The authors present what they claim to be an easier ab externo scleral fixation technique for repair of late in-the-bag IOL dislocation.
Their technique uses an iris hook for intraocular suture retrieval under direct visualization, which eliminates the need to mate the suture needle with a hypodermic needle. The hook site provides an ideal place for suture knot burial, potentially minimizing late suture erosion or exposure. This approach aims to spare the superior conjunctiva and sclera in patients with significant pseudoexfoliative glaucoma should future filtration surgery be necessary.
In my opinion, this is the most valuable and atraumatic technique to date for the vexing problem of late in-the-bag IOL dislocation. The video that accompanies this article is very helpful.
The authors note that the ab externo suture loop retrieval and scleral fixation technique described by Chan and colleagues provides the advantages of small incisions, fewer awkward intraocular manipulations, and excellent IOL positioning, and enhances IOP control by using a closed system for fixation of in-the bag IOL dislocations. Building on the advantages of this technique, the current study describes modifications to enhance this fixation strategy.
The authors present three cases of late in-the bag IOL dislocation with significant pseudoexfoliation glaucoma and accompanying zonular loss in which the technique was successful. They say these patients present instances in which late in-the-bag scleral suture fixation would be preferred to IOL exchange with an anterior chamber IOL or a sutured posterior chamber IOL. Given the significant concomitant pseudoexfoliation glaucoma, finding the most atraumatic method to reposition the IOL was essential.
These cases were also not amenable to iris fixation, as this technique might cause chronic iris chafing if the in-the-bag 1-piece acrylic IOL were sutured to the iris. They say that although stripping the capsular bag and suturing the IOL to the iris or sclera can be successful for 3-piece IOLs, this would not be advisable with the 1-piece acrylic IOLs in these three patients. They add that their technique with any in-the-bag IOL dislocation may be more atraumatic than techniques that involve intraocular capsular bag stripping.
They explain that their elimination of mating the suture needle with the hypodermic needle by retrieving the polypropylene suture with the 30-degree iris hook speeds the process of suturing the haptics with less intraocular manipulation. However, late in-the-bag IOL dislocation surgery requires additional time in clinical assessment, preoperative planning, and intraoperative repair. They say that many patients with late in-the-bag IOL dislocation have significant ocular comorbidities, and consideration of concomitant ocular disease, particularly pseudoexfoliation glaucoma, is critical to successful outcomes.
The authors conclude that although further study of a larger sample size with long-term follow-up is necessary to determine the long-term potential for this technique, their initial experience has been promising.