Javascript is currently disabled in your browser. When javascript is disabled, some functions of this website will not work.
Open access for scientific and medical research
From submission to the first editing decision.
From editor acceptance to publication.
Open access to peer-reviewed scientific and medical journals.
Dove Medical Press is a member of OAI.
Batch reprints for the pharmaceutical industry.
We provide real benefits for authors, including fast processing of papers.
Register your specific details and specific drugs of interest, and we will match the information you provide with articles in our extensive database and send you a PDF copy via email in a timely manner.
Back to Journal »Clinical Ophthalmology» Volume 12
Authors Cui Jingying and Han Yukun
Published on July 18, 2018, Volume 2018: 12 pages 1279-1284
DOI https://doi.org/10.2147/OPTH.S157462
Single anonymous peer review
Editor approved for publication: Dr. Scott Fraser
Supplementary video of intraocular lens and scleral fixation technique.
Jung Yeol Choi,1 Young Keun Han2,3 1 Department of Ophthalmology, Jeju National University Hospital, Jeju, South Korea; 2 Seoul Metropolitan Government Ophthalmology-Seoul National University Borama Medical Center, Seoul, South Korea; 3 Seoul National University School of Medicine, Seoul, South Korea Abstract: We describe an improved scleral fixation method to promote good alignment of the sutures at both ends and sufficient tension, and to increase the internal fixation knot to reduce IOL eccentricity in a postoperative aphakic patient. Use the ab externo suture technique to fix the loop on the scleral wall, and tie an extra loop 1 mm next to the fixed knot at the loop. In this technique, a needle holder or McPherson forceps is used to tie the internal suture and additional suture knots together while keeping them close to the tactile fixing knot. Secure the externalized suture by biting a bite through the sclera and tying the suture to itself. This technique is simple and easy to implement and adds an internal check valve to prevent excessive pulling and eccentricity of the intraocular lens on one side. Internal check valves can also be used as a standard for fixed points at each end. Keywords: modified technique, intraocular lens and scleral fixation, postoperative aphakia
Transscleral suture of the intraocular lens (IOL) is a well-known and effective technique for patients with insufficient capsular support. Various transscleral suture techniques for posterior chamber intraocular lens fixation have been introduced and have played an important role in various treatment methods. 1-8 However, the transscleral suture fixation technique has a problem that can cause refractive errors. The result of IOL eccentricity and tilt. It is well known that the tilt and eccentricity of IOL for scleral fixation are more extensive than other fixation methods. 9 Previous studies reported a center rate ranging from 48% to 100%. 10 Therefore, the tilt and eccentricity of the IOL are a particular concern when suturing the intraocular lens to the sclera. During the operation, if the suture passing through the sclera is pulled unevenly at both ends, it will loosen to the looser side of the fixation; therefore, the IOL loses its alignment. In addition, it is not easy to determine the center position of transscleral fixation during the operation, while keeping the tension at both ends of the suture equal, while maintaining the center position of the IOL. Equal and proper tension at the suture is necessary to ensure adequate centering of the IOL, and good positioning of the IOL is important to prevent postoperative complications (such as IOL subluxation into the anterior chamber or pupil capture). We describe a new method of transscleral fixation by adding an internal fixation knot that reduces the eccentricity of the IOL, which promotes good alignment of the sutures at both ends and sufficient tension.
Using superior methods, create a periconjunctival incision at 2 o'clock and 8 o'clock, and perform anterior vitrectomy or three-port vitrectomy based on clinical indications. After vitrectomy, symmetrically mark two points 3 mm from the limbus at 2 o'clock and 8 o'clock. A 10-0 polypropylene suture on both arms, with two curved needles at each end, passes through the sclera, and a 26-gauge curved hypodermic needle is placed on the other side to allow the 10-0 polypropylene needle to pass through. Then make a 2.75 mm clear corneal incision at 3 o'clock. Use the Sinskey hook to pull the 10-0 polypropylene suture behind the iris through the incision and cut it in the middle. A three-piece foldable intraocular lens is placed on the cornea after an adhesive surgical device is installed. The 10-0 polypropylene suture from the 2 o'clock position is firmly tied to the leading loop 3 mm in front of the tip, while another 10-0 polypropylene suture from the 8 o'clock position is tied to the back loop Tactile cue before 3mm. At the end of the binding haptics, add an extra suture knot with a loop next to the tactile fixation knot (Figure 1A). When the assistant uses a needle holder or Macpherson forceps to secure the 10-0 polypropylene suture next to the fixation, the second knot is connected to the two loops next to the tactile fixation (Figure 1B and C). Two knots 1 mm apart are tied together: one for tactile fixation and the other as an additional knot for the internal check valve (Figure 1D). Repeat the same process on the other side. While pulling the 10-0 polypropylene suture to fix it to the sclera, additional knots were made at both ends as an internal fixation device to hold the check valve against the sclera wall. After tying each loop, use a keratome to expand the incision, insert the intraocular lens into the anterior chamber, and pull the sutures completely at the 2 o'clock and 8 o'clock positions at both ends. Apply enough tension to the loop to suspend the IOL and minimize IOL movement through the internal fixation knot, which is blocked by the scleral walls at both ends (Figure 2A and B). After determining the proper centering of the IOL, two transscleral fixation sutures are tied together and buried under the conjunctiva. The IOL was sufficiently centered at the end of the operation (Figure 3A), and ultrasound biomicroscopy was performed to record the center of the IOL behind the iris (Figure 3B). Video S1 describes the technology in detail.
Figure 1 The access technology of intraocular lens and sclera fixation. Note: (A) After the tactile suture is completed, the assistant uses McPherson forceps to fix the polypropylene suture next to the tactile knot. (B) When the assistant uses McPherson forceps to secure the 10-0 polypropylene suture next to the fixture, a suture loop is formed. (C) After the loop is formed, pull both ends of the 10-0 polypropylene suture to tie another knot next to the tactile knot; the second loop with knot is for the extra knot. (D) Two looped knots were made: one for tactile fixation, and the other as an internal knot, which will act as a check valve to the inner scleral wall. To tie an extra knot on the other side of the touch, repeat the same process.
Figure 2 Schematic diagram of intraocular lens in and out of sclera fixation. Note: (A) Three knots are formed to fix the IOL to the sclera: the tactile knot, the additional knot next to the tactile knot, and the scleral fixation knot to fix the 10-0 polypropylene suture outside the eyeball. (B) Schematic diagram of the in and out fixing method. Abbreviation: IOL, intraocular lens.
Figure 3 Photos after intraocular lens in and out of sclera fixation. Note: (A) The intraocular lens is fully centered; (B) Ultrasound biomicroscopy shows that the intraocular lens is well centered 2 months after surgery.
Although many IOL implantation techniques have been described for transscleral fixation, the control of the center and tilt of the IOL is still the main concern of the surgeon when suturing the IOL to the sclera. It is well known that the eccentricity of the IOL in transscleral fixation is greater than that of intrapocket intraocular lens implantation. 9 Because the tilt and eccentricity of the IOL can lead to poor vision after transscleral fixation, this is a common goal. The tilt and eccentricity have been minimized. The optical eccentricity of the intraocular lens will cause the focus to shift laterally, and the eccentricity >1.0 mm will cause radial astigmatism. 11 Balance and sufficient tension must be maintained at each end of the suture to prevent eccentricity and tilt. During the scleral fixation intraocular lens surgery, the position of the intraocular lens fluctuates with the sudden change of intraocular pressure caused by the leakage of the incision, and may increase the eccentric tension of the intraocular lens tactile. Our technology helps reduce the eccentric offset of the IOL from the internal node as a check valve to the internal scleral wall by reducing the uneven distribution of the external tension of the scleral wall. Although a smooth eccentric tension is applied during the transscleral fixation on the outside of the eyeball, the inner additional knot will act as an internal check valve for the scleral wall and reduce the further tension applied to a certain extent. This technique is particularly useful in several surgical procedures, such as fixing the IOL behind the ciliary sulcus and flat part. In this case, the IOL may be prone to eccentricity and tilt because there is no compression from the ciliary sulcus and no posterior vitreous support. Therefore, the intraocular lens is only supported by sutures, and is easily displaced and tilted due to instability. For scleral suture intraocular lenses considered for scleral sulcus fixation, since the diameter of the intraocular lens exceeds the average diameter of the eye's ciliary sulcus of the average length (11.1 mm), it is expected to be better centered than flat fixation. 12 The touch in the ciliary sulcus is compressed by the tissue contact area in the ciliary sulcus. In most eyes, without the help of internal and external suture techniques, it is sufficient to fix the loop of the ciliary sulcus. However, the scleral fixation IOL technique based on the ab externo method requires blind passage through the sclera behind the iris. Therefore, the result of anatomy using the ab externo method may be different from the surgeon's fixation point. Pavlin et al.13 reported the results of ultrasound biomicroscopy after transscleral intraocular lens fixation: 38% of cases were located in the sulcus area. Manabe et al.14 reported the tactile position after fixation: 37% of the tactile sensation was fully located in the ciliary sulcus. Taking into account the anatomical results after gingival sulcus fixation and the blindness of the operation, the access technology can even help the sulcus fixation of the intraocular lens sutured in the sclera. In addition, due to the need for caution in highly myopic eyes (that is, the expected diameter of the ciliary sulcus is large), the in and out suture technique helps to balance the distribution of tactile ends during the operation. The recent use of fibrin glue for sutureless scleral fixation can eliminate complications related to sutures. The authors report that there is no significant IOL tilt or eccentricity. 15,16 However, seamless tactile externalization technology may be difficult to have a large horizontal white-to-white diameter, and the overall diameter of the IOL needs to be modified. 16 Second, the use of an infusion cannula for fixation in a vitrectomy eye can be challenging, and the IOL can easily be eccentric during surgery. During each operation, intraocular pressure fluctuates with the flow from the infusion point to the leakage site, resulting in insufficient tactile suture tension and increasing the difficulty of intraocular lens alignment. If the internal knot as a check valve is made correctly and symmetrically, and the applied tension is sufficient to fix the internal knot on the inner wall of the sclera, even if the tension is insufficient or the intraocular pressure due to leakage is low. Third, this internal knot as a check valve can be a good measure of the fixed point at each end of the tactile sensation. In order to determine the fixation point of the sclera while keeping the IOL well centered, the only operation the surgeon must perform is to pull the 10-0 polypropylene suture until the internal knot is secured to the inner scleral wall. This applies to the opposite side in the same way. In and out suture technology also has the advantages of universal application. Regardless of the suturing technique, this procedure can be added to various other techniques for fixing the intraocular lens using the sclera fixed with transscleral suture. Although in our case we performed a secondary enlargement of the transparent corneal incision without using an IOL syringe, the in-and-out suture technique can be applied to small transparent corneal incisions using IOL syringes or temporary tactile externalization. Initially, we recommended this technique to prevent the tactile fixation knots from loosening. However, in the initial simulation using IOL, we failed to close the additional junction through the tactile junction. Due to the thickness of the second instrument (ie McPherson forceps or needle holder), the extra knot is formed 1 mm from the tactile knot while maintaining the knot formation point. However, an inherent disadvantage of this technique is that it requires a second instrument or a qualified second assistant to add an internal knot next to the tactile fixation knot. Because our technique is the first technique that involves adding internal knots to ensure sufficient tension, even if an eccentric pull is performed during surgery, it is difficult to compare with other surgical techniques that reduce eccentricity and tilt.
Our internal and external suture technique should be suitable for vitrectomy eyes, eyes with a large groove diameter, such as high myopia, and surgery for IOL fixation of the sclera. In addition, internal check valves are used as a standard for fixed points at each end. We believe that this technique has wide applicability when using the previously described method to perform surgery by adding internal knots alongside tactile fixation. The internal knot acts as a check valve, reducing excessive strain on the scleral wall and assisting IOL centering. The technology also allows the surgeon to easily determine the location of the centered IOL.
The abstract of this article was published as an electronic poster at the 16th International Conference of Clinical and Experimental Ophthalmology and European Ophthalmology Society in 2017. The abstract of the electronic poster is published in "Poster Abstract" by J Clin Exp Ophthalmol.
The author has no proprietary interest in any technology or equipment used, and reports no conflicts of interest in this work.
Hoffman RS, Fine H, Packer M. Scleral fixation without conjunctival dissection. J cataract refractive surgery. 2006;32(11):1907-1912.
Khan MA, Gupta OP, Smith RG, etc. Using Gore-Tex sutures to fix the sclera of the intraocular lens: clinical results and safety. Br J Ophthalmol. 2016;100(5):638–643.
Hu BV, Shen DH, Gibbs KA, Hong YJ. The posterior chamber lens is implanted without cystic and ribbon support. Arched ophthalmology. 1988;106(3):416-420.
Epley KD, Levine ES, Katz HR. A simplified technique for stabilizing posterior chamber intraocular lens through scleral suture and fixation. Eye surgery laser. 1999;30(5):398-402.
Schmidt JC, Nietgen GW, Freisberg L, Neisskenwirth NN. Modified transscleral suture for fixation of posterior chamber lens groove. J cataract refractive surgery. 2002;28(1):15-17.
Lewis JS. The groove is fixed without flaps. ophthalmology. 1993;100(9):1346–1350.
Shapiro A, Ryan MM. External transscleral posterior chamber lens fixation. Arched ophthalmology. 1991;109(12):1759-1760.
Pannu JS. A new suture technique for fixing the ciliary sulcus without posterior capsule. Eye surgery. 1988;19(10):751-754.
Hayashi K, Hayashi H, Nakao F, Hayashi F. Tilt and eccentricity of intraocular lens, anterior chamber depth, and refractive error after transscleral suture fixation. ophthalmology. 1999;106(5):878-882.
Grigorian R, Chang J, Zarbin M, Del Priore L. A new technique for suturing and fixing posterior chamber intraocular lens to eliminate intraocular nodules. ophthalmology. 2003;110(7):1349–1356.
Holladay JT. Evaluate the optical components of the intraocular lens. Survival ophthalmology. 1986;30(6):385-390.
Ohmi S, Uenoyama K, Apple DJ. [Intraocular lens implantation of different diameters]. Ganka Gakkai Zasshi, Japan. 1992;96(9):1093-1098. Japanese.
Pavlin CJ, Rootman D, Arshinoff S, Harasiewicz K, Foster FS. Ultrasound biomicroscopy was used to determine the tactile position of the posterior chamber intraocular lens fixed by the sclera. J cataract refractive surgery. 1993;19(5):573–577.
Manabe S, Oh H, Amino K, Hata N, Yamakawa R. Ultrasound biomicroscopic analysis of posterior chamber intraocular lens sutured through the scleral groove. ophthalmology. 2000;107(12):2172-2178.
Narang P, Agarwal A, Kumar DA, Agarwal A. Clinical results of glued intraocular lens stents. J cataract refractive surgery. 2015;41(9):1867–1874.
Jacob S. Intrascleral intraocular lens fixation. Asia Pac J Ophthalmol (Phila). 2017; 6(4): 381–387.
Video S1 shows the intraocular lens and scleral fixation technique in the postoperative aphakic eye. This technique adds internal extension knots to offset the excessive tension at both ends as an internal check valve. Note: Using the ab externo suture technique, tie an extra loop knot 1 mm next to the fixed knot of the tactile point. In this technique, McPherson forceps are used to tie the internal suture and additional suture knots together while holding them close to the tactile fixing knot. Internal check valves can also be used as a standard for fixed points at each end.
This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and include the Creative Commons Attribution-Non-commercial (unported, v3.0) license. By accessing the work, you hereby accept the terms. The use of the work for non-commercial purposes is permitted without any further permission from Dove Medical Press Limited, provided that the work has an appropriate attribution. For permission to use this work for commercial purposes, please refer to paragraphs 4.2 and 5 of our terms.
Contact Us• Privacy Policy• Associations and Partners• Testimonials• Terms and Conditions• Recommend this site• Top
Contact Us• Privacy Policy
© Copyright 2021 • Dove Press Ltd • Software development of maffey.com • Web design of Adhesion
The views expressed in all articles published here are those of specific authors and do not necessarily reflect the views of Dove Medical Press Ltd or any of its employees.
Dove Medical Press is part of Taylor & Francis Group, the academic publishing department of Informa PLC. Copyright 2017 Informa PLC. all rights reserved. This website is owned and operated by Informa PLC ("Informa"), and its registered office address is 5 Howick Place, London SW1P 1WG. Registered in England and Wales. Number 3099067. UK VAT group: GB 365 4626 36
In order to provide our website visitors and registered users with services that suit their personal preferences, we use cookies to analyze visitor traffic and personalize content. You can understand our use of cookies by reading our privacy policy. We also retain data about visitors and registered users for internal purposes and to share information with our business partners. By reading our privacy policy, you can understand which of your data we retain, how to process it, with whom to share it, and your right to delete data.
If you agree to our use of cookies and the content of our privacy policy, please click "Accept".