Case with a Coloboma of the lens. Notice the lens in the center is half moon shaped as the rest of the lens has not developed. In such cases one can remove the entire lens and fix a glued IOL
In 1997, Maggi and Maggi were the first to report the sutureless scleral fixation of a special IOL. The sutureless intrascleral fixation of a posterior chamber IOL was first described by Gabor Scharioth.[4][5] This technique was further modified by making scleral flaps and creating scleral pockets for tucking the haptics. The flaps are then reattached to the bed with the help of glue.
On 14 December 2007, the first glued intraocular lens (IOL) surgery was performed, at Dr. Agarwal's Eye Hospital in Chennai, India. This new surgical procedure was invented and performed by Amar Agarwal. Subsequently, the first child on whom a glued IOL surgery was performed was a patient who had a history of injury to her right eye 3 months before, while bursting crackers. She underwent emergency surgery for lens removal due to severe injury to the lens and received a sutured IOL, which was specific for such cases. After 1 month, when the child came for follow up, it was found that there was a decenteration of the IOL. The parents had noted the child's difficulty in performing activities using the right eye. Under general anaesthesia, Agarwal removed the already existing IOL and placed a new IOL using the Glued IOL technique.
Indication
Glued IOL surgery can be done both as a primary and as a secondary procedure in cases where the lens capsule is deficient or absent. As a primary procedure it can be done in all cases of intraoperative posterior capsule rupture. It can also be done in all cases of subluxation or dislocation of the lens, such as in Marfan syndrome, traumatic dislocation of lens, etc. As a secondary procedure it can be done in all the aphakic cases or as a part of an IOL exchange, following an anterior chamber IOL, or subluxated or dislocated IOL.
Fibrin glue
Fibrin glue has been used previously, in various medical specialties, as a hemostatic agent to arrest bleeding, seal tissues, and as an adjunct to wound healing. It is available in a sealed pack that contains freeze-dried human fibrinogen (20mg/0.5 ml), freeze-dried human thrombin (250 IU/0.5 ml), aprotinin solution (1,500 KIU in 0.5 ml), one ampoule of sterile water, four 21-gauge needles, two 20-gauge blunt application needles, an applicator with two mixing chambers, and one plunger guide.
Preparation of glue: The vials are placed in a water bath which is preheated to 37 degrees for 2 to 3 minutes. 0.5 cc of distilled water is then added to the thrombinvial, and the aprotinin is mixed with fibrinogen. Each component is then placed in a separate syringe with a 26-gauge needle attached.
Surgical technique
Fig 3: Animation showing glued IOL surgery. Note the flaps made on the white portion of the eye (sclera). The IOL is injected inside the eye and one end (haptic) is grasped with the glued IOL forcepsFig 4: Glued IOL surgery. The IOL is inside the eye. Both the haptics (blue color) are externalized under the scleral flaps. They will be tucked into scleral pockets and fibrin glue applied to seal them
The glued IOL technique consists of making two partial-thickness, approximately 2.5mm by 2.5mm, scleral flaps exactly 180° apart, followed by a sclerotomy with a 20-gauge needle 1mm from the limbus. A 23-gauge vitrectomy cutter is introduced from the sclerotomy site, and a thorough vitrectomy is done to remove all the vitreous tractions. A corneal tunnel is fashioned, then a 23-gauge glued-IOL forceps is passed through the sclerotomy site, and the tip of the leading haptic of the IOL is grasped, which is then externalized and brought out onto the ocular surface (Fig 3). Similarly the trailing haptic is then externalized using the "handshake technique". Scleral pockets are made at the edge of the flap with a 26-gauge needle just parallel to the sclerotomy site, into which the two haptics are then tucked for additional stability (Fig 4). The scleral flaps are then glued back into place using biological glue. The IOLs that can be used are the three-piece foldable IOLs with slightly firm haptics, or a three-piece non-foldable IOL. The glue is then used to seal the conjunctival closure.
Vertical glued IOL
The concept of performing a "vertical glued IOL" was first suggested by Jeevan Ladi. The vertical corneal diameter is always less than the horizontal diameter. In cases of large eyes, the least corneal diameter (i.e. at 6 o'clock and 9 o'clock) along the vertical axis can be chosen for making the scleral flaps. The IOLs currently available in the market are 13mm in length. Choosing the least corneal diameter allows for extra length of the haptic available for tucking, and so gives extra stability.
Advantages:
Comfortable temporal seating.
Vortex veins are not disturbed. So, there is less bleeding.
The flaps are hidden beneath the lid margin in the fornices, which gives a better appearance.
Extra length of the haptic is available for tucking, which gives more stability to the IOL.
According to some studies by Steven Safran, it is essential to state that the diameter of the ciliary sulcus and the corneal horizontal white-white diameter may not co-relate exactly; and it has been suggested that the surgeon can go ahead with horizontal placement of haptics rather than orienting them vertically.[6]
Modifications in glued IOL surgery
No-Assistant technique – This technique works on the principle of vector forces and was first performed by Priya Narang.[7][8][9] In this technique, after the externalization of the leading haptic, the trailing haptic is flexed beyond the pupillary plane, towards the 6 o'clock position. This reverses the direction of vector forces and causes the leading haptic to extrude more from the previous sclerotomy site, thereby preventing haptic slippage and its subsequent complications.
Plugging Silicon Tires of Iris Hooks – This technique was developed by George Beiko and Roger Steinert, wherein the silicon tires of the iris hooks are plugged to the leading haptic, to prevent its accidental slippage.[10] Steven Safran developed the micro-bulldog technique for the same purpose.
Y-Fixation technique – This technique was developed by Ohta Toshihiko, et al., wherein a Y-shaped incision is made, in the sclera, that eliminates the need to make a scleral flap.[11] Mckee Yuri, Francis Price, et al., modified the scleral flap-making by lifting only two edges of the flap and keeping the flap adherent at the point of haptic enclavation.[12]
Handshake technique
Fig 5: A-A three piece IOL above the rhexis is still subluxated. B-Scleral flaps are made 180 degrees apart. One hand holding the ahptic with the glued IOL forceps while the other is doing vitrectomy. The capsule remnants are removed as they are not needed for the glued IOL. C-Handshake technique being done to catch the tip of the haptic. Notice the trocar cannula on the upper right. One needs fluid in the eye always. An AC maintainer also be used instead. D-One haptic externalized.Fig 6: Subluxated three piece IOL glued into place- Part 2. A- Second haptic is caught with the handshake technique. B- Both haptics externalized. C- Both haptics tucked in scleral pocket. D- Air in the AC, Fluid is switched off and glue applied. The air prevents any hypotony.
This technique is used for easy externalisation of haptics (Fig 5 and 6), especially for externalisation of the trailing haptic and in cases of there being small pupil.[13] Two glued IOL forceps are needed for this technique. The haptic is held with one forceps, which is introduced from the corneal tunnel, and the other forceps is introduced from the sclerotomy site. The tip of the haptic is then traced and is caught followed by externalisation from the sclerotomy site. Visualization of the tip of the haptic becomes very difficult in cases of a small pupil. Although iris hooks can be used, the handshake technique simplifies the procedure. The exteriorization of the haptics is a key step in the glued IOL surgery. Since the surgeon is maneuvering with both hands simultaneously, one hand injecting the IOL while the other grasps and exteriorizes the haptics, he/she needs to be familiar with the handshake technique as a means of transferring the haptic from one hand to the other.
If one of the haptics is not caught or if it is released accidentally after being grasped, the situation can be easily resolved using this technique. It utilizes two glued IOL forceps, one of which holds the haptic. Depending on ease of access, the other forceps is introduced through the opposite sclerotomy or through the side-port. The haptic is transferred from the first to the second forceps, such that the first forceps becomes free. It is essential to hold the haptic at its tip before exteriorizing it so that it doesn't snag on the sclerotomy while being brought out. For this reason, this handshake transfer of the haptic between the two glued IOL forceps is continued until the tip of the haptic is caught by the forceps on the side to which the haptic is to be exteriorized. This technique thus allows easy intra-ocular maneuvering of the entire haptic or IOL within a closed globe system.
Multifocal glued IOL
Multifocal IOLs allow for good vision at a range of distances. Monofocal intraocular lenses, which are commonly available, give clear far or near point-of-focus, but are limited to only one focal point. Multifocal intraocular lenses are designed to avoid the need for glasses by providing two or more points of focus.
Multifocal glued IOL procedures have been done with the ReZoom (Abbott Medical Optics), and Tecnis (Advanced Medical Optics (AMO)) IOLs. This makes it possible to offer the accommodative IOL advantage even to patients with an absent capsule. The modified Prolenepolyvinylidene fluoride haptic in these IOLs helps them in being more stiff as well as having superior structural memory. Sutured scleral-fixated IOLs in pediatric eyes have been known to lead to problems.
These intraocular lenses are intended to be placed in the capsular bag. Until recently, it was difficult to provide multifocality for patients who had complicated cataract surgeries and who lacked normal capsules. Aphakia with deficient capsule has been a limitation for obtaining multifocality. Now multifocality is possible even in complicated cataract surgeries by the Multifocal Glued IOL procedure, where multifocal IOL implantation can be done even in eyes with large posterior capsular rupture (PCR) and aphakias with deficient posterior capsule.
Fig 7A: Case with aniridia (no iris) glaucoma (increased pressure in the eye) and subluxated cataract.Fig 7B: Cataract removed, anti glaucoma surgery done and an aniridic glued IOL fixed which has artificial iris and IOL.
This glued IOL technique can be used in cases in which there is aphakia with aniridia (Fig 7 A and B). In such cases one can use an aniridia IOL, which has an artificial iris.[14]
Glued IOL Scaffold
This procedure combines two techniques: Glued IOL and IOL Scaffold.[15][16] In this technique, a glued IOL procedure is initially performed, followed by an IOL Scaffold procedure.[17] This technique is specially effective in cases with deficient posterior capsule support and sulcus or iris support. This technique is also applicable for managing a traumatic subluxated lens and Soemmering ring.[18]
Pre-Descemet's endothelial keratoplasty with glued IOL
Fig 8: Pre-Descemets Endothelial Keratoplasty – the latest technique of corneal eye transplantation photograph of a patient with corneal haziness due to endothelial damage with lens displaced before surgery (left) and the same patient after 6 months of PDEK with glued IOL surgery (Right). Note the white cornea is becoming clear (right). (Below) Anterior segment optical coherence tomography scan showing good adhesion of the graft on the inner side of cornea.
This is a combination of Pre-Descemet's endothelial keratoplasty (PDEK)[19] and glued IOL (Fig 8). This combined procedure helps to perform two procedures simultaneously, thereby limiting the number of the patient's post-operative hospital visits. PDEK is a kind of endothelial keratoplasty (corneal or eye transplantation), where the Pre-Descemet's layer (PDL), along with Descemet's membrane (DM) and endothelium, is transplanted. The normal cornea has from the front to the back the following layers:
For the human eye to see, the cornea, the front window of the eye, should be transparent. For that to happen, the inside corneal layer, the endothelium, pumps water from the cornea so that the cornea remains transparent and light can pass into the eye. If the endothelium is bad, the cornea retains a lot of water and becomes damaged, which is called Bullous Keratoplasty. Thus PDEK helps in replacing the non-functional endothelium.
On 4 September 2013, Amar Agarwal, in collaboration with Harminder Dua, performed the first PDEK surgery technique and demonstrated the significance of the Pre-Descemets layer in corneal transplantation. The initial surgery was performed for pseudophakic bullous keratopathy. Though donor eyes of all age groups were used in the initial PDEK cases, there was a marked difference in eyes with young donor corneas, which resulted in better corneal clarity and visual outcome. This paved the way for the difference of PDEK using young donors and the importance of the endothelial viability. Glued IOL can also be performed with various other corneal transplantation / keratoplasty procedures, such as Descemet's membrane endothelial keratoplasty (DMEK), Descemet's stripping endothelial keratoplasty (DSEK), and Penetrating keratoplasty (PK).
This glued IOL technique would be useful in many clinical situations in which scleral-fixated IOLs are indicated, such as luxated IOL, dislocated IOL, zonulopathy, or secondary IOL implantation. In a case with a dislocated posterior chamber, such as PMMA IOL, the same IOL can be repositioned, thereby reducing the need for further manipulation. Externalization of the greater part of the haptics along the curvature stabilizes the axial positioning of the IOL and thereby prevents any IOL tilt.
There is less incidence of uveitis-glaucoma-hyphema syndrome in a fibrin glue–assisted IOL implantation, as compared with a sutured scleral-fixated IOL implantation. In the former, the IOL is well stabilized and stuck onto the scleral bed, and thereby has decreased intraocular mobility; in the latter, there is increased possibility of IOL movement or persistent rub over the ciliary body. Visually significant complications due to late subluxation, which has been known to occur in sutured scleral-fixated IOLs, may also be prevented, as sutures are avoided in this technique. Moreover, the frequent complications of secondary IOL implantation—such as secondary glaucoma, cystoid macular edema, or bullous keratopathy—were not seen in any patients. Another important advantage of this technique is the prevention of suture-related complications, such as suture erosion, suture knot exposure, or dislocation of IOL after suture disintegration or broken suture.
The other advantages of this technique are the rapidity and ease of surgery. The technique eliminates tying the difficult-to-handle 10-0 Prolene suture to the IOL haptic eyelets, the time required to ensure good centration before tying down the knots, and the time required for suturing scleral flaps and closing the conjunctiva, thus significantly reducing total time in surgery. It is also easier and does not require much surgical expertise to use the 25-gauge forceps to grasp and exteriorize the haptic. Fibrin glue takes only 20 seconds to act in the scleral bed, and it helps in adhesion and hemostasis. Fibrin glue has been shown to provide airtight closure, and by the time the fibrin starts degrading, surgical adhesions would have already occurred in the scleral bed.
Related Research Articles
Far-sightedness, also known as long-sightedness, hypermetropia, and hyperopia, is a condition of the eye where distant objects are seen clearly but near objects appear blurred. This blur is due to incoming light being focused behind, instead of on, the retina due to insufficient accommodation by the lens. Minor hypermetropia in young patients is usually corrected by their accommodation, without any defects in vision. But, due to this accommodative effort for distant vision, people may complain of eye strain during prolonged reading. If the hypermetropia is high, there will be defective vision for both distance and near. People may also experience accommodative dysfunction, binocular dysfunction, amblyopia, and strabismus. Newborns are almost invariably hypermetropic, but it gradually decreases as the newborn gets older.
Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.
Radial keratotomy (RK) is a refractive surgical procedure to correct myopia (nearsightedness). It was developed in 1974 by Svyatoslav Fyodorov, a Russian ophthalmologist. It has been largely supplanted by newer, more accurate operations, such as photorefractive keratectomy, LASIK, Epi-LASIK and the phakic intraocular lens.
Refractive surgery is optional eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea (keratomileusis), lens implantation or lens replacement. The most common methods today use excimer lasers to reshape the curvature of the cornea. Refractive eye surgeries are used to treat common vision disorders such as myopia, hyperopia, presbyopia and astigmatism.
Phacoemulsification is a cataract surgery method in which the internal lens of the eye which has developed a cataract is emulsified with the tip of an ultrasonic handpiece and aspirated from the eye. Aspirated fluids are replaced with irrigation of balanced salt solution to maintain the volume of the anterior chamber during the procedure. This procedure minimises the incision size and reduces the recovery time and risk of surgery induced astigmatism.
An Intraocular lens (IOL) is a lens implanted in the eye usually as part of a treatment for cataracts or for correcting other vision problems such as short sightedness and long sightedness, a form of refractive surgery. If the natural lens is left in the eye, the IOL is known as phakic, otherwise it is a pseudophakic lens. Both kinds of IOLs are designed to provide the same light-focusing function as the natural crystalline lens. This can be an alternative to LASIK, but LASIK is not an alternative to an IOL for treatment of cataracts.
A phakic intraocular lens (PIOL) is a special kind of intraocular lens that is implanted surgically into the eye to correct myopia (nearsightedness). It is called "phakic" because the eye's natural lens is left untouched. Intraocular lenses that are implanted into eyes after the eye's natural lens has been removed during cataract surgery are known as pseudophakic.
The corneal endothelium is a single layer of endothelial cells on the inner surface of the cornea. It faces the chamber formed between the cornea and the iris.
Cataract surgery, also called lens replacement surgery, is the removal of the natural lens of the eye that has developed a cataract, an opaque or cloudy area. The eye's natural lens is usually replaced with an artificial intraocular lens (IOL) implant.
Capsulorhexis or capsulorrhexis, and the commonly used technique known as continuous curvilinear capsulorhexis (CCC), is a surgical technique used to remove the central anterior part of the capsule of the lens from the eye during cataract surgery by shear and tensile forces. It generally refers to removal of the central part of the anterior lens capsule, but in situations like a developmental cataract a part of the posterior capsule is also removed by a similar technique.
Howard V. Gimbel FRCSC, AOE, FACS, CABES, is a Canadian ophthalmologist, university professor, senior editor, and amateur musician. He is better known for his invention, along with Thomas Neuhann, of the continuous curvilinear capsulorhexis (CCC), a technique employed in modern cataract surgery.
Peter S. Hersh is an American ophthalmologist and specialist in LASIK eye surgery, keratoconus, and diseases of the cornea. He co-authored the article in the journal Ophthalmology that presented the results of the study that led to the first approval by the U.S. Food and Drug Administration (FDA) of the excimer laser for the correction of nearsightedness in the United States. Hersh was also medical monitor of the study that led to approval of corneal collagen crosslinking for the treatment of keratoconus.
The aim of an accurate intraocular lens power calculation is to provide an intraocular lens (IOL) that fits the specific needs and desires of the individual patient. The development of better instrumentation for measuring the eye's axial length (AL) and the use of more precise mathematical formulas to perform the appropriate calculations have significantly improved the accuracy with which the surgeon determines the IOL power.
Dr Amar Agarwal M.S., FRCS, F.R.C.Ophth is an Indian ophthalmologist and chairman and managing director of Dr. Agarwal's Eye Hospital and Eye Research Centre in India, which includes 140+ eye hospitals. He is the recipient of the Best Doctor award of the State government from then Chief Minister of Tamil Nadu J Jayalalithaa on 15 August 2014. He is also the past President of the International Society of Refractive Surgery (ISRS) and Secretary General of the Intraocular Implant and Refractive Society of India (IIRSI).
Pre Descemet's endothelial keratoplasty (PDEK) is a kind of endothelial keratoplasty, where the pre descemet's layer (PDL) along with descemet's membrane (DM) and endothelium is transplanted. Conventionally in a corneal transplantation, doctors use a whole cornea or parts of the five layers of the cornea to perform correction surgeries. In May 2013, Dr Harminder Dua discovered a sixth layer between the stroma and the descemet membrane which was named after him as the Dua's layer. In the PDEK technique, doctors take the innermost two layers of the cornea, along with the Dua's layer and graft it in the patient's eye.
Intraocular lens scaffold or IOL scaffold technique is a surgical procedure in ophthalmology. In cases where the posterior lens capsule is ruptured and the cataract has not yet been removed one can insert the intraocular lens (IOL) inside the eye under the cataract. This way the IOL acts as a scaffold and prevents the cataract pieces from falling inside the back of the eye. The cataract can then be removed safely by emulsifying it with ultrasound and aspiration. This technique is called IOL scaffold and was started by Amar Agarwal from Chennai, India, at Dr. Agarwal's Eye Hospital.
Burkhard Dick is a German ophthalmologist who has specialized in refractive and cataract surgery. With his many contributions to the scientific literature on this topic, he is considered one of the pioneers of employing the femtosecond laser in cataract surgery. In the "Power List 2023" ranking of the world's most influential ophthalmologists by the publication The Ophthalmologist, Burkhard Dick was listed among the Top 10.
An artificial iris is an intraocular implant that is used as both a cosmetic and to treat those with aniridia or other eye trauma. People with this condition experience photophobia, or increased sensitivity to light. The artificial iris, made from silicone, acts as a replacement iris. The artificial iris is implanted in the eye using different surgery techniques depending on the patient's eye trauma. Most of the major artificial iris manufacturers are European and the treatment is used sparingly in the United States because of limited FDA approval, in part due to possibility of vision loss and other risks.
Manual small incision cataract surgery (MSICS) is an evolution of extracapsular cataract extraction (ECCE); the lens is removed from the eye through a self-sealing scleral tunnel wound. A well-constructed scleral tunnel is held closed by internal pressure, is watertight, and does not require suturing. The wound is relatively smaller than that in ECCE but is still markedly larger than a phacoemulsification wound. Comparative trials of MSICS against phaco in dense cataracts have found no difference in outcomes but MSICS had shorter operating times and significantly lower costs. MSICS has become the method of choice in the developing world because it provides high-quality outcomes with less surgically induced astigmatism than ECCE, no suture-related problems, quick rehabilitation, and fewer post-operative visits. MSICS is easy and fast to learn for the surgeon, cost effective, simple, and applicable to almost all types of cataract.
↑ Narang, P (2013-06-01). "Postoperative analysis of glued intrascleral fixation of intraocular lens and comparison of intraoperative parameters and visual outcome with 2 methods of haptic externalization". J Cataract Refract Surg. ncbi.nlm.nih.gov//. 39 (7): 1118–9. doi:10.1016/j.jcrs.2013.05.017. PMID23809948. S2CID8371821.
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