Retina Today - Scleral Fixation of a Four-Haptic Intraocular Lens Using Gore-Tex Suture (November/December 2015)

摘要

At a Glance • In situations in which there is poor capsular support, four-point fixation of an IOL may allow excellent IOL stability, and PFTE suture material might reduce concerns regarding polypropylene suture breakage. • This technique can be employed by any vitreoretinal surgeon and combined with standard three-port PPV. • To date, the technique has resulted in favorable visual outcomes with low rates of intraoperative and postoperative complications. In situations in which there is poor capsular support, such as a complicated cataract surgery or dislocated intraocular lens (IOL)-capsular bag complex, scleral fixation of a posterior chamber IOL can be an effective approach for the vitreoretinal surgeon.1 In 2014, our institution described a modified ab externo technique for sutured scleral fixation of an Akreos AO60 IOL (Bausch + Lomb) using a polytetrafluoroethylene (PFTE; Gore-Tex, W.L. Gore & Associates) suture.2 It was hypothesized that four-point fixation of an Akreos AO60 IOL would allow excellent IOL stabilization, while the resilient PFTE material might reduce concerns regarding suture breakage encountered with polypropylene sutures.3,4 In addition, the technique could easily be paired with concurrent three-port pars plana vitrectomy (PPV), which might be necessary in the setting of a dislocated IOL or retained lens material. Iris fixation or sutureless scleral fixation of an IOL, or placement of an anterior chamber IOL, may also be employed effectively in the setting of poor capsular support.1 However, we believe that scleral fixation of an Akreos AO60 IOL with PFTE suture has many advantages, including relative ease of insertion and fixation, use of small corneal incisions, avoidance of iris contact, and (theoretically) a lower risk of dislocation. The key steps of this procedure are illustrated in a supplemental video (Video 1), and full details of the procedure have previously been published.2,5 The procedure was also presented at the 2015 Vit-Buckle Society meeting in Miami, Fla., by Rahul Khurana, MD (Video 2). This article presents a brief recap of the technique along with helpful tips for achieving best results. Video 1: Scleral Fixation of an IOL Figure 1. The suture is passed through the first IOL eyelet from anterior to posterior and then through the corresponding second eyelet from posterior to anterior. This pattern is then repeated on the contralateral side. TECHNIQUE A toric lens marker is used to mark the corneal limbus at two points in the horizontal plane 180° apart. Nasal and temporal conjunctival peritomies are created; hemostasis is maintained using external cautery. A standard infusion line for PPV is installed. The two remaining trocars are placed superotemporally and superonasally to the marked horizontal axis, 2 mm to 3 mm posterior to the limbus, using a straight-in, nontunneled approach. The introducers are then used to construct two additional sclerotomies, each 4 mm from one of the superonasal and superotemporal trocars, while maintaining the same 2- to 3-mm distance from the limbus. Standard PPV is then performed. This technique is compatible with 23-, 25-, or 27-gauge instrumentation. The anterior chamber is entered through a clear corneal incision that was created using a phaco keratome blade and then slightly enlarged. (A previously constructed incision can be used if cataract extraction was recently performed.) The anterior chamber is stabilized using a viscoelastic substance while the infusion line is clamped. Next, the CV-8 needles of the 8-0 PFTE suture are removed, and the suture is cut into halves. Each suture end is threaded through the two adjacent eyelets of the Akreos AO60 IOL. The suture is passed through the first IOL eyelet from anterior to posterior and then through the corresponding second eyelet from posterior to anterior (Figure 1). This pattern is repeated on the contralateral side of the IOL. In a