Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules Amar Agarwal, MS, FRCS, FRCOphth, Dhivya Ashok Kumar, MD, Soosan Jacob, MS, DNB, FRCS, MNAMS, Chandresh Baid, MS, Athiya Agarwal, MD, DO, Sridhar Srinivasan, MBBS, DO We report a new surgical technique that uses biological glue to implant a posterior chamber in- traocular lens (PC IOL) in eyes with a deficient or absent posterior capsule. Two partial-thickness limbal-based scleral flaps are made 180 degrees apart diagonally, and the haptics of the PC IOL are externalized to place them beneath the flaps. Fibrin glue is used to attach the haptics to the scleral bed, beneath the flap. This simple method of PC IOL implantation requires no specially designed haptics. It provides good flap closure and IOL centration and stability without suture-related complications. J Cataract Refract Surg 2008; 34:1433–1438 Q 2008 ASCRS and ESCRS Intraocular lens (IOL) implantation in eyes that lack posterior capsule support has been accomplished with an iris-fixated IOL, 1 an anterior chamber IOL, and transscleral IOL fixation 2–6 through the ciliary sulcus or pars plana. Surgical expertise, prolonged surgical time, suture-induced inflammation, suture degradation, and delayed IOL subluxation or disloca- tion due to broken sutures are limitations of sutured scleral-fixated IOLs. We report a new technique that places a posterior chamber IOL (PC IOL) in eyes with deficient posterior capsule using a quick-acting surgical fibrin sealant derived from human blood plasma, with both hemostatic and adhesive properties. Fibrin glue has been used in various medical special- ties as a hemostatic agent to arrest bleeding and seal tissues and as an adjunct to wound healing. 7,8 SURGICAL TECHNIQUE Under peribulbar anesthesia, the superior rectus is caught and clamped. Localized peritomy and wet cautery of the sclera are done at the desired site of exit of the IOL haptics. An infusion cannula or anterior chamber maintainer is inserted. To prevent interfer- ence in the creation of the scleral flaps, the infusion cannula should be positioned in the inferonasal quadrant. Two partial-thickness limbal-based scleral flaps about 2.5 mm 3.0 mm are created exactly 180 degrees apart diagonally (Figure 1) and about 1.5 mm from the limbus. This is followed by vitrec- tomy via the pars plana or the anterior route to remove all vitreous traction. Two straight sclerotomies are made with a 22-gauge needle about 1.5 mm from the limbus under the existing scleral flaps. The scleroto- mies are positioned so the superior one lies close to the upper edge of the flap and the inferior one, close to the lower edge of the flap. A scleral tunnel incision is then prepared for introducing the IOL in secondary IOL implantation. While the IOL is being introduced by one hand using a McPherson forceps, an end- gripping 25-gauge microrhexis forceps (Micro Surgical Technology) is passed through the inferior sclerotomy with the other hand. The tip of the leading haptic is grasped with the microrhexis forceps, pulled through the inferior sclerotomy following the curve of the haptic (Figure 2), and externalized under the inferior scleral flap. The trailing haptic is also externalized through the superior sclerotomy under the scleral flap. The biological glue used is the ReliSeal fibrin kit (Reliance Life Sciences), which is available in a sealed pack that contains freeze-dried human fibrinogen (20 mg/0.5 mL), freeze-dried human thrombin (250 IU/0.5 mL), aprotinin solution (1500 KIU in Accepted for publication April 9, 2008. From Dr. Agarwal’s Eye Hospital and Eye Research Centre, Tamil Nadu, India. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Professor Amar Agarwal, MS, FRCS, FRCOphth, Dr. Agarwal’s Eye Hospital and Eye Research Centre, 19, Cathedral Road, Chennai - 600086, Tamil Nadu, India. E-mail: [email protected]. Q 2008 ASCRS and ESCRS Published by Elsevier Inc. 0886-3350/08/$dsee front matter 1433 doi:10.1016/j.jcrs.2008.04.040 TECHNIQUE
We report a new surgical technique that uses biological glue to implant a posterior chamber in-traocular lens (PC IOL) in eyes with a deficient or absent posterior capsule. Two partial-thicknesslimbal-based scleral flaps are made 180 degrees apart diagonally, and the haptics of the PC IOL areexternalized to place them beneath the flaps. Fibrin glue is used to attach the haptics to the scleralbed, beneath the flap. This simple method of PC IOL implantation requires no specially designedhaptics. It provides good flap closure and IOL centration and stability without suture-relatedcomplications.
Intraocular lens (IOL) implantation in eyes that lackposterior capsule support has been accomplishedwith an iris-fixated IOL,1 an anterior chamber IOL,and transscleral IOL fixation2–6 through the ciliarysulcus or pars plana. Surgical expertise, prolongedsurgical time, suture-induced inflammation, suturedegradation, and delayed IOL subluxation or disloca-tion due to broken sutures are limitations of suturedscleral-fixated IOLs. We report a new technique thatplaces a posterior chamber IOL (PC IOL) in eyeswith deficient posterior capsule using a quick-actingsurgical fibrin sealant derived from human bloodplasma,with both hemostatic and adhesive properties.Fibrin glue has been used in various medical special-ties as a hemostatic agent to arrest bleeding and sealtissues and as an adjunct to wound healing.7,8
SURGICAL TECHNIQUE
Under peribulbar anesthesia, the superior rectus iscaught and clamped. Localized peritomy and wet
Accepted for publication April 9, 2008.
From Dr. Agarwal’s Eye Hospital and Eye Research Centre, TamilNadu, India.
No author has a financial or proprietary interest in any material ormethod mentioned.
Corresponding author: Professor Amar Agarwal, MS, FRCS,FRCOphth, Dr. Agarwal’s Eye Hospital and Eye Research Centre,19, Cathedral Road, Chennai - 600086, Tamil Nadu, India. E-mail:[email protected].
Q 2008 ASCRS and ESCRS
Published by Elsevier Inc.
cautery of the sclera are done at the desired site ofexit of the IOL haptics. An infusion cannula or anteriorchamber maintainer is inserted. To prevent interfer-ence in the creation of the scleral flaps, the infusioncannula should be positioned in the inferonasalquadrant. Two partial-thickness limbal-based scleralflaps about 2.5 mm � 3.0 mm are created exactly 180degrees apart diagonally (Figure 1) and about1.5 mm from the limbus. This is followed by vitrec-tomy via the pars plana or the anterior route to removeall vitreous traction. Two straight sclerotomies aremade with a 22-gauge needle about 1.5 mm from thelimbus under the existing scleral flaps. The scleroto-mies are positioned so the superior one lies close tothe upper edge of the flap and the inferior one, closeto the lower edge of the flap. A scleral tunnel incisionis then prepared for introducing the IOL in secondaryIOL implantation. While the IOL is being introducedby one hand using a McPherson forceps, an end-gripping 25-gaugemicrorhexis forceps (Micro SurgicalTechnology) is passed through the inferior sclerotomywith the other hand. The tip of the leading haptic isgrasped with the microrhexis forceps, pulled throughthe inferior sclerotomy following the curve of thehaptic (Figure 2), and externalized under the inferiorscleral flap. The trailing haptic is also externalizedthrough the superior sclerotomy under the scleral flap.
The biological glue used is the ReliSeal fibrin kit(Reliance Life Sciences), which is available in a sealedpack that contains freeze-dried human fibrinogen(20 mg/0.5 mL), freeze-dried human thrombin(250 IU/0.5 mL), aprotinin solution (1500 KIU in
0886-3350/08/$dsee front matter 1433doi:10.1016/j.jcrs.2008.04.040
1434 TECHNIQUE: GLUED IOLs IN EYES WITH DEFICIENT POSTERIOR CAPSULES
Figure 1. A: Scleral flaps (sf) of2.5 mm � 3.0 mm placed about1.5 mm from the limbus. B: Twoflaps made exactly 180 degreesapart diagonally.
Figure 3. A: Reconstituted fibrino-gen and thrombin preparation of fi-brin glue (FG) injected beneath thescleral flaps. B: Scleral flaps sealedwell with the scleral bed.
Figure 2. Two images showing thehaptics being externalized by a 25-gauge forceps (f) beneath the scleralflap (sf).
Figure 4. Two images showing thehaptics (h) being externalized bya 25-gauge forceps (f) beneath thescleral flap (sf) in a patient witha dislocated PC IOL.
0.5 mL), 1 ampoule of sterile water, four 21-gauge nee-dles, two 20-gauge blunt application needles, and anapplicator with 2 mixing chambers and 1 plungerguide. The aprotinin solution is taken in a 2 mL sterile
J CATARACT REFRACT SUR
syringe, mixed with the freeze-dried fibrinogen, andthen shaken in a slow circular motion. The reconsti-tuted vial is placed in a preheated water bath of 37�Cfor no more than 10 minutes. Next, about 0.5 mL of
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1435TECHNIQUE: GLUED IOLs IN EYES WITH DEFICIENT POSTERIOR CAPSULES
Figure 5. Fibrin glue (FG) is injectedbeneath the flaps with the ReliSealapplicator on the externalized hap-tics (left) and local pressure appliedfor 20 seconds (right).
water for injection is aspirated and injected intothe vial of freeze-dried thrombin, followed by gentleagitation of the vial. Reconstitution is consideredcomplete when no undissolved particles are visible.
The reconstituted fibrinogen and the thrombin areloaded separately in two 2.0 mL sterile syringes andmounted onto the ReliSeal applicator for use. Thusprepared, the reconstituted fibrin glue is injectedthrough the cannula of the double syringe deliverysystem under the superior and inferior scleral flaps(Figure 3). Local pressure is applied to the flaps for10 to 20 seconds while fibrin polypeptides form. If anIOL with longer haptics is used, the tip of the hapticthat extends beyond the scleral flap is buried insidea small scleral pocket made by a 22-gauge needle atthe point of extension. In patients with a subluxatedIOL, lamellar scleral flaps as described earlier aremade and the subluxated IOL haptic is grasped with
ARMD Z age-related macular degeneration; BCVA Z best corrected visual acuity (Snellen acuity in decimal equivalent); CME Z cystoid macular edema;IOP Z intraocular pressure (noncontact tonometer); Preop Z preoperative; Post Z postoperative ; % Change Z % change in endothelial cell count
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1436 TECHNIQUE: GLUED IOLs IN EYES WITH DEFICIENT POSTERIOR CAPSULES
the 25-gauge capsulorhexis forceps and externalized(Figure 4) and glued under the scleral flaps (Figure 5).The anterior chamber maintainer or the infusion can-nula is removed. The conjunctiva is closed with thesame fibrin glue (Figure 6).
RESULTS
The technique was used in 10 eyes of 10 patients. Themean preoperative Snellen best corrected visual acuity(BCVA) in decimal equivalent was 0.46 G 0.42, andthe mean postoperative BCVA on day 1 was 0.50 G0.38. At 6 weeks, the mean BCVAwas 0.50 G 0.37 (Ta-ble 1). No patient showed a drop in BCVA. In 2 eyesthat had a dislocated PC IOL, the same IOL was im-planted with fibrin glue; in the other 8 eyes, a newPC IOL was placed using the fibrin glue technique.In 3 eyes (30%), the BCVA was 1.0 postoperatively.The cause of the lower BCVA in the other 7 eyes(70%) was preexisting retinal pathology (Table 1). Inall patients, the visual acuity was stable during the 6-week follow-up. In 1 patient on occlusion therapy,the BCVA improved (Table 1) from day 1 to 6 weeks.There was no significant change in the mean intraocu-lar pressure. The mean percentage change in the endo-thelial cell count was �1.64% G 1.29% cells/mm2
(Table 1). No major complications were encounteredduring the follow-up.
DISCUSSION
This technique would be useful in myriad clinical situ-ations in which scleral-fixated IOLs are indicated, suchas a subluxated IOL, a dislocated IOL, zonulopathy, orsecondary IOL implantation. With dislocated PC IOLsmade of poly(methyl methacrylate) (PMMA), the IOLcan be repositioned, reducing the need for further ma-nipulation. The technique can be used with rigidPMMA IOLs, 3-piece PC IOLs, or IOLs with modifiedPMMA haptics. One does not need special scleral-fixated IOLs with eyelets or new haptic designs. Sincethe haptic is being placed in its normal curved config-uration without traction, there is no distortion orchange in the shape of the IOL optic. Externalizationof the greater part of the haptic along its curvature sta-bilizes the axial positioning of the IOL and therebyprevents IOL tilt.9 Placing the IOL haptic beneath theflap prevents further movement of the haptic, reduc-ing the pseudophacodonesis10 that leads to constantmotion in the vitreous and, ultimately, to retinal dam-age. Longer follow-ups are needed to confirm this.
In the 10 eyes of our 10 patients, complications suchas postoperative inflammation, hyphema, decentration,glaucoma, corneal edema, or fibrin glue–induced reac-tion have not been seen in the regular follow-up exam-inations. Themean change in endothelial cell loss after 6
J CATARACT REFRACT SUR
weeks was less than that with anterior chamber IOLs.11
We expect a lower incidence of uveitis-glaucoma-hy-phema syndrome with glued IOLs than with suturedscleral-fixated IOLs.12 This is because in the former,the IOL is well stabilized and glued to the scleral bed,with decreased intraocular mobility, whereas in the lat-ter, there is an increased possibility of IOLmovement orpersistent rub over the ciliary body. Visually significantcomplications due to late subluxation,13,14 complica-tions related to sutures,15–18 and secondary IOL implan-tation19 may also be prevented as sutures are avoided.Chances of scleral melt20 and haptic exposure are notincreased by this technique, except possibly in high-risk patients such as those with rheumatoid arthritis.
The other advantage of this technique is the rapidityand ease of surgery, thereby reducing the risk forretinal photic injury,21,22 which is known to occurwith scleral-fixated IOLs. Fibrin glue takes only 20 sec-onds to act in the scleral bed, and it helps in adhesionas well as hemostasis. The preparation time can be re-duced in elective procedures by preparing the glue be-fore surgery as it remains stable up to 4 hours from thetime of reconstitution. Fibrin glue has been shown toprovide airtight closure and by the time the fibrinstarts degrading, surgical adhesions would haveoccurred in the scleral bed. This is shown in our fol-low-up anterior segment optical coherence tomogra-phy (OCT) images (Figure 7) in which postoperativeperfect scleral flap adhesion was observed as early asday 1 and was well sealed at 6 weeks.
The commercially available fibrin glue that we usedis virus inactivated and is checked for viral antigenand antibodies with polymerase chain reaction; hence,
Figure 7. The scleral flap as seen by anterior segment OCT on day 1(above) and well-sealed scleral flaps at 6 weeks (below).
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1437TECHNIQUE: GLUED IOLs IN EYES WITH DEFICIENT POSTERIOR CAPSULES
Figure 8. Postoperative anteriorsegment OCT showing a 360-de-gree well-centered IOL at 6 weeks.
the chances for transmission of infection are low. Withtissue derivatives, there is a theoretical possibility oftransmission of viral infections23; it is thereforemanda-tory to have informed consent from the patient beforethe procedure. Fibrin glue has been successfully usedto treat various ocular conditions.24–27 Gabor and Pavi-lidis28 describe sutureless scleral IOL fixation in whichthe IOL haptic is placed in a scleral tunnel. Our tech-nique differs from other sutureless methods28,29 inthe use of the fibrin glue,which enhances the rate of ad-hesion with hemostasis, and in the use of the availableIOL design. Scleral indentation performed in the oper-ated eyes for fundus examination showed no change inthe axial positioning of the IOL. After 6 weeks of fol-low-up, we found no IOL decentration (Figure 8) orother complications in any of the 10 eyes. We believethis method of PC IOL implantation is appropriatefor eyes with deficient or absent posterior capsules; itcan be performed easily with the available IOL designsand instruments and requires less surgical time. A clin-ical studywithmore patients and a longer follow-up isrequired to determine the long-term functional and an-atomical results of the procedure.
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ular lenses. J Cataract Refract Surg 2000; 26:1028–1034
2. Bleckmann H, Kaczmarek U. Functional results of posterior
chamber lens implantation with scleral fixation. J Cataract Re-
