EyeWorld India December 2014 Issue

December 2014 21 EWAP FEATURE keratome is made for introducing the IOL. This is followed by anterior vitrectomy to remove the anterior vitreous in the anterior chamber. When an IOL with rigid optic is planned, the corneo-limbal incision is extended to 6 mm size. The cartridge loaded with the foldable IOL is then passed into the anterior chamber. A glued-IOL forceps (Microsurgical Technology, Redmond, Wash., U.S. or Epsilon Eye Care Pvt. Ltd., Mumbai, India) is passed through the sclerotomy and the tip of the leading haptic is grasped and externalized using the glued-IOL forceps. An assistant or silicone tires hold the haptic. The second haptic is then flexed into the anterior chamber and pulled through the opposite sclerotomy using the glued-IOL forceps by the handshake technique. In the handshake technique, the end opening forceps is passed through the opposite sclerotomy site while another forceps is in the pupillary plane ready to receive the haptic (Figure 2). Any portion of the leading haptic is initially grasped with the forceps. Now the other forceps starts grabbing the haptic like a handshake and this process is continued till the tip of the haptic is held by the forceps. When both haptics are externalized under the flaps, they are tucked into an intralamellar Gabor Scharioth scleral tunnel made with a 26-gauge needle at the point of haptic externalization (Figure 3). Reconstituted fibrin glue (Tisseel, Baxter Healthcare Corp., Deerfield, Ill., U.S.) is then injected under the scleral flaps, and local pressure is applied for 10 seconds. The corneal wound is closed with fibrin glue or 10-0 monofilament nylon suture. The conjunctiva is closed with the fibrin glue in all eyes. Fibrin glue replaces suture In the glued IOL method, the PC IOL is transsclerally fixed by the haptics. 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. Although complete scleral wound healing with collagen fibrils may take up to 3 months, since the haptic is snugly placed inside a scleral pocket, the IOL remains stable. There is no need of haptic or optic suturing. The main corneal wound is closed with 10-0 monofilament nylon in eyes with large incision and rigid IOL implantation. However, in eyes with foldable IOL implantation, the main wound can be stromally hydrated and one suture is placed (Figure 3). Combined surgeries Glued IOL can be combined with keratoplasty procedures like optical penetrating keratoplasty (OPK), Descemet’s-membrane endothelial keratoplasty (DMEK), Descemet’s-stripping endothelial keratoplasty (DSEK), and pre-Descemet’s endothelial keratoplasty (PDEK). Abnormal iris configuration in iatrogenic iris defect or congenital coloboma can be corrected by pupilloplasty along with glued IOL. In eyes with congenital subluxated lens or ectopia lentis, lensectomy is performed, followed by glued IOL implantation. Choice of IOL Both foldable and rigid IOL can be implanted by this technique. A three-piece foldable IOL is ideal for glued IOL implantation. There is no need for special IOL designs, which can be costly for the patient in an unplanned situation, such as intraoperative posterior capsule rupture. Haptic made of polymethyl methacrylate (PMMA) or polyvinylidene fluoride (PVDF) is preferred. The foldable glued IOL has reduced the need for the large incisions initially required for rigid IOLs. In eyes with defective iris, an aniridia IOL can be implanted by the glued IOL technique. The glued IOL procedure can be performed with multifocal (diffractive or refractive) IOLs. When glued IOL is performed in an eye with dislocated posterior chamber IOL, the same IOL can be positioned by the glued IOL method without explantation (Figure 4). In eyes with malpositioned PC IOL in the anterior chamber, the PC IOL is repositioned in a closed globe method. Surgical modifications Initially, the surgery was performed with a 20-gauge transscleral infusion cannula; subsequently, 23-gauge transconjunctival trocar cannulas or an anterior chamber maintainer have been used for intraoperative infusion. In the Glued IOL Scaffold technique, the glued IOL technique and the IOL scaffold are combined (Figure 5). Here, in case of intraoperative PCR, a three-piece foldable IOL is placed (by glued IOL method) behind the existing PCR and the phacoemulsification is completed above the IOL. During glued IOL, if the horizontal white-to-white is more than 11 mm, it would be better to do a vertical glued IOL in which the scleral flaps are made at the 12 and 6 o’clock positions. The reason is that the vertical diameter of the cornea is shorter than the horizontal and one would get more haptic externalized to tuck and glue. When there is not enough haptic to tuck due to posteriorly placed sclerotomy, an additional sclerotomy anterior to the existing one can be made and the haptic can be externalized through it. In eyes with microcornea, customized trimming of the IOL haptics and use of a small-sized IOL optic has shown good IOL centeration. Comparison with other techniques Glued IOL has shown lesser complications as compared to anterior chamber (AC) lenses. In a recent study, we noted that the patients noted decrease in visual symptoms after AC IOL explantation followed by glued IOL implantation in complicated eyes. There are no reports of IOL continued on page 22