EyeWorld Asia-Pacific March 2021 Issue

SECONDARY FEATURE 24 EWAP MAR C H 2021 T he implantation of intraocular lenses (IOLs) in eyes with compromised zonular support or a deficient lens capsule is often challenging. In such situations, the IOL can be implanted in the anterior chamber (ACIOL), fixated to the iris (iris fixation), or fixated to the scleral wall (scleral fixation), with each technique having certain limitations. Scleral fixation can be performed using sutured or sutureless techniques. Commonly used sutures include 9-0 or 10-0 polypropylene (Prolene), and polytetrafluoroethylene (ePTFE) (GORE-TEX). Suture fixation with polypropylene is associated with late suture breakage from biodegradation, which makes it less favorable for use in younger patients. The use of GORE-TEX CV-8 sutures for IOL fixation has been gaining in popularity due to its durability but it remains an off-label item for use in the eye and it comes with a thick needle that is suboptimal for intraocular surgery. Sutureless methods of fixating an IOL to the sclera include the glued-IOL and Yamane by John Wong, MD 6-0 polypropylene flanged fixation of intraocular lenses Contact information Wong: drjohnwong@yahoo.com.sg On 27 November 2020, the APACRS held a webinar in conjunction with the Bangladesh Society of Cataract & Refractive Surgeons (BSCRS) annual conference 2020 on “What’s New in Cataract & Refractive Surgery.” This article was written by the author based on his presentation on “6-0 polypropylene flanged fixation of IOLs.” techniques. The Yamane technique relies on the creation of flanges by heating the haptic tips of 3-piece IOLs, which fixates the flange intrasclerally within the scleral tunnel . More recently, Canabrava modified the concept of flanged fixation by creating flanges on 5-0 or 6-0 polypropylene sutures, thus expanding the use of flanges for scleral fixation without being limited to 3-piece IOLs. Otherwise known as “Double- flanged fixation” or “Adjustable- flanged fixation,” this versatile technique can be used on a variety of clinical situations to secure either IOLs or capsular stabilizing devices to the scleral wall using thicker polypropylene sutures: Fixation of a capsular tension segment (CTS) In this cataract with deficient zonular support in at least 4 superior clock hours, phacoemulsification was completed with the aid of capsular hooks. After insertion of a capsular tension ring and an IOL within the capsular bag, a 27-G needle enters the superior sclera transconjunctivally 2mm posterior to the limbus to receive the 6-0 polypropylene suture through the main incision (Figure 1a). One end of the suture is externalized above the sclera while a CTS is threaded through the other free end of the suture. A flange was created to prevent the CTS from slipping off the suture. The CTS was positioned within the capsular bag (Figure 1b). The externalized suture end was shortened and a flange created. The flange was tucked under the conjunctiva and should sit within the scleral tunnel or flushed with the sclera (Figure 1c). Scleral fixation with 6-0 polypropylene in aphakia Two (2) separate lengths of 6-0 polypropylene were passed through the optic-haptic junction of a 1-piece acrylic IOL. Flanges were created on the undersurface of the IOL to secure the sutures in place to create “pseudo-haptics” (Figure 2a). In this case, each free end of the suture entered the anterior chamber through a scleral tunnel and was docked into the 27-G needle and externalized 2 mm posterior to the limbus 180 degrees apart to create 2-point fixation (Figure 2b). The IOL Figure 1 John WONG, Singapore Consultant, Dept of Ophthalmology Tan Tock Seng Hospital