Scleral fixation technique

various technique for scleral fixation from various documentation
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1. SCLERAL FIXATION TECHNIQUE Resident Panit Cherdchu, M.D. Ophthalmology department Phramongkutklao Hospital

2. T able of content Definition Material Technique Complication Take home message

3. D efinition Scleral fixation of an intraocular lens implant is a procedure used in specialized cases of lens dislocation or lensectomy where the normal lens structures are no longer functional. This procedure involves securing an intraocular lens implant to the wall of the eye using surgically created tunnels or sutures.

4. E tiology

5. T iming of Surgery In case of SF-IOL implantation following complicated cataract surgery Retrospective study comparing primary vs secondary IOL implantation Both surgical approach results in similar visual outcomes and complication rates Conclusion = primary or secondary implantation is likely largely depend on the surgeon’s comfort zone and experience with SF-IOL placement and circumstance

6. S uture Material

7. P OLYPROPYLENE monofilament polymer composed of propene and is the most commonly used suture material for scleral-fixated IOLs. Rates of suture breakage have been reported from 0 to 27.9% with 10-0 polypropylene. For this reason, 9-0 polypropylene has been increasingly used in order to reduce the rate of breakage.

8. G ore-Tex Gore-Tex (W.L. Gore & Associates, Elkton, Maryland, USA) is a non-absorbable, polytetrafluoroethylene monofilament suture. Gore-Tex has greater tensile strength and has been reported to have lower suture breakage rates when used in the eye. Gore-Tex is also commonly used for heart valve and vascular procedures.

9. I OL CHOICE As most IOL power calculations are based on endocapsular IOL localization, power adjustment is necessary to account for a more anteriorly positioned lens in the ciliary sulcus. Calcification of hydrophilic acrylic IOLs has been recently reported following procedures involving intraocular gas or air. This may be an important consideration in patients who are at increased risk of requiring retinal detachment repair or endothelial keratoplasty in the future.

10. Alcon CZ70BD PMMA

11. Bausch & Lomb Akreos AO60 hydrophilic acrylic lens

12. THE BAUSCH&LOMB ENVISTA MX60

13. MAXIM SCLERAL FIXATION SC6530 

14. Complications corneal edema retinal detachment intraocular hemorrhage (due to the passage of suture through uveal tissue) suture erosion and infection (due to externalized or exposed sutures) IOL dislocation or tilt.

15. SURGICAL TECHNIQUE SUTURE OR SUTURELESS

16. TECHNIQUE Ab externo suture fixation Ab interno suture fixation Hoffman pockets Four Point Suture Fixation Modified Technique of Shapirno and Leen Novel Method for SF-1-piece IOLS Sutureless scleral fixation

17. A long way before today’s Surgical techniques

18. 10-0 polypropylene suture to fix haptics to the sclera at 3-9 o’clock at distance of 2 mm posterior to the limbus 28-gauge needle suture loops = ab externo to create internal loop of suture at each horizontal clock hour From a corneal incision to an open sky approach The two suture loops are externalized and secured with a hitch to each haptic IOL is dawn inside Sutures are tied onto the sclera Scleral sutured IOLs (past) 1980s : Malbran and colleaques first published description of sutured SF-IOL for aphakia following ICCE

19. 1986, ab interno , sutures are made from inside the eye to outside blind maneuver which increased risk of RD, Hemorrhage , unpredictable haptics So Lewis introduced the concept of “docking” a straight needle on a 10-0 polypropylene suture into a 28-gauge needle 180 degree away Entry points for both needles were 2 mm away from limbus Sutures were made sulcus to sulcus Second instrument manipulate via corneal wound Suture was cut and tied to each haptics This technique is still being used today with good success rates Scleral-sutured IOL 1991, lewis develop ab externo suture passes and made use of scleral flaps to cover the suture knots

20. Lewis technique

21. Ab externo suture fixation

22. Ab externo suture fixation Ab externo fixation refers to scleral fixation in which sutures are passed from the outside to the inside of the eye. The location of the ciliary sulcus is established using external landmarks. Most authors utilize 9-0 or 10-0 double-armed polypropylene suture ( Prolene ). The suture needle may be straight (STC-6), which provides longer range of access, or curved (CIF-4 or CTC-6), which provides a more rigid needle. A hollow 27-gauge needle can be used as a docking guide to ensure exit of the suture needle through the correct site in the sclera. Scleral flaps, tunnels, or grooves can be used to protect the knot and prevent external suture erosion.

23. VDO : ICCE with Ab externo SF-IOL

24. Double-knot transscleral suture fixation technique for displaced intraocular lenses

25. Inferior displacement of IOL (surgeon’s view) Straight needle passed with 10-0 prolene suture from inferonasal scleral flap through haptic anterior to the iris and then out to superotemporal paracentesis site with 30-guage needle as a guide wire

26. Repeat step 2 with 1 mm away from first suture and pass above, not through the haptic islet and tie ends of prolene in superotemporal site IOL is brought up into AC with forcep and sinskey through paracentesis sites, rotate IOL clockwise

27. IOL is dropped down into posterior chamber and prolene were tied with sclera with good position The other haptic is supported in the ciliary sulcus with capsule and zonular support

28. 4-point SF-IOL of posterior chamber IOL without scleral flaps

29. Conjunctival peritomy at 2,8 o’clock (left eye) or 10,4 o’clock (right eye) Half thickness 3 mm scleral grooves 1 mm behind the limbus Partial thickness corneal incision 7mm at the superior or superotemporal cornea in between the sites of the scleral incision by Bard-Parker knife no.15, then 3mm keratome enter the AC Anterior vitrectomy Double armed 10-0 prolene on straight needles were used Straight needle enter AC via scleral groove directed perpendicularly towards mid-vitreous and guided by a 25-guage cannula to exit the globe

30. Single piece IOL (PMMA with 2 holes in 1 haptic) was connected with prolene Repeat the same step with other side Corneal incision was enlarged and the IOL was implanted by pulling on the prolene suture Close corneal incision with monofilament nylon suture

31. Adjust IOL position and tie the two ends of prolene Close conjunctiva with 8-0 silk

32. 4-point fixation with AKAO IOL

33. VDO : 4-point fixation AKAO with vitreoretinal surgery

34. Ab interno scleral fixation

35. Ab interno suture fixation In ab interno fixation, the suture is passed from the inside to the outside of the eye. In order to avoid a blind pass through the ciliary sulcus, the suture needle can be inserted into and externalized using a hollow needle that was placed at a known landmark or by utilizing endoscopic visualization.

36. VDO : New modified technique with foldable IOL looks similar to Ab interno method

37. Modified Technique of Shapirno and Leen

38. Modified Technique of Shapirno and Leen This technique is similar to the Ab externo except that it does not require specialized sutures, IOL's or instruments . Here, same conventional 10-0 polypropylene sutures are required having curved needle which after passing through the sclera is pulled out of the eye with the help of a Mc'pherson foceps

39. Hoffman pockets

40. Hoffman pockets This technique of suture knot coverage was described in 2006 by Hoffman et al and avoids the need for conjunctival dissection , scleral cauterization, or scleral wound closure. A scleral pocket is created by initiating a scleral tunnel from a clear corneal incision. A double-armed suture can then be passed full thickness through the conjunctiva and scleral pocket, and the suture ends can be retrieved subsequently through the external corneal incision. The knots can then be buried within the pockets.

41. VDO : Dislocated IOL with vitrectomy with Hoffman pocket

42. The advantages of the scleral pocket Simpler creation of a suture knot and avoids the need to rotate the knots No conjunctival dissection or scleral cautery = faster procedure than traditional triangular flap method Easier dissection and possibly less induced astigmatism

43. New technique with no intraocular knots

44. A New Technique for Suture Fixation of Posterior Chamber Intraocular Lenses that Eliminates Intraocular Knots

45. Sutureless scleral fixation

46. Sutureless scleral fixation IOL haptics can be externalized and fixated within the sclera without the use of sutures. Many techniques involve the use of scleral flaps or scleral tunnels parallel to the limbus. Haptics can be externalized using 25-gauge forceps or hollow needle. Scleral flaps can then be closed with 10-0 nylon or fibrin glue . Some surgeons recommend using larger IOLs for these techniques in order to prevent torsion of the haptics and subsequent scleral erosion or IOL dislocation.

47. Sutureless SF-IOL fixation of IOL 2007 paper describing the SIS technique Utilize 24-gauge cannulas to create diametrically opposite ab externo sclerotomies at a distance of 1.5-2.0 mm from the limbus Cannulas were used to create 50% thick scleral tunnels parallel to the limbus near each of the original sclerotomy sites 3-pieces IOL is inserted Haptics are externalized in turn through the sclerotomy incisions and fed into the scleral tunnels Leave small portion of each haptic exposed between scleral tunnel and the sclerotomy site

48. Adaptation of SIS technique Prenner and colleagues used a microvitreoretinal blade and 23-gauge trocars for sclerotomies and scleral tunnel to insert 3-piece IOL Abbey and coworkers didn’t do a conjunctival peritomy they used 25-gauge trocars to create 3 mm transconjunctival scleral tunnels that are 180 degrees apart from each other 3-piece IOL is inserted via limbal incision Tip of the haptic is grasped with a 25-gauge forceps via cannulas and pulled through the sclerotomy and scleral tunnel

49. 2008, Agarwal and colleagues In place of sutures, fibrin glue has also been used to secure the haptics of an IOL to the sclera

50. Sutureless techinque

51. VDO : Sutureless technique

52. Is that that perfect? There might be some advantages It’s not that easy as it look because sclerotomy and scleral tunnel are too close to each other haptic insertion might be challenging Vertical dissection resolve this problem The distance between the end of the haptic and the site of sclerotomy is important

53. Sutureless with glue

54. VDO : ABBEY’s sutureless technique (vitrectomy)

55. Yamane and co-worker’s sutureless technique Insert 3-piece IOL into AC Used 27-gauge needle to create a sceral tunnel at a distance of 1.7 mm from the limbus Microforceps were used to feed 1 haptic into the lumen of the 27-guage needle Remove 27-gauge needle to allow the haptics to rest in the scleral tunnels

56. VDO : Double Needle Fixation Technique ISHF Yamane Technique

57. Suture VS sutureless SF-IOL

58. Ganekal and colleagues compared sutured SF-IOL (n=25) with fibrin glue-assisted SF-IOL implantation similar VA outcome Sutured IOL group= significantly more complications compared to the fidrin glue group (56% vs 28%, P = 0.045) Higher rates of postoperative glaucoma and inflammation occurred in the sutured IOL group compared to the fibrin glue group

59. Pros and cons of Posterior Chamber SF-IOL

60. TAKE HOME MESSAGE

61. Ocular trauma, disease causing zonular weakness, and zonular trauma after complex cataract surgery can disrupt the capsule  IOL insertion to the bag is impossible ACIOL,IFIOL or SFIOL are the procedure of choice SFIOL is the only option for eyes lack both iris and capsular support Beware complication of suture technique : suture breakage, lens dislocation, RD, suprachoroidal haemorrhage and suture-related endophthalmitis Beware complication of sutureless technique : IOL can still dislocate (long term data of stability and severe complication rates are lacking)

62. REFERENCES