Two surgeons (M.K. and T.K.) performed the silicone microtube–assisted scleral fixation of a posterior chamber IOL in six eyes of six patients. The patient characteristics are shown in Table 1. The mean patient age at the time of surgery was 65.2 ± 16.8 years (range, 41–88 years). Two eyes were aphakic, one had a dislocated posterior chamber IOL in the vitreous cavity, two had subluxated crystalline lenses, and one had IOL whitening and glistenings. The mean follow-up time was 3.3 ± 2.7 months (range, 1–8 months).
Standard ophthalmologic examinations were performed, i.e., measurements of the best-corrected visual acuity and intraocular pressure, slit-lamp examination, and indirect fundus examination preoperatively and postoperatively. The mean preoperative best-corrected visual acuity was 0.96 logarithm of the minimum angle of resolution (20/182) that improved to 0.62 logarithm of the minimum angle of resolution (20/43) at 1 month. The mean postoperative refraction was -0.06 ± 0.4 diopter, which did not differ markedly (P = 0.53) from the predicted value. Postoperative hypotony and intraocular pressure elevations were defined, respectively, as intraocular pressures below 6 mmHg and higher than 25 mmHg.
One intraoperative complication occurred in which the silicone microtube broke during withdrawal in one (16.7%) eye, and the haptic was drawn through with a 25-gauge forceps.
The average surgical time of the six cases was 158 minutes (range, 133–205 minutes). The average time spent solely on this procedure was 99 minutes (range, 78–137 minutes).
The postoperative complications included transient ocular hypotension in one (16.7%) eye, vitreous hemorrhage in two (33.3%) eyes, and choroidal detachment in one (16.7%) eye, all of which resolved without treatment in a few days. One eye that underwent a simultaneous trabeculotomy presented with hypotension and a vitreous hemorrhage, and it was difficult to know which surgery was responsible. No other severe complications such as retinal detachment, endophthalmitis, or IOL dislocation occurred during the follow-up period.
The benefit of this novel technique of IOL scleral fixation is minimal or no intraocular IOL manipulation, the most difficult part of this surgery, resulting in greater ease and safety. The only intraocular manipulation required is insertion of the IOL into the chamber, which represents the same or fewer procedures as during an uncomplicated IOL implantation in a treatment-naïve cataract case.
Any previous methods, such as the forceps-guided, sleeve-guided, or needle-guided techniques,1–15 require at least holding the haptic with forceps in the chamber, which requires a clear cornea, a well-dilated pupil, and a certain level of surgical skill. Using the current technique, an IOL was implanted smoothly in an eye with only 4 mm of pupillary dilation. Furthermore, manipulating forceps through a corneal side port exerts stress on the cornea, especially when gasping and manipulating the second haptic.4,13,15
The current technique reduced the difficulty of drawing out the haptics from the posterior chamber to the outside of the eye through the sclera. Pulling the silicone microtube through the sclerotomy site facilitated easy and simple haptic manipulation once the IOL that was connected to the silicone microtube was inserted into the chamber. The silicone microtube is very thin and sufficiently soft and, therefore, is less invasive to the eye, and there is less stress on the IOL and the haptics. Thus, this technique reduces the risk of haptic breakage or ocular tissue damage.
Hypotony and bleeding related to existing scleral fixation surgeries were postoperative complications that might occur due to ciliary detachment or wound leakage. Inserting or manipulating vitreous forceps or specially designed 25- or 27-gauge forceps through a diagonally constructed sclerotomy, in contrast to a perpendicular sclerotomy, without a trocar poses some risk of ciliary detachment.1–8 In addition, because the diameters of the 25- or 27-gauge instruments are larger than that of the haptics, the vitreous fluid might leak after vitreous shaving if the sclerotomy site is not well sutured.1 The current technique using a silicone microtube with a 0.2-mm external diameter, which is only 0.05 mm wider than the haptic diameter, reduced the possible risks of ciliary detachment and leakage as well as the double-needle technique in which a 30-gauge sharp needle is used.13 The risk of ciliary detachment also was reduced by introducing the silicone microtube from the posterior chamber to the sclera through a 9 to 0 polypropylene thread, in an ab-interno manner.
The hypotony and choroidal detachment occurred in the same patient. A capsular rupture during a previous cataract surgery resulted in dislocation and phacolysis. Fortunately, no leak was observed after our surgery, and therefore, we could not determine whether the procedure under discussion or the original inflammation caused the postoperative hypotony and choroidal detachment. We will address these complications in subsequent studies and consider suturing of the scleral slit if the complications are frequent occurrences. Regarding the two cases of vitreous hemorrhage, one seemed to result from administration of oral warfarin, and the other cause was unknown.
This technique also has the additional following advantages. The risk of the IOL dropping into the vitreous cavity is eliminated when it is inserted into the chamber because the haptics are already connected to the tubes; fewer special skills are required because the procedures are similar to the IOL-suturing technique with which many surgeons are familiar; a scleral flap and suture are not required because the haptics are introduced easily into the sclerotomy and scleral tunnel through the silicone microtube; and the procedure is cost effective because the silicone microtubes costs only approximately $1.50/surgery.
However, improvements are needed in the insertion of the haptics into the silicone microtube, which requires fine forceps manipulations, although this step is performed outside the eye. Because the diameter of a haptic of a typical three-piece IOL is approximately 0.15 mm and the inner diameter of the silicone microtube is 0.1 mm, the tube should be expanded slightly; this is challenging because the tube is very thin and difficult to handle. One intraoperative complication that we experienced in an eye in the current series was tube breakage, possibly due to a minute tear that developed during the connection of the tube to the haptic. A special tool to facilitate this should be developed. We currently pinch a haptic and a microtube 0.5 mm from the end with suturing forceps (Geuder, Heidelberg, Germany) in each hand, insert only the haptic tip, and stroke the tube toward the haptic root. Only a 1-mm cover provided sufficient adhesion, and the tube did not detach from the haptic when drawn out through the sclerotomy if it was made with a 30-gauge needle or a thicker needle or blade. Unlinking of the tube and haptic occurred when the sclerotomy was made with a 9 to 0 polypropylene straight needle and not with a 30-gauge needle.
However, our procedure required more time compared with previously reported methods. We believe that the time required to perform the procedure will become shorter as the number of cases increases because this procedure is still in the initial exploratory trial-and-error stage. We should evaluate the surgical time again in the future when the surgeons become more adept at performing it.
This novel technique of silicone microtube–assisted scleral fixation of a posterior chamber IOL is easier and safer than the previous methods for implanting an IOL in cases with IOL dislocation, crystalline lens subluxation, or aphakic eyes without an adequate residual lens capsule. A novice surgeon can perform this technique because it does not require IOL manipulation intraocularly. A longer follow-up analysis of more cases is required to confirm the anatomical and functional advantages of this technique.
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posterior chamber intraocular lens; scleral fixation; silicone microtube
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