The optimal approach for secondary intraocular lens (IOL) placement in patients lacking capsular support remains controversial. Standard surgical procedures used in the management of these cases include anterior chamber IOLs, scleral-fixated posterior chamber IOLs with or without suture fixation, and iris-fixated posterior chamber IOLs. A review conducted by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee evaluated these techniques.1 Although each method was shown to be safe and effective, the authors did not find significant evidence to recommend one approach over the others. However, this review was performed nearly 15 years ago and did not evaluate many of the modern surgical approaches to this problem.
Limitations of the current approaches are well recognized. Anterior chamber IOL placement may lead to cystoid macular edema, corneal decompensation, and angle compromise.2–4 Sutured scleral- and iris-fixated posterior chamber IOLs may develop suture rupture, and sutureless scleral fixation may result in haptic damage or dislocation from the intrascleral tunnel. These complications may lead to subsequent lens subluxation.5,6 We offer a technique that allows for sutureless intrascleral fixation of a 3-piece IOL using a 30-gauge needle and chandelier lighting to mitigate these liabilities.
We have modified the procedure initially described by Yamane et al7 to take advantage of the unique approach of the posterior segment surgeon. This minimally invasive surgery ensures scleral fixation of a posterior chamber IOL in the ciliary sulcus through a transconjunctival approach. The modified approach has two main advantages. First, it allows one to avoid the presence of the uncontrolled needle used for haptic stabilization in the original procedure. Second, it allows for more reliable and reproducible placement of the second haptic. The procedure can be used for the rescue of a dislocated 3-piece IOL or the implantation of a secondary IOL.
A standard 3-port, 25-gauge vitrectomy is used, and a complete vitrectomy with shaving of the vitreous base is performed (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/A760). The midline is identified with marks made on the conjunctiva at the 3-o'clock and 9-o'clock positions, 2 mm from the limbus. A second set of marks is then made 3-mm inferior or superior to the first mark, to identify the future path of the intrascleral tunnel nasally and temporally. A 3.2-mm clear corneal incision is then made at the 12-o'clock position, and a paracentesis wound is created adjacent to the trochar, that is, contralateral to the side of the first needle pass. An ultra thin-walled 30-gauge needle (TSK, Japan) is then bent at the hub to approximately 70° and placed on a tuberculin syringe. A 2.5-mm to 3.0-mm intrascleral tunnel is made at the previously marked position, 2 mm from the limbus, and the sulcus is entered (Figure 1). The leading haptic of a 3-piece IOL is inserted into the inferior angle. When a new IOL is to be used, we prefer to use the Aaren Scientific EC-3 because the haptics are particularly durable. A 25-gauge forceps is placed through the paracentesis and used to engage the leading haptic and dock it into the 30-gauge needle. The leading haptic is guided through the intrascleral tunnel by the 30-gauge needle and externalized. The tip of the haptic is thermally deformed using a low-temperature diathermy to create a bulb or “nail head” shape (Figure 2).
The trailing haptic and optic are then placed into the posterior segment. A second 2.5-mm to 3.0-mm intrascleral tunnel is created with a second 30-gauge needle, 180° from the first tunnel. A chandelier is placed through the trochar on the ipsilateral side as the second tunnel. The 25-gauge forceps is then placed through the contralateral trochar and used to guide the trailing haptic into the second 30-gauge needle (Figure 3) with lighting provided by the chandelier. The needle and haptic are then externalized, and the tip of the haptic is thermally deformed. The haptic tips are pushed back so that the nail head is engaged with the end of the tunnel to insure IOL centration.
To date, we have performed this procedure in three eyes that have had at least 3 months of follow-up. Significant short-term complications have not been seen in any of these eyes. There are several key advantages to this modified approach compared with the original description from Yamane et al.7 In the original procedure, the 30-gauge needle is left unattended after the first haptic is placed. This needle is uncontrolled and has the potential to cause unintended damage during the placement of the second haptic. In addition, the first haptic may slip from the docked position in the 30-gauge needle during this process. Removing the needle and thermally deforming the first haptic before attending to the second haptic avoids these issues. The most challenging and unreliable portion of the original procedure is the placement of the second haptic in the anterior segment. This can be very difficult in certain eyes where the hand positions and angles required to place the second haptic into the 30-gauge needle may be extremely challenging. Our modified approach to the placement of the second haptic attends to this surgical complexity, by docking the second haptic in the posterior segment with chandelier lighting. The posterior segment allows for more freedom of movement for the surgical approach compared with the restrictive plane of the anterior segment and allows the surgeon many more options for the angles of attack used. This flexibility greatly reduces the technical complexity required to place the second haptic. These modifications allow for a reliable and reproducible operation that is well tolerated in the short term in this limited series.
1. Wagner M, Cox T, Ariyasu R, et al. Intraocular lens implantation in absence of capsular support. Ophthalmology 2003;110:840–859.
2. Auffarth GU, Wesendahl TA, Brown SJ, Apple DJ. Are there acceptable anterior chamber intraocular lenses for clinical use in the 1990s? An analysis of 4104 explanted anterior chamber intraocular lenses. Ophthalmology 1994;101:1913–1922.
3. Ellerton CR, Rattigan SM, Chapman FM, et al. Secondary implantation of open-loop, flexible, anterior chamber intraocular lenses. J Cataract Refract Surg 1996;22:951–954.
4. Hennig A, Evans JR, Pradhan D, et al. Randomised controlled trial of anterior-chamber intraocular lenses. Lancet 1997;349:1129–1133.
5. Asadi R, Kheirkhah A. Long-term results of scleral fixation of posterior chamber intraocular lenses in children. Ophthalmology 2008;115:67–72.e1.
6. Yen KG, Reddy AK, Weikert MP, et al. Iris-fixated posterior chamber intraocular lenses in children. Am J Ophthalmol 2009;147:121–126.
7. Yamane S, Inoue M, Arakawa A, Kadonosono K. Sutureless
27-gauge needle–guided intrascleral intraocular lens implantation with lamellar scleral dissection. Ophthalmology 2014;121:61–66.
intraocular lens rescue; intrascleral tunnel; scleral fixated; secondary intraocular lens; sutureless
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