In case of aphakia or intraocular lens (IOL) luxation, there exists a variety of options for refractive rehabilitation. Suturing an IOL or the enclavation of an IOL to the iris in the anterior or posterior chamber is widely used in modern ophthalmic surgery. More recently, intrascleral haptic fixation techniques were introduced.1–3 Other techniques using flanged haptics, flanged polypropylene sutures or conventional sutures with knots for IOLs, and capsular tension rings or iris (re)fixation were described previously.4–6 These procedures are often found surgically demanding even by experienced and skilled ophthalmic surgeons. Complex maneuvers dependent on additional incisions, 2 sharp instruments within the eye or specific needles such as spatula or thin-walled needles are often needed to succeed in a given clinical scenario.7,8
The previous described flanged intrascleral haptic fixation (FIHF) technique uses a bent thin-walled 30-gauge (or alternatively 27-gauge) needle to externalize the polypropylene haptic of an IOL.1,9–11 Although this might work well in many cases, sometimes, the surgeon is faced with difficulties when trying to feed the haptic into the needle despite multiple efforts. Possible reasons for this include an inner needle diameter chosen too small relative to the size of the haptic or an inadequate working angle between the needle and the end of the haptic. In addition, the haptics simply might slide out from the needle enclavation during the externalization maneuver.
The “forceps-needle” was designed to overcome some of the shortcomings experienced with the FIHF technique and to facilitate other surgical procedures described. The instrument combines the properties of tissue perforation with grasping of material (eg, IOL haptic, suture, or foreign body) and its manipulation. All surgical techniques that combine intraocular grasping and externalization of IOL haptics, sutures, or other intraocular structures might be greatly facilitated by the presented instrument. In a series of 10 consecutive cases for FIHF, the functionality and performance of the new device was initially tested. Indications included primary aphakia, IOL exchange, and refixation of an already dislocated IOL.
Currently, the single-use forceps-needle device (Nadelpinzette nach Amon, S04097, Geuder AG) is available in 2 different sizes: diameters of 27 gauge (inner diameter of lumen: 0.3 mm) and 30 gauge (inner diameter of lumen: 0.2 mm). In both types, the needle is bent 145 degrees, and it holds a blunt grasping forceps within the lumen of the needle (Figure 1). The length of the needle is 10 mm (27 gauge) and 7.0 mm (30 gauge), respectively. To avoid deformation during scleral or corneal perforation, emphasis was made on mechanical stability during the design phase of the instrument. A standard functional handpiece by the same manufacturer (model G-38240, Geuder AG) is used and locked to the forceps-needle to maintain good stability. Activation of the handpiece triggers the forceps inside the sharp needle to open and to move forward outside of the tip to grasp. On closure, it retracts inside the needle to hold an object. The orientation of the forceps is 90 degrees to the pointed tip of the needle.
IOL Exchange or Primary IOL Implantation
In the first consecutive cases, the site of perforation was marked at 180 degrees 2.0 mm away from the limbus. Then, a 3-piece IOL with polypropylene haptics (TECNIS CL Z9002, Johnson & Johnson Vision Care, Inc., or AcrySof MA60AT, Alcon Laboratories, Inc.) was folded and implanted through a 2.75 mm incision partially into the anterior chamber. A transconjunctival, scleral tunnel of about 2.0 mm length parallel to the limbus was performed with the forceps-needle on 1 side, with the second hand grasping the leading haptic through a side-port incision with a 25-gauge serrated forceps (Bausch & Lomb Surgical Instruments). The forceps-needle was then turned and moved close to the end of the haptic that was grasped using the handshake technique.12 Pressing the handpiece locked it at the tip of the forceps-needle. The first haptic was then externalized after which the end of the first haptic was flanged in the previously described fashion.1 The trailing haptic was then grasped and introduced into the anterior chamber. Subsequently, a second scleral tunnel was prepared with the forceps-needle and, with a similar maneuver, the second haptic externalized and flanged. Finally, the IOL was centered, and the ends of its haptics put into position (Figure 2) (Supplemental Digital Content, Video 1, available at http://links.lww.com/JRS/A127).
Before replacement of a luxated 3-piece IOL, care was taken to use only the dislocated IOL for FIHF, if there was no severe haptic distortion. In cases with IOL damage and/or severe capsular bag alteration, extraction of IOL and capsular bag was performed first, followed by implantation of a new 3-piece IOL using the above-described technique.
In some cases, anterior or pars plana vitrectomy was necessary before refixation of an IOL. When capsular alteration such as fibrosis, phimosis, or Soemmering’s ring formation occurred, the bag together with regenerative lens material was removed with a vitrectome. The technique of fixation was very similar to the one described earlier. The only differences were the position of the IOL within the eye before refixation and the fact that, in some cases, the IOL was still in the luxated capsular bag. In all cases, the first haptic was grasped and lifted with a serrated forceps, moved into the forceps-needle using the handshake technique and externalized. In cases with a clear capsular bag, the capsule was perforated at the end of the haptic with the forceps-needle and externalized without clearing the capsular bag. The same procedure was performed with the second haptic, and the surgery ended as in all other cases. In these cases, the capsular bag was kept in place.
In case of aphakia or IOL luxation, suturing an IOL to the sclera or iris represent viable alternatives to the enclavation of an IOL to the iris. Intrascleral haptic fixation offers an alternative to anterior or posterior IOL enclavation or sutured IOL fixation.13 First described by Scharioth and Pavlidis, primarily the haptic was externalized and intrasclerally buried into a tunnel.8 A similar technique is the glued haptic fixation.11 These techniques were modified such as double tunnel, but all need a scleral perforation for a forceps to grasp the haptics. Yamane et al. described a very elegant procedure, feeding the haptic in a thin-walled needle and flanging the haptic end with heat.1 This technique does not need a primary scleral perforation and, therefore, avoids aqueous leakage. Feeding the haptic into the lumen of the needle in some cases might be difficult to achieve due to a suboptimal working angle. Despite the use of thin-walled needles, the feeding of the haptic into the lumen is sometimes blocked due to surface irregularities at the inner wall of the needle. Furthermore, the haptic might slide out of the needle during externalization because of the lack of a holding force. From the idea of flanging, the haptic techniques derived flanging polypropylene sutures for the fixation of 1-piece IOL.14,15
To overcome shortcomings of the above-described techniques, we designed a single instrument that combines the properties of a forceps and a needle. With this forceps-needle, the haptic end, a suture end, or the suture itself can be grasped directly after scleral perforation. When the technique described by Yamane et al. is used, the haptic end can be grasped without the need to feed the haptic inside the narrow inner lumen of the needle. In the technique described in this study, the leading haptic is fixed by a crocodile 25-gauge forceps and, almost independent from the working angle between haptic and forceps-needle, the haptic is grasped in a handshake maneuver and externalized right after. Advantages are easier grasping without the need of feeding the needle with the haptic, less need of distortion of the haptic because grasping is less dependent on the working angle, and prevention of losing it during externalization. Immediately after externalization of the first haptic, its end is flanged, and then, the trailing haptic is grasped by the forceps-needle, externalized, and flanged appropriately. The described technique can be performed using both 27- and 30-gauge needles alike.
In cases where refixation of the IOL–capsular bag complex seems to be a viable option, we could grasp the ends of the haptic after perforation of the equatorial capsule and externalize and flange them without extraction of the clear capsular bag. The advantage of this procedure is to avoid an incision for IOL implantation. We were able to complete the successful procedure with only 2 side ports for the crocodile forceps and 1 for an anterior chamber maintainer. Even so we never tried this with the classic technique described by Yamane et al., we think that it would not work that easily because the haptics could not slide gently into the needle because the capsule would counteract the action of feeding.
Apart from all different techniques for intrascleral haptic fixation, the forceps-needle could prove helpful for suturing an IOL and/or iris to the sclera. With the forceps-needle, surgeons are able to grasp the needle-free end of sutures and externalize them. For the different indications, we externalized 10-0, 9-0, and 6-0 polypropylene sutures to fixate an IOL or capsular tension ring–capsular bag–IOL complex to the sclera. We flanged the 6-0 Prolene to the sclera and attached the 10-0 and 9-0 sutures. In comparison with the double needle technique for suturing, the forceps-needle technique does not need a spatula needle or any other additional needle within the eye because the suture might be grasped at its and/or if needed in between its ends, no matter which material is used (Prolene, Gore-Tex, etc.). This fact could potentially increase surgical safety.
Even for those techniques where primarily a scleral perforation is made for a forceps followed by a scleral tunnel preparation, we think that using the forceps-needle is advantageous too.8 First, there is no second instrument needed, and second, scleral perforation and scleral tunnel can be kept smaller.
Because this instrument is very new and until now there is limited experience using it for different techniques, we have to wait for detailed prospective studies to prove the additional benefit of this instrument. We believe that this instrument facilitates intrascleral haptic fixation and suturing. It might increase surgical safety and help to create new innovative ideas in the future for the anterior and posterior segments.
WHAT WAS KNOWN
- Intrascleral IOLs fixation and suturing IOLs are well-established techniques.
- In cases without capsular support, IOLs might be fixed by flanging IOL haptics, by flanging polypropylene sutures, and haptic suturing.
- Several suturing techniques exist to attach IOLs, capsular tension rings, or iris to ocular tissue.
WHAT THIS PAPER ADDS
- Combining needle and grasping functions in a single instrument facilitates IOL fixation or refixation.
- Externalization of haptics or sutures is achieved with the forceps-needle in a single step.
- The forceps-needle might be used for different intraocular maneuvers in anterior and posterior segments eye surgery.
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