Scleral Fixated IOLs-an experience

Context: Scleral fixation of IOL is the procedure of implanting a posterior chamber IOL in the sulcus in absence of posterior capsular support as in prior cataract extraction or Aphakia, Traumatic cataract, subluxation/dislocation of natural lens. Aims: To study the outcome of 68 Aphakic eyes which underwent Sutured Scleral Fixation of IOLs. Results in terms of Intraoperative difficulties, Postoperative complications and Visual recovery were noted. Settings and Design: Prospective Interventional Study. Materials and Methods : 68 eyes of 68 patients were subjected to Sutured Scleral fixation of Posterior chamber IOL surgery in Dept. of Ophthalmology in a tertiary Government teaching institute, either primary or as secondary surgery. Good Best Corrected Visual Acuity and a quiet eye with no fundus abnormality were the prerequisites. Two point fixation was done using 10-0 Prolene straight needle suture by a single surgeon. Results: Intraoperative difficulties encountered were Hypotony, hyphaema, and suture entangling. Postoperative complications like Hyphaema and Iritis were seen. Postoperative Best Corrected Visual Acuity in 92% cases was 6/6 to 6/18. No special IOL or instruments were required in this technique. Conclusions: Sutured Scleral fixation is the best option for Aphakic patients without capsular support in the hands of a careful surgeon. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license (https://creativecommons.org/licenses/by-nc/4.0/)


Introduction
Scleral fixation of IOL is the procedure of implanting a posterior chamber IOL in the sulcus in absence of posterior capsular support as in prior cataract extraction or Aphakia, Traumatic cataract, subluxation/dislocation of natural lens.
Various options for Secondary IOLs available are AC IOLs, Iris claw IOLs, Sutured IOLs, Glued IOLs and Sutureless Intrascleral IOLs. All of them have their own advantages and drawbacks. 1

History
Scleral fixation of posterior chamber IOLs was first described by Malbran

Aims and Objectives
To study the outcome of 68 eyes who underwent sutured scleral fixation of posterior chamber IOL. Results  Fundus examination for CME or RD. followed by Keratometry and A Scan, and IOL power calculation. Intraocular Pressure measurement and Sac Syringing.
Timing of Scleral Fixation Surgery was decided as Primary or Secondary-minimum 4 wks. after first surgery to take care of inflammation, hypotony and CME.

Procedure
After written consent and Peribulbar block, eye painted and draped, Speculum and Bridle suture applied, Conjunctival Peritomy performed, vessels cauterized, Triangular scleral flaps made 180 deg apart, 2 point (10-4, or 2-8 clock) 3 mm behind the limbus Pars Plana fixation, using One Straight and one curved needle10-0 Prolene suture. The straight needle was fed into a bent 26G needle and brought out. The suture loop brought out through the scleral tunnel incision with Mc pherson's forcep, cut and then tied to the routine one piece pcIOL haptics at the highest point with 3 throws of tight knots. Posterior chamber IOL was then introduced behind the Iris taking care to avoid suture entangling. Scleral flaps covered the suture knots were sutured with 10-0 nylon.
Lewis technique was employed.

Selection of IOL and suture
Specifications of Suture supported IOLs 6-6.5 mm optic, 13-14 mm length We used routinely available IOLs without eyelets, because these were available at our Government setup.
Suture used was10-0 prolene with one straight and one curved needle. The same suture needle was used to suture under the scleral flaps. Scleral flaps and scleral tunnel incision was sutured with 10-0 nylon.
At each visit Vision, Slit Lamp examination and Fundus was examined.
We had a long term followup of about 5-10 years.

Timing of surgery
Primary surgery was done in 9 cases. Whereas we preferred Secondary surgery after 4 weeks in 59 (86.76%) cases.

Introperative difficulties
Hypotony made operating difficult in Primary surgery in 4 cases. Bleeding from Iris, ciliary body was seen in 2 cases. Suture entangling was seen in 2 cases. Suture breakage on one end was encountered on the table and the procedure needed to be repeated.

Postoperative complications
Hyphaema was seen in 2 cases. Immediate postop. Iritis was noted in 4 cases and was treated. CME was seen in 2 patients. RD was seen in 1 patient of traumatic Cataract after 1 month of surgery. Suture erosion, Decentration of IOL or Endophthalmitis was not seen.

Secondary A/C IOLs 3,4
Advantages being-Easy to implant, Easy to explant and require less surgical time.

Conclusion
Sutured Scleral fixation is the best cost effective option for aphakic patients without posterior capsular support in hands of a careful surgeon

Source of Funding
None.

Conflict of Interest
None.