there was significant deviation from the marking, endoscopy showed the needle had not pierced the ciliary sulcus.13
Catching the vitreous while piercing the ciliary sulcus is a major cause of postoperative retinal detachment. Therefore, a sufficient vitrectomy should be performed with the intent of doing a core vitrectomy. The use of 11-deoxycortisol is effective at this time.17,18
Even with a vitrector, it is sometimes not possible to sufficiently incise the posterior iris synechia resulting from the residual lens capsule and cortex from the previous surgery. In this case, the synechia should be incised using surgical scissors while adequate ophthalmic viscosurgical devices are injected. The cortex that is wrapped with the anterior and posterior lens capsule cannot be removed with a vitrector. Therefore, the capsule should be incised adequately using surgical scissors; then, the packed cortex should be eliminated by the vitrector.
In cases of poor pupil dilation arising from previous surgery, it is possible to perform a sufficient vitrectomy by creating 2 ports for the irrigation of the sclera and to use the vitrector to perform the vitrectomy. In addition, creating another port and inserting an endoscope through it to perform an endoscopic vitrectomy is effective in eliminating residual vitreous strands adhered to the iris near the ciliary sulcus.
Closer investigation of the piercing location in the ciliary sulcus showed that the ideal piercing point is slightly below the deepest part of the ciliary sulcus. This is because when this part is pierced, the suture thread can pull on the pupillary dilator muscle, which can cause corectopia (Figure 15). The hole in the tip of the Ciliary Sulcus Pad Injector, into which the needle is loaded, is 0.45 mm below the upper surface of the tip. If the tip of the injector is correctly placed at the deepest part of the ciliary sulcus, the needle will pierce slightly below the deepest part (Figure 16).
The suture is fixed to the haptics using a cow-hitch suture to prevent damage to the ciliary sulcus. This is because the cut end of the suture after knotting can damage the ciliary sulcus and can cause considerable bleeding.
Half-thickness scleral flaps are another option; with this method, the suture is buried in the half-thickness incision.6,12 Although this technique is to prevent exposure of the suture, we did not it. The rationale was that doing so would complicate the procedure and increase its invasiveness. If another surgery is required on the same patient, for example because of postoperative IOL dislocation, it would be extremely difficult to remove the suture. If the suture is cut approximately 5.0 mm longer, it can be placed under the conjunctiva and will remain stable for a long period after surgery (Figure 14).
The loop thread of Mani 1486L straight suture needle is made of polypropylene and is slightly hard. However, it can be placed under the conjunctiva without tearing the conjunctiva by leaving the cut ends of the suture approximately 5.0 mm longer. This also prevents endophthalmitis. The suture is cut if it is exposed above the conjunctiva. Even cut, the haptics fixated in the ciliary sulcus will stay in place because they are buried in the superficial stroma of the ciliary body and covered by the fibrous membranes or granulation tissue with multinucleated giant cells. Küchle et al.19 reported that haptics fixated in the ciliary sulcus were buried in the superficial stroma of the ciliary body and were covered by fibrous membranes. Ishibashi20 stated that the haptics were covered by granulation tissue with multinucleated giant cells in out-of-the-bag fixation in the cadaver eyes.
Of the 128 cases we describe here, the suture was removed in 8 cases (6.25%) 6 or more months after surgery; however, no IOL dislocation and no cases of dropped IOL were observed. This indicates that the haptics were fixated parallel to the ciliary sulcus and were covered and fixated by fibrous membranes or granulation tissue with multinucleated giant cells in the ciliary sulcus postoperatively. This is a major advantage of ciliary sulcus suture fixation.
The current technique uses 2-point fixation, as do all other suture fixation techniques. However, IOL dislocation rarely occurs with ciliary sulcus suture fixation because the haptics are placed in the ciliary sulcus and then covered by the fibrous membranes or granulation tissue with multinucleated giant cells. This also is an advantage of the ciliary sulcus suture fixation over other methods of suture fixation.
Å large incision (range 6.0 mm to 7.0 mm) is required with this technique because haptics of IOLs for suture fixation have a notch or eyelet for ligating the loop suture thread and are single-piece models. The development of a foldable IOL for suture fixation whose haptics have a notch or eyelet will further improve the technique.
A 20-gauge irrigation cannula is recommended. Using 25-gauge or 27-gauge trocars is not advisable because irrigation is insufficient; these cause the eye to collapse when the IOL is inserted.
Correct suturing of the ciliary sulcus resulted in a shift toward myopia of 0.63 D relative to the expected preoperative refractive power. Thus, when choosing the IOL power, one should take the 0.63 D shift into consideration to obtain a more accurate postoperative refractive power. The probable cause of this myopia is that the IOL shifts toward the cornea more than it does with in-the-bag fixation because the haptics are fixated in the ciliary sulcus.
Recently, IOL fixation techniques using intrascleral haptic fixation have gained popularity for suture fixation of IOLs.21–23 It might be better to fixate the haptics using intrascleral haptic fixation in the ciliary sulcus. However, the ciliary sulcus is hemorrhagic, and this could be dangerous. We await future discussion on this topic.
What Was Known
- In previous methods of ciliary sulcus suture fixation of an intraocular lens (IOL), the needle is inserted blindly because it is not possible to directly observe the ciliary sulcus using microscopy.
What This Paper Adds
- The rate of successful, accurate piercing of the ciliary sulcus was markedly improved by using the ancillary injector.
- Ciliary sulcus suture fixation of IOLs using injector reduced complications and enabled the safer suture fixation of the IOL in the ciliary sulcus.
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Video 1 Ciliary Sulcus Pad auxiliary device is used for ciliary sulcus suture fixation of an intraocular lens.
Video 2 Surgery using the Ciliary Sulcus Pad Injector for ciliary sulcus suture fixation of an intraocular lens.
Video 3 Correct method of ciliary sulcus fixation of an intraocular lens using the Ciliary Sulcus Pad Injector.
Video 4 Basic method of ciliary sulcus fixation of intraocular lenses and pars plana fixation of intraocular lenses.
Dr. Sugiura receives royalties for the Ciliary Sulcus Pad Injector. None of the other authors has a financial or proprietary interest in any material or method mentioned.
Other Cited Material
A. Sugiura T, Minami N, Miyake K, “Ciliary Sulcus Pad,” film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Seattle, Washington, USA, April 1999 and at the 12th Internationale Kongress der Deutschen Ophthalmochirurgen, Nürnberg, Germany, June 1999
B. Sugiura T, “New Technique of Ciliary Sulcus Fixation of IOL,” film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, April 2007
C. Sugiura T, “Correct Method of Ciliary Sulcus Fixation of Intraocular Lens,” film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Francisco, California, USA, April 2009 and at the 22nd annual meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons, Tokyo, Japan, June 2009
D. Sugiura T, Inoue Y, “The Basic Method of Ciliary Sulcus Fixation of Intraocular lenses and Pars Plana Fixation of Intraocular Lenses,” film presented at the XXVII Congress of the European Society of Cataract and Refractive Surgeons, Barcelona, Spain, September 2009