Peter H. Tang, M.D., Ph.D.
Vitreoretinal Surgery Fellow
Byers Eye Institute, Stanford
This afternoon, we had a lively and informative discussion regarding techniques for surgical fixation of intraocular lenses. It was moderated by Drs. Jonathan Prenner of NJ Retina and Philip Ferrone of VRC of Long Island and Queens. We had 8 presentations of surgical techniques and studies involving fixation of intraocular lenses as well as a panel discussion of various scenarios of intraocular lens dislocation or other associated issues.
Dr. Richard Johnston of Edina Retina Consultants in Edina, Minnesota presented an interesting modified flanged scleral-fixation technqiue for a 3-piece intraocular lens. This included inserting two 30-gauge needles 180 degrees apart approximately 1.5 mm posterior to the limbus. With both needles inserted, the surgeon is able to easily insert the haptics into the needle lumen for capture and externalization. This is a modification to the standard technique promoted by Dr. Yamane, but allows for more control by the surgeon and less need for a skilled assistant.
Dr. Gareth Lema of Ross Eye Institute at SUNY Buffalo followed with a presentation on the long-term outcomes of scleral tunnel fixation techniques, highlighting that although complications are rare, they can be significant including hypotony, kinked haptics, UGH syndrome, and corneal edema.
Dr. Aditya Kelkar at the National Institute of Ophthalmology in India compared two modified sutreless techqniues for scleral fixation: Gabor’s techqniue using scleral pockets versus Yamane’s technique with transconjunctival externalization of the haptic of the 3-piece intraocular lens. His studies found that the Yamane technique demonstrated a shorter learning curve without the need for a conjunictval peritomy.
Dr. Gregg Kokame of Retinal Consultants of Hawaii presented the long-sterm stability of pars plana vitrectomy and sutured scleral-fixated intraocular lens using a two-suture knot techqniue with 10-0 polypropylene. He had data up to 25 year follow up with a suture breakage rate of 0.5%. Dr. Aniruddha Maiti of Aditya Jyot Eye Hospital in Mumbai, India presented an interesting technique of fixating a retropupillary iris claw intraocular lens that demonstrated great outcomes and safety. Finally, Dr. Jonathan Prenner reported a sutureless intrascleral fixation technique for a 3-piece intraocular lens using a 30-gauge needle, which was shown to be safe and very effective after 1 year of follow up.
Dr. Maxwell Stem gave the Fellows Forum Research Award presentation for his work involving 27 gauge sutureless intrascleral fixation of intraocular lens with haptic flanging. This involved initially investigating how much force was necessary to dislocate a MA60AC 3-piece intraocular lens in cadaver eyes and then performing a clinical case series study from 52 eyes to see if flanged intraocular lens haptics were less prone to dislocation. His results definitively showed that having flanged haptics for the intraocular lens created a more stable fixation for the lens with less dislocation complications.
The session concluded with a panel discussion regarding how to surgically approach complex intraocular lens dislocation scenarios. Highlights from the discussion are as follows:
– if the anterior capsule is intact, try to perform an lens optic capture. With a 3-piece intraocular lens, one should plan for an “anterior capture” where the haptics are placed into the sulcus and the lens is positioned so that it is captured by the anterior capsule. In a situation where the lens is a single piece acrylic type, one should plan for a “posterior capture” where the haptics are kept in the bag but the lens optic is anteriorized to be captured by the anterior capsule.
– if the anterior capsule is not intact, especially in situations with a single piece acrylic lens, then a lens exchange will be necessary
– in the situation of a non-foldable PMMA lens, to avoid a large corneal wound, one can attempt to sclerally fixate this lens. However, if this is not possible, a sclero-corneal wound is preferred since it will be a large wound to remove this non-foldable lens. Once out, one can either insert an anterior chamber lens or proceed with a scleral fixated lens. A key point to remember is that the large wound must be closed once the new lens is inserted to ensure proper intraocular pressure during the remainder of the case.
– in a lens/bag subluxation scenario, a suture can be passed through the haptics to fixate the lens properaly, and the externalized sutures can be tucked into scleral tunnels or flaps.
– in situations where there is uveitis-glaucoma-hyphema syndrome caused by an intraocular lens, the panel suggests fixate the intraocular lens further posterior than the usual amount. The recommendation from the panel was to target fixation of the lens 3 mm posterior to the limbus.
This was an immensely interesting topic that generated a lot of interaction and questions from the audience. It has been one of the highlights of the ASRS meeting this year.