various technique for scleral fixation from various documentation it took quiet sometimes to gather all material hope you find it's useful

1. SCLERAL FIXATION
TECHNIQUE
Resident Panit Cherdchu, M.D.
Ophthalmology department
Phramongkutklao Hospital

2. Table of content
• Definition
• Material
• Technique
• Complication
• Take home message

3. Definition
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. Etiology

5. Timing 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. Suture Material

7. POLYPROPYLENE
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. Gore-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. IOL 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.

26. VDO : ICCE with Ab externo SF-IOL

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

28. • 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

29. • 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

30. • 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

31. 4-point SF-IOL of posterior chamber IOL without
scleral flaps

32. • 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

33. • 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

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

35. 4-point fixation with AKAO IOL

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

37. Ab interno scleral fixation

38. 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.

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

42. Modified Technique of Shapirno and Leen

43. 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

45. Hoffman pockets

46. 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.

49. VDO : Dislocated IOL with vitrectomy with Hoffman pocket

50. 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

51. New technique with no intraocular knots

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

60. Sutureless scleral fixation

61. 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.

62. 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

63. • 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

64. • 2008, Agarwal and colleagues
• In place of sutures, fibrin glue has also been used to secure the haptics of an
IOL to the sclera

65. Sutureless techinque

68. VDO : Sutureless technique

69. 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

70. Sutureless with glue

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

72. 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

73. VDO : Double Needle Fixation Technique ISHF Yamane Technique

74. Suture VS sutureless SF-IOL

75. • 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

76. Pros and cons of Posterior Chamber SF-IOL

77. TAKE HOME MESSAGE

78. • 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)

79. REFERENCES