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Sutureless technique for repositioning and scleral fixation of the capsular bag–intraocular lens complex with permanent use of iris retractors

Krix-Jachym, Karolina M. MD, PhD; Błagun, Natalia MD; Kicińska, Aleksandra K. MD; Dyda, Wojciech MD; Rękas, Marek T. MD, PhD

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Journal of Cataract & Refractive Surgery: January 2022 - Volume 48 - Issue 1 - p 118-124
doi: 10.1097/j.jcrs.0000000000000838
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Adequate stabilization of the capsular bag and intraocular lens (IOL) implantation in patients with poor zonular support has been a difficult challenge for the cataract surgeon. In mild to moderate zonular dialysis, the capsular bag may be preserved and used for IOL implantation by using a capsular tension ring (CTR). Although in the presence of severe zonular dialysis, this may not provide appropriate IOL centration and capsular bag–IOL complex stabilization. Flexible iris retractors can be used to facilitate phacoemulsification in eyes with small pupils or damaged zonular fibers. In addition to their conventional use as an iris retractor, the hooks can create a tenting effect of the anterior capsule.1 In 1998, Cionni and Osher introduced a modified CTR for use in patients with significant zonular compromise or lens subluxation, which is fixated to the sclera with sutures.2 Suture fixation, however, has disadvantages, including the need for surgical skill and expertise, increased surgical time, and the possibility of suture-related complications. The technique we describe is performed with the use of a CTR and iris retractors; it is sutureless, and it can be safely performed in eyes with extensive subluxation. This method extends the ideas of the Yamane technique and provides intraoperative and postoperative capsular bag–IOL complex stabilization.3


The technique can be used in case of patients with subluxated cataracts, colobomatous lenses, or subluxated IOLs with wide zonular dialysis, especially after ocular trauma. The surgery was performed in retrobulbar anesthesia with Xylocaine 2% and bupivacaine 0.5% solution. A procedure started with the creation of 2.2 mm temporal clear corneal incision and 3 additional ports (1 superonasal and 1 or 2 at the site of subluxation). The next step was capsulorhexis performed with forceps (Figure 1, A), with avoiding excessive traction on the zonular fibers. Sometimes, 2 surgical instruments were used at this stage for stabilization of the nucleus—for example, microcapsulorhexis forceps with Sinskey hook or with another microcapsulorhexis forceps. For the limited vitreous prolapse, anterior vitrectomy was ordinary necessary (Figure 1, B). Then, through additional side ports, flexible iris retractor(s) made of bright blue polypropylene (Iris Care, Madhu Instruments Pvt Ltd.) was inserted. The iris retractor consists of a flexible hook and an adjustable silicone stopper. Devices were placed beneath the anterior capsule margin in the area of damaged zonular fibers to grasp the edges of the capsulorhexis. The capsular opening became central, and the capsule was stabilized with iris retractors. Lens extraction was performed relatively comfortably and safely after the lens capsule was secured (Figure 1, C). Phacoemulsification was completed using standard or decreased flow. The CTR was implanted in the capsular bag (Figure 1, D), which was followed by residual cortex aspiration. Then, a foldable 1-piece IOL was inserted in the capsular bag (Figure 1, E). After removing the silicone stoppers, the retractors were detached from the capsulotomy margin and placed in the anterior chamber. A 25-gauge needle was inserted through the sclera (2.0 mm posteriorly from the limbus) at the site of zonular compromise into the anterior chamber. The needle was advanced anteriorly to the capsular rim. The end of 1 retractor was put into the lumen of the needle using forceps and then externalized (Figure 1, F). A second sclerotomy using the same needle was performed about 90 degrees from the first one, and the procedure was repeated. After the externalization of both retractors, the hooks stretched the capsule margin, and the IOL optic was situated within the visual axis (Figure 1, G). The ends of the devices were trimmed and cauterized with an ophthalmic cautery device (Figure 1, H). The half sphere–shaped melted tip was then withdrawn and fixed subconjunctivally (Figure 1, I). No scleral flaps or conjunctival sutures were needed.

Figure 1.
Figure 1.:
(AI) Surgical technique of phacoemulsification of the subluxated lens with CTR implantation and sutureless scleral fixation of the capsular bag using cauterized iris retractors. (A) Capsulorhexis centered on the crystalline lens. (B) Anterior vitrectomy. (C) Phacoemulsification of the subluxated lens after centration of the capsular bag with iris retractors. (D) Implantation of the CTR. (E) The IOL implanted in the capsular bag secured with iris retractors. (F, G) Externalization of the retractors using a 25-gauge needle. (H) Cauterization of the trimmed iris retractors. (I) The cauterized tips of the retractors fixed subconjunctivally. CTR = capsular tension ring

The surgery was published online on Video Journal of Cataract, Refractive & Glaucoma Surgery, Vol. 35, Issue 1 [History and Evolution of Zonular Surgery (Part 2)].4


The surgery was performed with the technique mentioned above in 7 eyes of 7 patients. The institutional review board approved the study, and all patients provided informed consent. A zonular defect greater than or equal to 90 degrees (judged visually in biomicroscopic examination) was present in all cases. Zonular dialysis had diverse (traumatic or congenital) etiology. Indication for lens extraction was subluxation of the lens with vision deterioration due to the presence of cataract. Exclusion criteria were previous ocular surgery, additional severe ocular pathology unrelated to cataract subluxation, or trauma. The study was performed between 2017 and 2020 in the Ophthalmology Department, Military Institute of Medicine, Warsaw, Poland, and the operations were conducted by 1 surgeon (M.R.). The technique was the same in all eyes; however, closure of iris coloboma (patient 3) and closure of iris dialysis (patient 6) were additionally performed when needed. Typical postoperative treatment was introduced (antibiotic and anti-inflammatory topical drugs). The follow-up range was 3 to 33 months. During the follow-up visits, a complete ophthalmic examination was performed including uncorrected visual acuity, corrected distance visual acuity (CDVA), slitlamp evaluation, applanation tonometry, fundus evaluation, and B-scan ultrasonography (when the fundus was not visible). Clinical evaluation of inflammation included conjunctival congestion, corneal edema, cells and flare in the anterior chamber, and synechia formation.


This technique was used as described in 7 eyes of 7 patients with greater than or equal to 90 degrees of cataractous lens subluxation (mean 150 degrees; SD ± 34.6 (SD) (range 90 to 180). The mean age of patients was 40.9 years ± 15.9 (SD) (range 23 to 70 years). The mean duration of subluxation was 64.9 months ± 107.8 (SD) (range 1 to 300 months). The mean follow-up was 12 months ± 11.2 (SD) (range 3 to 33 months). Demographic and clinical data are summarized in Table 1.

Table 1. - Patient Demographic and Clinical Data.
Case Sex Eye Age (y) Etiology Duration of subluxation (mo) Ocular comorbidity Defect site (o’clock) Area of subluxation (°) Iris retractors location (o’clock)
1 M Right 50 Trauma 18 Temporal (6, 12) 180 7, 11
2 F Left 33 Congenital 60 Temporal (12, 6) 180 1, 5
3 F Left 27 Congenital 72 Iris coloboma, amblyopia Inferonasal (5, 10) 150 5, 9
4 M Left 44 Trauma 1 Vitreous prolapse Temporal (1, 6) 150 2, 5
5 M Left 70 Trauma 2 Pupil sphincter damage, IOP rise before surgery Nasal (7.30, 10.30) 90 9
6 M Left 39 Trauma 300 Iris dialysis, choroidal (macular) rupture Nasal (6, 10) 120 7, 9
7 F Right 23 Trauma 1 Iris dialysis, secondary glaucoma Nasal (12, 6) 180 2, 5
CTR = capsular tension ring; IOP = intraocular pressure

The anatomical and functional results were good (Table 2). There were no surgical complications that affected visual function during the postoperative period. The mean preoperative and postoperative CDVAs on Snellen chart were 0.29 ± 0.24 (SD) (range 0.01 to 0.7) and 0.72 ± 0.43 (SD) (range: 0.01 to 1.0), respectively. The mean preoperative and postoperative intraocular pressures (IOPs) were 17.5 mm Hg ± 3.4 (SD) (range 12 to 22 mm Hg) and 16.7 mm Hg ± 3.4 (SD) (range 13 to 21 mm Hg), respectively. One patient had secondary glaucoma treated initially with antiglaucoma topical drugs, and antiglaucoma surgery (nonpenetrating deep sclerectomy) was eventually necessary.

Table 2. - Follow-Up Data of 7 Patients.
Case Sex Eye Area of subluxation (°) Etiology CDVA Follow-up (mo) Complications
Preop Postop
1 M Right 180 Trauma 10/20 20/20 3 Transient IOP rise resolving after topical steroid was withdrawn
2 F Left 180 Congenital 20/60 20/20 6 None
3 F Left 180 Congenital 20/100 20/25 24 Hypotony lasting 3 d postop
4 M Left 120 Trauma 20/30 20/20 33 Grade 2 cells and flare resolving after topical treatment
5 M Left 90 Trauma 20/100 20/20 12 None
6 M Left 120 Trauma 20/200 20/100 4 None
7 F Right 180 Trauma 20/1500 20/1500 12 None
CTR = capsular tension ring; IOP = intraocular pressure; postop = postoperative; preop = preoperative

In the postoperative period grade 2 cells and flare were seen in 1 patient (case 4) and responded well to topical steroids. Minimal corneal edema and Descemet's folds were present in 1 eye (case 4) (14.3%) and resolved after 2 weeks. One eye (14.3%) developed raised IOP that responded well to medical therapy and subsided after topical steroid withdrawn (case 1). Hypotony was observed in 1 patient (14.3%) (case 3) and lasted 3 days after surgery. Two eyes had a final low CDVA because of coexisting fundus pathology (choroidal rupture encompassing macular area—case 6; secondary glaucomatous neuropathy—case 7). The capsular bag–IOL complex remained stable in all eyes during the follow-up, and the capsular bag and IOL maintained their central position. A dilated pupil examination on the last visit showed a well-centered IOL in all eyes. Complications such as cauterized iris retractors exposure have not occurred. No other postoperative complications were encountered.

Case 1

A 50-year-old man with a history of right eye trauma 1.5 years ago complained of deterioration of vision in this eye. The CDVA was 10/20 in the right eye and 20/20 in the left eye. The IOP was 17 mm Hg and 13 mm Hg in the right and left eyes, respectively. The lens in the right eye was decentered with 180 degrees of temporal zonular dehiscence. The patient was qualified for surgical treatment. The procedure described above was completed without complications (Figure 2).

Figure 2.
Figure 2.:
Postoperative view of case 1—the right eye 3 months after surgery (A, B) and Anterion examination of the right eye 3 months after surgery (C).

Transient IOP rise was noted 2 weeks postsurgery, and 0.2% brimonidine was prescribed. The problem was finally resolved after topical steroid was withdrawn and brimonidine was no more needed. Three months after surgery, CDVA was 20/20, and the IOP was 13 mm Hg. The capsular bag–IOL complex has remained centered and stable.

Case 2

A 33-year-old woman with bilateral lens subluxation presented to our department with a decreased vision for 5 years and astigmatism of 10 DCyl in her left eye. CDVA was initially 20/60, and the IOP was 15 mm Hg in the left eye. In the biomicroscopic examination, the lens was decentered nasally. We proceeded with lens phacoemulsification and capsule fixation with the use of iris retractors as described earlier without intraoperative complications. Postoperatively, her vision continued to improve, and CDVA after 6 months was 20/20, and the IOP was 14 mm Hg. The astigmatism after capsular bag–IOL complex centration decreased to 0.75 DCyl (Figure 3).

Figure 3.
Figure 3.:
Case 2—the left eye before (A) and 6 months after surgery (B, C).

Case 3

A 27-year-old woman with bilateral inherited iris coloboma had zonular dehiscence in her left eye. CDVA before surgery was 20/100 in the left eye, and the IOP was 18 mm Hg. The procedure described above has been carried out accompanied by closure of iris coloboma. There were no intraoperative complications in both eyes. After left eye surgery, the IOP on the first day was low (hypotony), and CDVA was 20/200. Three days after surgery, the IOP in this eye raised to 18 mm Hg, and CDVA improved and was 20/30 on the Snellen chart. Two years after surgeries, CDVA was 20/25 in the left eye, and the IOP was 18 mm Hg (Figure 4).

Figure 4.
Figure 4.:
Case 3—the left eye before (A) and after phacoemulsification of subluxated cataract with CTR implantation and sutureless scleral fixation of the capsular bag using cauterized iris retractors 2 years after surgery (B, C). CTR = capsular tension ring

Case 4

A 44-year-old man had ocular blunt trauma in his left eye 1 month before his visit to the Ophthalmology Department of Military Institute of Medicine in Warsaw, Poland. Anterior segment examination of the left eye revealed residual subconjunctival hemorrhage, iridodonesis, phacodonesis, and vitreous prolapse. CDVA was 20/30, and the IOP was 22 mm Hg. The procedure described above was performed. In the short postoperative period, CDVA improved to 20/25 on the Snellen chart, and the IOP was 15 mm Hg. On biomicroscopic examination, grade 2 cells and flare were observed, which were resolved after topical treatment. One month after surgery, CDVA was 20/20, and the IOP was 21 mm Hg. The IOL was well centered. On the last visit, about 3 years after surgery, the capsular bag–IOL complex remained stable and well centered, and no complications occurred (Figure 5).

Figure 5.
Figure 5.:
Case 4—the left eye before (A) and 33 weeks after surgery (B) and Anterion examination (C) of the left eye 33 months after surgery.

Case 5

A 70-year-old man with a history of ocular trauma of his left eye 2 months before the assessment complained of poor vision in this eye. Anterior segment examination of the left eye revealed iridodonesis, phacodonesis, and pupil sphincter local damage. Preoperative CDVA was 20/100, and the IOP was 29 mm Hg. Antiglaucoma medication was introduced, the IOP decreased to 21 mm Hg, and the patient was qualified for surgical treatment. The surgical procedure described earlier with the use of 1 iris retractor was performed. Twelve months after surgery, CDVA was 20/20 on the Snellen chart, and the IOP was 21 mm Hg without antiglaucoma drops. The IOL was well centered. On the last visit, the capsular bag–IOL complex has remained well centered (Figure 6).

Figure 6.
Figure 6.:
Postoperative view of case 5—the left eye 12 months after surgery (A, B).

Case 6

A 39-year-old man had ocular trauma in his left eye 25 years before. The examination revealed corneal scar, subluxated cataract with zonular dialysis approximately from 6 to 10 o'clock, and iris dialysis from 7:00 to 9:00 o'clock. CDVA was 20/200, and the IOP was 12 mm Hg. The procedure as described earlier was performed without complications. After 4 months of follow-up, CDVA was the same as before surgery due to choroidal rupture in the macular region. The IOP was 14 mm Hg. The surgical procedure provided stability and centration of the capsular bag–IOL complex (Figure 7).

Figure 7.
Figure 7.:
Case 6—the left eye before (A) and after surgery (B, C).

Case 7

A 23-year-old woman with the deterioration of vision after ocular trauma was qualified to surgery because of posttraumatic subluxated cataract with concomitant iris dialysis from 12:00 to 3:00 o'clock in her right eye. CDVA before surgery was 20/1500. The IOP was 18 mm Hg with maximal antiglaucomatous therapy. There were no intraoperative or postoperative complications. There was no improvement in CDVA after surgery due to advanced glaucomatous neuropathy. Antiglaucoma surgery was further performed because of poor glaucoma control. Twelve months after surgery, the capsular bag–IOL complex was well centered, and the IOP was 16 mm Hg with 1 antiglaucoma topical drug.


The choice of the best surgical technique for the treatment of subluxated lens depends on the extent of zonular dialysis. With a zonular defect of fewer than 90 degrees (3 clock hours), phacoemulsification with in-the-bag IOL implantation can be performed. When the zonular tear is larger than 90 degrees, all tractional surgical maneuvers are difficult and increase the chance of further zonular disinsertion.5 Even in cases of severe zonular dialysis, the capsular bag can still be used for IOL fixation provided using a Cionni ring or Ahmed segments and suturing it to the scleral wall.6 For severe or progressive cases of zonular deficiency, a modified design of the CTR is widely used; however, the problem with possibility of decentration still exists. 2,7–10

To stabilize the lens intraoperatively, during phacoemulsification, hook-shaped iris-capsular retractors are widely used.1,11 Initially, iris retractors were used to achieve intraoperative mydriasis. Furthermore, a change in design and adaptation of the technique made it possible to use them to stabilize the capsular bag in the zone of a defect in the zonular fibers.12 The modern designs of these devices make it possible to securely fix the capsular bag, ensuring the safety and predictability of the phacoemulsification stages.13

In 2002, Ahmed designed the CTS (Morcher), intended for use in cases of severe zonular compromise. It is capable of providing intraoperative capsular stability and postoperative centration of the capsular bag and IOL. The CTS is a partial open ring, poly(methyl methacrylate) segment (120 degrees) with an anteriorly placed eyelet that allows suture fixation to the sclera.14 Nonetheless, this technique involves using sutures, which is associated with suture-related complications.

There are some advantages of avoiding using sutures for fixating devices. In a 2003 study, Cionni et al. reported that in 90 eyes with congenital loss of zonular support, breakage of the 10-0 polypropylene suture occurred in 10.0% of eyes, with late decentration occurring in 6.7% of eyes after the placement of a modified CTR.10 The need to put tension on the suture to effect the capsular bag centration increases the risk for eventual suture lysis.15

In 2006, other authors reported the use of a T-shaped capsule hook (capsule expander [CE]) to suspend and stabilize the lens capsule and facilitate safe phacoemulsification.12 In turn, the modified CE is a modified form of the CE that was designed to be used for permanent repositioning and scleral fixation of subluxated and phacodonesis lens capsules.15 Similarly, as the modified CTR and CTS, the modified CE was fixated to the sclera with the use of sutures.

In 2009, Assia et al. described the anchor device to manage moderate to severe lens subluxation provided long-term centration and stabilization of the preserved capsular bag and enabled IOL implantation in the posterior chamber. Initial limited clinical experience was encouraging.16 This method also required the use of sutures.

Jacob et al. described the glued capsular hook technique, which anchors the capsular bag to the sclera without the use of sutures. In combination with a standard CTR, the technique provided both vertical and horizontal stability and allowed sutureless fibrin glue–assisted transscleral fixation of the capsular bag.17

Karadag et al. recommended a scleral fixation technique of the capsular bag and IOL using iris hooks in an eye with intraoperative zonular dialysis for 6 clock hours that dislocated on the first postoperative day despite intraoperative centralization of the IOL bag with the CTR. The tips of the iris hooks were implanted into the scleral tunnels. Each of them was fixed with a 10.0 nylon suture to the scleral bed. The scleral flaps and conjunctiva were sutured.18 Similarly, as Karadag, we preferred to use iris retractors more than capsular hooks due to their smaller and narrower hook part.

Canabrava et al. used a suture-free technique for stabilizing the capsular bag in eyes with zonular dialysis of greater than 120 degrees undergoing cataract surgery. The procedure was performed using a CTS or M-CTR and a flanged IOL haptic to fix the capsular bag to the sclera without the need for a suture. The haptics were cauterized to produce a flange that keeps the IOL in place without the need for sutures or glue.19 However, M-CTR implantation can be difficult in eyes with a small capsulorhexis, extensive subluxation of the lens, or smaller than normal capsular bags.20 When the technique we propose in this study is compared to the method described by Canabrava, it seems to be easier and requires fewer maneuvers.

Our study was directed to evaluate the security and efficiency of the procedure described above in eyes without appropriate capsular support to sustain the posterior chamber IOL. In this study, for management of the subluxated cataract with profound zonular dialysis, we used a combined approach of the CTR for internal support and iris retractors for permanent capsulorhexis fixation for external support. Till now, iris retractors were used for temporary stabilization of the capsular bag during surgery.21–23 We propose here permanent placement of iris retractors accompanied by CTR insertion for long-term stabilization of the capsular bag–IOL complex. The technique we describe extends the ideas of the Yamane technique for sutureless intrascleral IOL fixation with the use of needles to dock and externalize the haptics, which protruding ends are finally cauterized, fashioning flanges that prevent the haptics from slipping back into the eye through the tunnels.3 Similarly, the ends of iris retractors are externalized and cauterized in the procedure we propose.

Using a CTR and iris retractors together provides adequate support for a capsular bag–IOL complex. Although the CTR reduces asymmetric capsular forces and prevents severe contraction of the posterior capsule after surgery, iris retractors enable to centralize capsular bag and give support in the area of damaged zonular apparatus. The technique described here offers numerous advantages. Used devices provided excellent support and centration of the capsular bag and IOL intraoperatively and postoperatively. The sutureless technique of scleral fixation of the capsular bag–IOL complex attempts to elude suture-related complications. The procedure is safe and avoids difficult and time-consuming manipulations in the anterior segment of the eye, such as guiding the needle of the scleral suture for fixating intraocular devices. No need to create flaps or use sutures or glue in this approach makes the procedure faster, easier to perform, and minimalizes ocular trauma. The cost of the procedure remains low; the same hooks are used for supporting capsular bag during phacoemulsification and providing permanent stabilization of the capsular bag–IOL complex. The operation is significantly shortened; we can perform it under topical anesthesia, and therefore, it does not differ significantly from a standard procedure. Postoperatively, the absence of the exposed suture knot on the sclera prevents complications such as scleral erosion or scleral atrophy. Moreover, there is no problem with suture degradation and subsequent IOL misalignment or dislocation over time. In this case series, postoperatively, each patient achieved proper capsular bag and IOL centration. In addition, there was a complete absence of iridodonesis and pseudophacodonesis during the follow-up, confirming the increased level of stability. During the observation, we did not notice any case of IOL decentration, and capsular bag maintained its shape and did not collapse.

There were no complications related to performed surgery, despite of unstable glaucoma, which was considered to be more linked to prior trauma than applied surgical treatment. None of the eyes had surgery-related conditions, which clinically altered visual outcomes. On the other hand, further studies with a larger group of patients and longer follow-up are required to assess the long-term safety and stability and to ensure whether none unpredictable complications occur.


  • In case of severe zonular dialysis, the capsular bag can still be used for IOL fixation using various devices and suturing them to the scleral wall.
  • The use of sutures may be linked to late decentration of the IOL because of lysis or breakage of material they are made of.


  • In this sutureless technique, the normal CTR is used together with cauterized iris retractors, which stabilize the lens capsule at the location of zonular weakness. The new method provides a predictable course of the surgical procedure, with a low risk for postoperative capsular bag–IOL complex decentration. No need to create flaps and using sutures or glue in this approach makes the procedure faster, easier to perform, and minimalizes ocular trauma.


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