We describe an ab externo technique for scleral fixation of a subluxated single piece AcrySof (Alcon, Texas, USA) intraocular lens (IOL). A 10-0 polypropylene transcleral suture brought out of a paracentesis and traced back to form a loop is used to tie a cow hitch knot around a temporarily externalised haptic. The one piece design of the IOL, with flexible haptics, allows temporary externalisation through a 1.2 mm paracentesis. The tacky nature of the haptic material, square edges and the knob at the tip prevent slippage of the knot. The advantage of this technique is that the same one piece AcrySof IOL is retained and secured, while the risks and manipulations associated with explantation and exchange are avoided. While mere sulcus placement of a single piece AcrySof IOL may be associated with complications, scleral fixation is a viable solution.
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Review history and Supplementary material
Minimally invasive relocation of subluxated single piece AcrySof IOLSuven Bhattacharjee(1), Arup Chakrabarti(2), and Abhijit Ghosh(3)
1Apollo Gleneagles Hospital & AMRI Hospital and Complete Care Eye Clinic, Kolkata, India; 2Arup Chakrabarti, Chakrabarti Eye Care Centre, in Trivandrum, India; 3Abhijit Ghosh, Aurobindo Netralaya, Kolkata, India.
Correspondence: Dr Suven Bhattacharjee
Email: Complete Care, 40/2/1Z, Lake Road, Kolkata, India -700029 Tel: +913324651391, +919830060348.
Date of acceptance: 16th April 2008
A subluxated single piece AcrySof IOL can be secured by temporarily externalizing the haptics and using cow hitch knots on externalized loops of transcleral sutures; just by using two paracenteses.
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A single piece AcrySof IOL could be subluxated due to an unrecognized capsular tear prior to implantation, willful implantation of the IOL despite a capsular tear or inherent weakness of the zonules.
Single piece AcrySof IOLs, when placed in the ciliary sulcus, without scleral fixation, were explanted and exchanged because of pigment dispersion, pigmentary glaucoma, uveitis, Iris chafing etc.1 IOL explantation and exchange with scleral fixation requires a larger incision, is traumatic to the cornea and iris and involves greater risk of vitreous loss, postoperative astigmatism and endophthalmitis. Secondary implantation by transcleral suture fixation of a one-piece foldable, AcrySof IOL through clear corneal incision has been reported to be a reasonable technique.2, 3 Hence, the possibility of repositioning the same IOL safely and securely by a minimally invasive technique must be explored.
The sclera is bared in diametrically opposite areas and two 2mm x 2mm rectangular scleral flaps are made 1mm posterior to the surgical limbus. The original paracentesis are gently opened with a 1mm spatula or two paracentesis are made 4 clock hours apart. The anterior chamber is filled with OVD. The subluxated IOL is brought into the anterior chamber bimanually using a Hirschman hook and a spatula. Bimanual anterior vitrectomy is performed through the paracentesis to free the anterior chamber, pupillary area and anterior vitreous space of capsular remnants and vitreous strands.
Under one of the reflected scleral flaps, a 10-0 polypropylene suture mounted on straight needle is passed 1.5 mm posterior to the limbus and perpendicular to the sclera. A 26G hypodermic needle introduced though the paracentesis diametrically opposite to the point of entry of the needle is used to dock the straight needle and guide it out through this paracentesis. These needles may be passed either anterior or posterior to the IOL. Under the same scleral flap, a second 26G needle is passed 1mm adjacent to the point of entry of the straight needle. The straight needle is now retraced through the paracentesis and retrieved by docking it into the second 26 G needle. This results in a loop of 10-0 polypropylene outside the paracentesis.
The haptic is exteriorized as a knuckle, through the other paracentesis. One of the limbs of the polypropylene loop is hooked out of the same paracentesis. The loop is folded over itself and the limbs are drawn out to make a cow hitch knot. The knot is tightened after passing the haptic through the loop. The haptic is reposited into the anterior chamber either by pushing or dialing it in.
The haptic is tucked under the iris as the limbs of the polypropylene suture are drawn through the sclera and a temporary knot is tied. The other haptic is also secured in similar manner. The tension on both the transcleral sutures is finally adjusted and each side is knotted with multiple throws. The scleral flap is reposited and conjunctiva is closed.
3 eyes were managed for postoperatively detected malpositioned single piece AcrySof IOL during the period February 2006 to July 2006. All the patients were referred within 2 weeks of surgery. In 2 eyes the surgeon had attempted to place the IOL in the bag despite having noted a posterior capsule tear. In the third eye, the surgeon had attempted dialing the haptics away from a tear in the capsulorhexis.
2 eyes had AcrySof SA60AT lenses and 1 eye had a SN60WF lens. Both the SA60AT IOLs were found to be dislocated in the anterior vitreous and the SN60WF IOL had one haptic in the bag and the other in the anterior vitreous. All three eyes had disturbed anterior vitreous at presentation.
1 eye had hyphema from Iris trauma while introducing the straight needle which was controlled by raising the IOP. The mean postoperative follow up was 13 months. 1 eye developed cystoid macular edema two weeks after surgery, which resolved within 3 months with topical steroids and anti-inflammatory agents. No evidence of pigment dispersion on the IOL surface or angle was seen. Intraocular pressure remained within normal range in all eyes.
All eyes had a well centered PC IOL and best corrected visual acuity of 20/20 at the end of mean post operative follow up period of 13 months. Though all eyes showed a myopic shift of 0.5 to 1.0 D from target refraction, no significant astigmatism was noted. None of the eyes showed evidence of suture erosion, endophthalmitis or redislocation in the postoperative period.
Anatomic studies have shown that the ciliary sulcus is located 0.50 to 1.0 mm posterior to the limbus. Securing the single piece AcrySof IOL by transcleral sutures placed about 1.5 mm posterior to the limbus, ensures that the IOL is placed at the posterior part of the ciliary sulcus just impinging on the pars plicata. This eliminates the possibility of contact between the haptic and iris. The flexible haptic and stable force design of the single piece AcrySof allows externalization of the haptic without damage to the haptic optic junction or haptic. The haptic can be bent into a knuckle while externalizing it, without fear of damaging it unlike a PMMA haptic which requires difficult maneuvers. The cow hitch knot is a simple knot and requires no specialized maneuvers or instruments when tied outside the eye. The knob at the tip, square edges and tacky nature of the haptic material, prevent slippage of the cow hitch knot. The one-piece design at the haptic-optic junction and the ability of the haptic to be straightened compensates for any disparity in the overall diameter of the IOL and the sulcus-to-sulcus diameter and eliminates the possibility of antero-posterior vaulting of the IOL or movement of the IOL parallel to the Iris plane. Our technique is easy to perform, minimally invasive, safe and takes advantage of the unique design and material characteristics of the single piece AcrySof IOL.
Conflict of Interest Statement
No author has financial interest in any of the products, materials or methods mentioned.
- LeBoyer RM, Werner L, Snyder ME. Acute haptic-induced ciliary sulcus irritation associated with single-piece AcrySof intraocular lenses. J Cataract Refract Surg 2005; 31:1421–1427.
- Wafapoor H. Annual meeting of the Am Acad of Ophthalmol.2003.
- Petri I, Mandi Z, Lacmanovi et al. Sulcus fixation of a foldable acrylic intraocular lens. Acta Med Croatica. 2006; 60(2):137-40.
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Competing interests: None.
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