EyeWorld Asia-Pacific December 2015 Issue

December 2015 21 EWAP FEATURE makes two 350-micron grooves 180 microns apart. These are dissected posteriorly underneath the conjunctiva to create a space that’s intrascleral. So there is a roof of sclera on top of the pocket and the surgeon can keep a suture knot underneath, Dr. Hoffman explained, adding that this way it can’t erode through the conjunctiva and allow bacteria to get in. If there is a capsular tension ring left in place, as Dr. Hoffman tends to do in pseudoexfoliation cases, over the years if the lens becomes loose, the surgeon can fixate the ring to the sclera anywhere for 360 degrees around the capsular bag, he said. Using a glued approach Another way to fixate an IOL without capsular support is with the use of glue. Amar Agarwal, MD , chairman and medical director, Dr. Agarwal’s Group of Eye Hospitals, Chennai, India, uses this approach. He credits Gabor B. Scharioth, MD, with performing the first glued intrascleral haptic fixation. The technique involves making scleral flaps and using fibrin glue to seal the IOL inside, Dr. Agarwal explained, adding that Tisseel glue (Baxter Healthcare, Deerfield, Ill.) is made from normal blood and is safe. With this approach, the lens remains solidly in place and does not move as a sutured or anterior chamber lens would, he said. With the suture technique, the lens can swing between the 2 suture points and there can be tilt of the IOL, which can be tighter on one side than the other. With the glued IOL technique, such tilt is negligible and the IOL remains steady, he said. Because there is no movement with glued IOLs, there is no inflammation postoperatively. This can have particular appeal for young patients. If you put an anterior chamber lens in the eye, over the next 70 years this can move and create damage, Dr. Agarwal pointed out. “If you put in a sutured lens, the suture can break after some time,” he said. “The advantage of a glued IOL is it remains steady.” There are many others who can benefit, he said. He pointed to cases of pseudoexfoliation in which measures such as the use of endocapsular rings may only buy time, but don’t fix the problem of progressively loosening zonules. “We take out the whole cataract and fix a glued IOL inside,” he said. In gluing the lens here, Dr. Agarwal uses what is known as the handshake technique. With this approach, the tip of the haptic is externalized by first grasping it with one glued IOL forceps and then handing it off to another. Once the first haptic has been externalized and the lens fully inserted, the practitioner moves on to the second. Again the handshake technique is used, transferring the haptic from hand to hand until it is fully externalized on the other side. Each of the haptics is then tucked into a separate intrascleral pocket on opposite sides and the glue is applied to seal the pocket and subsequently ensure that the conjunctiva adheres over this, Dr. Agarwal said. When gluing the IOL in place, it is important to have fluid not viscoelastic in the eye, he stressed, adding that without a capsule any viscoelastic will fall on the retina. Dr. Agarwal uses an instrument he designed called the trocar anterior chamber maintainer, which inserts fluid through the sclera into the anterior chamber during the procedure. Dr. Agarwal has also recently started using the glued IOL technique in conjunction with pre-Descemet’s endothelial keratoplasty (PDEK) in which 25 microns of tissue are transplanted from one patient to another. When combining the techniques, Dr. Agarwal will first perform the glued IOL technique and then perform the PDEK procedure. “Now the glued IOL works like a trampoline, so when I inject air inside the eye it pushes against the graft,” he said, adding that corneas become clear, making for happy patients. Overall, there can be a bit of a learning curve with the techniques, Dr. Agarwal acknowledged. He advised practitioners to watch videos of the procedures first. Dr. Hoffman recommended becoming versed in a variety of approaches for non-capsular IOL fixation. “There are certain instances where a particular technique might be better or easier to do, so it’s nice to be able to do them all or at least be aware of them all,” Dr. Hoffman said. EWAP Editors’ note: Dr. Agarwal and Dr. Hoffman have no financial interests related to this article. Contact information Agarwal: dragarwal@vsnl.com Hoffman: rshoffman@finemd.com Come listen to Prof. Oliver Findl as he delivers the 2016 APACRS LIM Lecture on “Achieving Emmetropia with Lens Surgery – SSll some way to go?” Chair of the Department of Ophthalmology, Hanusch Hospital, Vienna, Austria Authored over 250 arrcles in internaaonal peer-reviewed journals Founder and chair of the Vienna Insstute for Research in Ocular Surgery (VIROS), A Karl Landsteiner Insstute, Vienna, Austria 2016 APACRS LIM LECTURE ORGANIZED BY: