The authors of this study describe a new monoscleral fixation technique they've dubbed "cupid fixation" that uses a 10-0 polypropylene suture on a straight needle to pierce an IOL as a cupid's arrow would pierce a heart. They report in the September issue of the Journal of Cataract & Refractive Surgery that the procedure can safely reposition a subluxated IOL and is a simple, inexpensive, minimally invasive and effective option for providing long-lasting fixation of a dislocated IOL. One of the authors has performed it in 24 patients, with successful IOL centration in all cases and no intraoperative or immediate postoperative complications.
During the procedure, which is performed under subconjunctival anesthesia, after the body of the subluxated IOL is perforated with the suture, the IOL is centered and fixated at the sclera overlying the ciliary sulcus. The knot is tied beneath a previously created limbal intrascleral pocket.
The patients who have undergone the procedure have been followed for a mean of 26 months (range, 16 to 34 months), with all repositioned IOLs remaining centered and postoperative Scheimpflug imaging corneal topography (Pentacam HR, Oculus, Inc.) showing minimal corneal astigmatism and no IOL tilt or decentration. The mean interval from the original cataract surgery to the repositioning surgery was four years (range, seven months to eight years). Causes of IOL subluxation were poor anterior capsule support (nine cases), ocular trauma (three cases) and subluxation associated with pseudoexfoliative zonular dehiscence (12 cases).
One case of inferior haptic subluxation into the vitreous occurred one month after surgery and required an additional cupid fixation 180 degrees from the first fixation because of insufficient inferior capsular support. In two cases presenting with sunset syndrome, primary double cupid fixation was performed with two scleral pockets created at 6 o'clock and 12 o'clock.
The authors believe that cupid fixation is successful for recentering subluxated IOLs due to its low level of surgical trauma. It is performed through small corneal incisions, involves minimal IOL manipulation and, in most cases, requires only one scleral fixation. Because the IOL optic has a much higher surface area than the haptics, using the optic edge as a traction point provides the surgeon with more options in placing the fixating suture, with the cupid fixation independent of limiting factors, such as existing capsule support or pupil morphology.
A primary advantage of the technique becomes apparent in cases in which the subluxation axis is perpendicular to the haptics, as the IOL fixating suture will pass through the optic, bringing the IOL into a centered position and creating a three-point support system (i.e., the two IOL haptics ideally placed in the ciliary sulcus plus the cupid suture fixated at the scleral pocket). The authors believe this three-point system provides increased stability, diminishing the risk for postoperative IOL tilt or displacement.
They say that even if the axis of subluxation coincides with the IOL haptic axis, the cupid fixation technique allows better fixation because when the knot is tied, the subluxated haptic is brought into contact with the ciliary sulcus, similar to other scleral fixation techniques. The difference is that one of the suture threads passes under the optic edge and the subluxated haptic, providing extended support for the IOL.