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 Table of Contents  
Year : 2018  |  Volume : 56  |  Issue : 4  |  Page : 237-243

Scleral-fixated intraocular lenses

1 Vitreoretinal Services, Eye and Retina Speciality Hospital, Tirupur, Tamil Nadu, India
2 Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
3 Vitreoretinal Services, Aravind Eye Hospital, Chennai, Tamil Nadu, India

Date of Web Publication19-Feb-2019

Correspondence Address:
Dr. V G Madanagopalan
Eye and Retina Speciality Hospital, No. 35, Fabrication Road, Bridgeway Colony, Tirupur - 641 607, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_99_18

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Scleral-fixated intraocular lenses (SFIOLs) are important tools for an ophthalmologist when dealing with the eyes that have inadequate capsular support. Since the time of its introduction, SFIOLs and techniques for their implantation have seen many innovations. Initially, sutured SFIOLs were widely performed. In the last two decades, sutureless SFIOLs are gaining popularity. Both these methods and the different surgical techniques to perform them offer unique advantages to the surgeon. Therefore, careful consideration is to be given to the choice of technique and steps to be employed for a particular eye. In this article, we aim to provide an overview of the commonly used techniques in SFIOL surgery and provide certain surgical tips that may help the surgeon in the operating room.

Keywords: Cataract surgery, scleral-fixated intraocular lenses, techniques

How to cite this article:
Madanagopalan V G, Sen P, Baskaran P. Scleral-fixated intraocular lenses. TNOA J Ophthalmic Sci Res 2018;56:237-43

How to cite this URL:
Madanagopalan V G, Sen P, Baskaran P. Scleral-fixated intraocular lenses. TNOA J Ophthalmic Sci Res [serial online] 2018 [cited 2022 Oct 6];56:237-43. Available from: https://www.tnoajosr.com/text.asp?2018/56/4/237/252506

  Introduction Top

Cataract surgery with implantation of an intraocular lens (IOL) within the capsular bag, although ideal, does not always happen. This eventuality is a result of varied preoperative and intraoperative events. In these situations, anterior chamber IOLs (PCIOLs), iris claw lenses, and scleral-fixated IOLs (SFIOL) are the options available to the surgeon. With respect to refractive rehabilitation, placing an IOL as close as possible to the actual location of the capsular bag is of paramount importance. SFIOLs provide the surgeon with this advantage, as the position of the IOL closely approximates the normal anatomic position that would have been occupied by an IOL placed within the capsular bag in an uncomplicated cataract surgery. With an SFIOL, pupillary dilation is unhindered. Moreover, the occurrence of untoward events such as corneal endothelial decompensation, pupillary block, angle closure, and ocular inflammation is lesser.

In this article, we delve into the subject of fixing an IOL to the sclera. More specifically, we aim to explore the relationship between the SFIOL haptics and the sclera when the numerous techniques described for SFIOL placement are performed. In this manner, we elaborate on the surgical techniques that help the surgeon achieve stable IOL fixation with minimum time and tissue handling.

Principles of scleral-fixated intraocular lenses surgery

As early as 1993, Sundmacher and Althaus put forward three rules that have to be followed to obtain an anatomically correct position for the transsclerally fixed IOL:

  1. The suture should penetrate only the sulcus and not the adjacent iris or ciliary body
  2. The loops of the IOL haptic must be primarily directed into the ciliary sulcus
  3. The IOL chosen must be so designed that it suits the anatomic needs of the procedure and provides a safe distance between the lens and the iris.[1]

When fixing the SFIOL to the sclera, three important considerations present themselves. First, are the haptics remaining within the eye or are they being externalized? Second, is the fixation intended to be achieved using sutures or in a sutureless manner? Third, is the surgeon using a single piece or three-piece IOL? Interestingly, the combinations choose themselves. If the haptics has to remain within the eye, they have to be fixed with sutures and more often than not, a single piece IOL would be used. On the other hand, if the haptics is being externalized, sutureless fixation of a three-piece IOL is usually done.

The availability of eyelets in the IOL haptics has improved the stability of SFIOLs. Models such as CZ70BD (Alcon, Fort Worth, TX), Akreos AO60 (Bausch and Lomb, Rochester, NY), SC6530 (Aurolab, Madurai, India), and SSF6521 (Excelens, Chennai, India) are in common use today. Although 10-0 polypropylene sutures are preferred for fixing the IOL, there are few concerns with regard to its long-term stability.[2] Hence, surgeons these days use 9-0 polypropylene and 9-0 polytetrafluoroethylene (Gore Tex) sutures as well.[3],[4] The sutureless variants of SFIOLs are made of three pieces and the optic–haptic junction is resistant to handling. Models commonly used are Tecnis ZA9003 (Abbott Medical Optics, Santa Ana, CA, USA), Sensar AR40e (Abbott Medical Optics, Santa Ana, CA, USA), B3602 (Aurolab, Madurai, India), and MMC6522 (Excelens, Chennai, India). It has been shown that sutured and sutureless techniques are comparable in terms of anatomical and visual outcomes.[5]

In today's practice, an SFIOL is almost always fixed to the sclera in the region of the ciliary sulcus.[6] Endoscopes have also been used to directly visualize the ciliary sulcus before precise fixation of the SFIOL.[7] Besides the sulcus, SFIOLs have been fixed in locations such as the pars plana and outcomes have been comparable to SFIOLs fixed to the ciliary sulcus.[8],[9] However, these alternate locations have not found much favor with surgeons, and the ciliary sulcus continues to hold its charm as the preferred site for scleral fixation of an IOL. While many techniques and different modifications have been described in literature, this article attempts to present the most commonly employed techniques for SFIOL to the reader.

Surgical considerations

Occasionally, an SFIOL would be fixed at the time primary surgery. However, on most occasions, the vitreoretinal surgeon embarks on placing an SFIOL in an eye that has undergone an eventful antecedent surgical procedure or has sustained ocular trauma. In case the primary surgery was performed more than 3 months ago, it is expected that scleral and corneal wounds be well healed to allow a stable biometry. Moreover, a quiet intraoperative and postoperative course can be expected. Importance must be given to limbal architecture and integrity of scleral and corneal wounds. These factors decide the extent of peritomy, location and type of scleral incisions, and the eventual orientation of the SFIOL. In the presence of scarred and thin conjunctival tissue, cotton-tipped applicators can be used in place of forceps to stabilize the globe while creating scleral tunnels.

Creation of scleral tunnels after placing the infusion line or making paracentesis wounds could lead to persistent leaks and globe hypotony. Therefore, creating intrascleral flaps before creating transscleral openings helps to maintain globe integrity that is necessary to fashion good scleral flaps. Poor sclerocorneal or corneal wound architecture can create corneal folds as the IOL is being inserted into the eye. This impedes clear visualization of the haptic that has to be grasped. Three-port pars plana vitrectomy is completed before implantation of an SFIOL is attempted. Clearance of pars plana membranes, capsular and cataract remnants, and thorough inspection of the peripheral retina is essential.

Any instrument passed through the sclerotomy is directed at the center of the eye and then brought anteriorly to the pupillary plane. It is common to have ciliary body damage or iridodialysis if the forceps are advanced horizontally from the sclerotomy. Iatrogenic ocular trauma occurs if entry with a needle is made in a hypotonous globe.

Symmetry in haptic exteriorization (180° apart) prevents problems such as IOL tilt and optic capture. When grasping the leading haptic, it is important that the forceps grasps the haptic at its tip lest there is deformation of the haptic as it is being exteriorized. The use of retroillumination during this maneuver helps the surgeon visualize the haptic and forceps better. In case the haptic tip breaks and there is inadequate length of the haptic within the scleral tunnel, the surgeon may place a retaining 10-0 nylon suture with partial thickness scleral bites in shoelace pattern to stabilize the haptic.

In case of sutured SFIOLs, to prevent entanglement of the sutures, adequate care is necessary if the procedure is being carried out simultaneously on both sides (3 and 9 'o' clock positions). To have a clear uncluttered field, the surgeon can complete the suture passage on one side (3 'o' clock meridian) before commencing the procedure on the other side (9 'o' clock meridian). Good peritomy closure is essential. Primary closure is often adequate. Occasionally, conjunctival flaps or grafts may be required to cover the haptic well.

If the dislocated IOL is a single-piece polymethyl methacrylate IOL, it requires removal and replacement by an SFIOL of appropriate design. If the dislocated or subluxated IOL is an SFIOL (with eyelets in its haptic), it may be utilized as such for refixation using sutures. After stabilizing the IOL within the eye with the help of a forceps, the straight needle of a 10-0 polypropylene suture is threaded through the eyelet. In this manner, both haptics can be refixed to the sclera.

In case a three-piece IOL has dislocated, a “cow hitch” or “lasso” knot can be used to convert these IOLs to SFIOLs.[10],[11] After vitrectomy and clearance of all vitreous remnants around the haptic [Figure 1]a, sutures can be deftly passed to create snares or loops that eventually capture the haptics. Nakashizuka et al. described the use of 10-0 polypropylene suture thrown into a “cow-hitch” knot that tightens when the long end is pulled. An intraocular forceps is used to grasp the neck of the cow-hitch loop. The loop is then used to “lasso” the haptic which is pulled forward toward the sclera as the “lasso” tightens around the haptic and ensures that haptic slippage does not occur [Figure 1]b.[10] A dislocated three-piece IOL can easily be converted into a sutureless SFIOL as well. After complete removal of vitreous surrounding the IOL, the tip of its haptic is held with and intraocular forceps and the haptic is exteriorized [arrow, [Figure 1]c]. The haptic can then be buried in a partial thickness scleral tunnel.
Figure 1: Complete vitrectomy is performed and all vitreous strands and capsular remnants around the intraocular lens haptic are cleared (a). For the sutured technique, an intraocular forceps is used to carry a “lasso” knot (inset, b) into the vitreous cavity and snare the intraocular lens haptic (b). For the sutureless technique, intraocular forceps is used to grasp the haptic tip and externalize the haptic (arrow, 1c)

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In eyes with traumatic aphakia where the lens has been surgically removed in a preceding surgery, it is prudent to wait for complete resolution of inflammation and hemorrhage within the eye and ascertain the status of tissues in the posterior segment before planning refractive rehabilitation with an SFIOL. If there is extensive loss of iris tissue, an aniridia SFIOL, that has a large optic with peripheral opacification and a central clear area, has to be used.

Surgical techniques – sutured scleral-fixated intraocular lenses

In 1986, a surgical technique to describe suturing of a posterior chamber IOL to the sclera at the region of the sulcus after intracapsular cataract extraction was described by Malbran et al.[12] A 10-0 polypropylene suture was used to fix the SFIOL. Suture loops were introduced into the eye in the horizontal meridian and were externalized through a large corneal wound. The IOL was then secured to these suture loops before being internalized. Despite this description of ab externo method (suture pass from outside of the eye to inside of the eye), many surgeons continued to use the ab interno method (suture pass from inside the eye to outside).[13] This technique was essentially a blind pass and had the propensity to cause retinal complications. The final IOL position could not be predicted as well. The idea of using scleral flaps to cover the sutures and the use of a hollow bore 28-gauge needle to “dock” the needle carrying the 10-0 polypropylene suture were introduced by Lewis.[14] Improving upon the flap technique, Hoffman et al. created a scleral pocket to fix the anchoring knots.[15] The advantages offered were easier dissection and greater surface area for suture placement.

In two-point fixation, the IOL with a single eyelet in each haptic is fixed at two diametrically opposite points in the sclera. The “rail-road” technique that entails passing the suture needle through a 26-gauge needle within the eye is commonly used [Figure 2]. In the true sense, a two-point fixation has taken place when the suture has passed through the full thickness of the sclera at two points only. An IOL that is fixed at two diametrically opposite points can be subjected to a rotation or torque around an axis passing through these two points, and hence, higher-order aberrations are seen. An IOL with just two eyelets can still have a four-point fixation if the suture is passed through full thickness of the sclera at four separate points [Figure 3].
Figure 2: The “railroad” technique is used to relay the straight needle of a 10-0 polypropylene suture (arrow, a). The central part of the suture is hooked and pulled out of the eye (b). After the loop is cut, the two ends are tied to eyelets in the scleral-fixated intraocular lenses (c)

Click here to view
Figure 3: The “railroad” technique is used to retrieve the suture from a superior wound (arrow, a and b). After the eyelet is threaded, the suture is passed out through a second scleral opening (arrow, c and d). The securing sutures thus pass through the sclera at four points (e and f)

Click here to view

The “in-and-out technique” for stabilizing an IOL that has been fixed in two points has been put forward by Choi and Han.[16] They employ three knots on each haptic (one on the haptic, one additional knot on the internal surface of the sclera, and one external fixation knot). The additional internal knot is placed and acts as a check valve against inner scleral wall. Theoretically, the use of four points to fix an IOL prevents the rotational instability. Four-point fixation that is employed in IOLs with four eyelets (Akreos, AO60) has the theoretical advantage of greater IOL stability.[17]

While these techniques offered refractive solutions in aphakic eyes, a posteriorly dislocated IOL without eyelets had to be removed. Mensiz et al. devised a surgical technique where, after vitrectomy, the haptics of IOL is pulled out of the eye through diametrically opposite sclerotomies. Thereafter, the tip of the haptic was heated to form a knob to avoid suture slippage. 10-0 polypropylene sutures were tied to the haptic using a sailor knot. The haptic was pushed back intraocularly and outstaying part of sutures was tied on the sclera in a conventional fashion.[18] Kokame et al. reported the benefits of stabilizing the posteriorly dislocated PCIOL in the anterior chamber before gently withdrawing each haptic through a clear corneal incision for suture knot placement. The IOL is then reinserted into the eye and a scleral fixation suture is placed 1.5 mm posterior to the limbus under a scleral flap.[19] In a similar manner, if adequate capsular support is present, the superior haptic alone can be exteriorized, tied to a suture, and the suture fixed in an ab interno manner to the meridian opposite to the one with adequate capsular support.[20] Regular foldable single-piece IOLs have also been fixed to the sclera.[21] A looped 10-0 polypropylene (PC-9 Alcon) suture is threaded into the IOL cartridge using a microforceps. The suture loop is retrieved from within the IOL cartridge (in the space where the IOL is to be loaded) and tied to the IOL haptic [Figure 4]. Thereafter, the IOL is loaded onto the cartridge and thence into the injector in the routine fashion. To fix this IOL to the sclera, the suture needle is passed into the eye through the clear corneal incision and out of the eye through the sclera in an ab interno manner (inside to outside) to emerge from the eye 1–1.5 mm behind the limbus at 3 'o' clock meridian. The leading haptic, after injection into the eye, is thus guided to the 3 'o' clock meridian and fixed to the sclera. The trailing haptic is intentionally kept extraocular to enable tying of a second suture. This haptic is then fixed to the sclera at 9 'o' clock meridian in the same ab interno method.
Figure 4: A looped 10-0 polypropylene suture is threaded through the intraocular lens cartridge. The leading haptic is then anchored to the looped end of this suture. This foldable intraocular lens is later loaded onto the cartridge and injected into the eye

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Before the introduction of eyelets on the haptic, the problem of knot slippage and SFIOL dislocation was common. However, the latest IOL models for sutured SFIOLs have an eyelet, and therefore, slippage is eliminated. When sutured SFIOL surgery is planned, these models are used no matter what technique is chosen for securing the IOL. In fact, if such an IOL is dislocated a long time after primary surgery, there exists the option of threading the needle of a suture through the eyelet, while the IOL is stabilized and held in position by an intraocular forceps.[22] In this simplified ab externo method, the IOL is retained within the eye throughout the procedure. A suture knot to fix the IOL to the sclera could serve as a nidus for infection. The knot could also erode through the conjunctiva and get exposed. To prevent these untoward effects, clinicians have proposed the avoidance of knots altogether and instead advocated the use of multiple zigzag passes of suture through partial thickness of the sclera (Z suture technique).[23],[24] They showed that five passes are sufficient to reliably fix a suture that can resist maximal tractive forces.

Surgical techniques – sutureless scleral-fixated intraocular lenses

One of the earliest descriptions of sutureless scleral fixation of the IOL, albeit, at the pars plana, by utilizing transscleral passage of IOL haptics was by Maggi and Maggi.[25] In 2007, Gabor and Pavlidis described sutureless SFIOL fixation with the exteriorization of haptics of a three-piece IOL.[26] A 23-gauge trocar or needle can be used to create partial thickness scleral tunnels parallel to the limbus [Figure 5]a and [Figure 5]b. These scleral pockets are used to house the exteriorized haptics. This technique provided for shorter surgical times and good IOL centration. Agarwal et al. used partial thickness scleral flaps [Figure 5]c and [Figure 5]d and biological glue to fix the three-piece SFIOL.[27] Placing the IOL haptics beneath scleral flaps helped in preventing pseudophacodonesis and exposure of haptics. In both these techniques, exteriorization of the haptics is performed with microforceps [Figure 6].
Figure 5: To create the partial thickness scleral pockets parallel to the limbus, 23-gauge trocars (a) or 23- or 26-gauge needles (b) may be used. Partial thickness scleral flaps are created using a crescent blade (c). The lateral ends can be opened in a controlled manner by the use of Westcott scissors (d)

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Figure 6: As the leading haptic is introduced into the eye, its tip is grasped with an intraocular forceps (a and b). Intraocular exchange with “handshake technique” is performed by passing the trailing haptic from one forceps to another before exteriorization (c and d)

Click here to view

To make the haptic placement within the scleral tunnel easier, Ohta et al. suggested that a Y-shaped partial thickness scleral incision be created in the scleral bed before proceeding with flap and tunnel creation [Figure 7].[28] With the use of 25-gauge trocar cannulas, Abbey et al. improvised on the technique described by Gabor. Since the cannulas were retained, the surgery could be completed without the need for conjunctival peritomies.[29] When compared to many sutured techniques that offer two-point fixation, all sutureless fixations where the haptic is tucked into the scleral pockets are essentially four-point fixations. Moving forward in this direction, Yamane et al. described a transconjunctival, flapless, glueless, and sutureless technique for SFIOL.[30] They exteriorize the haptics using thin-walled 30-gauge needles and proceed to cauterize the distal part of the externalized haptics [Figure 8]. Careful application of heat shortens the length of the haptic outside the eye and also creates a bulb-shaped flange whose diameter is larger than the thickness of the haptic. This flange is then pushed back so that it lodges within the substance of the sclera.
Figure 7: A “Y”-shaped scleral incision is made (a). After raising a partial thickness scleral flap as shown, a trocar is used to create a tunnel under the scleral flap (arrow, b). The intraocular lens haptic is placed under this flap and within the scleral tunnel (c)

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Figure 8: Application of heat from a diathermy tip creates a bulb-shaped flange at the tip of the exteriorized haptic (a). Clinical picture shows the flange created at the tip of the haptic (b)

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Baskaran et al. put forward the extraocular needle-guided haptic insertion technique that eliminates intraocular maneuvers and the “handshake technique” that presents a steep learning curve.[31] They use two bent 26-gauge needles to thread the haptics and externalize them [Figure 9]. This technique is completely extraocular, and thereby, difficulties associated with haptic exchange within the eye, small pupils, or corneal opacities are eliminated. They have also described the use of silicone stoppers that help to stabilize and retain the leading haptic that has been exteriorized as the second haptic is being manipulated. Adopting the same technique, Khatri et al. improvised by using a hollow bore visco cannula to deliver the tip of the sharp 26-gauge needle outside the eye.[32] This modification, they claim, reduces iatrogenic ocular trauma.
Figure 9: The leading haptic is threaded into a 26-gauge bent needle outside the eye (arrow, a and b). The trailing haptic is also threaded into the needle in a similar manner as the leading haptic is held in place by the silicone stopper (arrow, c and d)

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Soft pliable catheters have been used as guides for SFIOL haptics. A “lock and lead” method utilizing two modified 24-gauge catheter needles was reported by Takayama et al. from Japan.[33] The haptics of a foldable IOL are threaded into the catheter needle and then exteriorized in a smooth manner. Similarly, Can has introduced a scleral fixation guide that is threaded in a retrograde manner from the distal end of the scleral tunnel for haptic to the proximal end of the tunnel and thence into the eye through the sclerotomy at 3 'o' clock meridian [Figure 10].[34] It is brought out of the eye through the superior corneal incision. The leading haptic of the foldable three-piece IOL is then inserted into the hollow bore guide outside the eye. As the IOL is being injected into the eye with the right hand, the guide is gently pulled back with the left hand. It carries the haptic out of the eye and into the scleral tunnel meant for it. The same process is repeated for the other haptic. This method eliminates the relatively difficult process of tucking the haptic into the scleral tunnel.
Figure 10: Partial thickness scleral tunnels for scleral-fixated intraocular lenses haptics are created using a needle (arrow, a). The scleral fixation guide is passed in a retrograde manner through the scleral tunnels, into the eye through the sclerotomy, and out of the eye through the corneal incision (arrows, b). The leading haptic of intraocular lens is threaded into the pliable guide

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Late-onset endophthalmitis is a known complication when sutures are used to secure the SFIOL.[35],[36] Erosion of the conjunctival tissue overlying the suture knots provides an avenue for exogenous bacteria to enter the eye. Suture breakage and late dislocation of the SFIOL is a reported complication.[37],[38] The thinner 10-0 polypropylene sutures are often implicated as they tend to erode relatively quickly. Therefore, there is now a trend to shift toward thicker sutures such as 9-0 polypropylene or 7-0 or 9-0 Gore Tex. Occasionally, the haptic of a three-piece IOL may break away from the optic. This event can occur intraoperatively or postoperatively. Besides these specific complications, lens tilt, choroidal or vitreous hemorrhage, retinal detachment, hypotony, and endophthalmitis are potential untoward events.[39]

Sindal et al. reported that sutured and sutureless techniques for SFIOL appeared to be equally good in eyes with aphakia after cataract surgery or trauma.[5] The rate of adverse events in SFIOL surgeries has been shown to be lesser when an endoscope is used for transscleral sulcus suturing of an IOL.[40]

  Conclusion Top

In eyes with inadequate capsular support, SFIOLs are a versatile option for stable visual rehabilitation. Sutured SFIOLs were the mainstay until the last decade. With innovations, both in the operating room by enterprising surgeons and in the laboratory by skilled technicians, sutureless SFIOLs have come to the forefront.

Although we await the long-term results of these new techniques, it is clear that the intraoperative difficulties are lesser with sutureless methods. It is judicious to remember that the choice of IOL and technique will depend on the ocular anatomy and integrity of tissues. Availability of specialized instruments and the surgeon's confidence in performing a particular surgical technique are also important variables that determine a technique's utility. Overall, the visual outcomes with any technique of SFIOL implantation are good and poor outcomes are usually associated with comorbid ocular conditions.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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