Sneak Preview: 4-point Scleral Sutured IOL

One surgeon cannot be a master of all. Often, teamwork with colleagues can provide the best results for our patients with each surgeon doing what he does best. I have performed many suture-fixated IOL surgeries with success, but my good friend and colleague Pradeep Prasad MD simply does it better. Today is a sneak preview of his method and in the near future we will have a more detailed video and an interview with him to learn more about his approach to these cases.

Guest Surgeon Pradeep Prasad MD, is a vitreo-retinal surgeon, Chief of Ophthalmology at Harbor-UCLA Medical Center, and faculty at the Jules Stein Eye Institute at the UCLA School of Medicine.

This is a young patient with a prior pars plana vitrectomy and trauma causing complete dislocation of the IOL-capsular bag complex into the vitreous cavity. The patient does not want to wear an aphakic contact lens. What are the options for secondary IOL placement in this patient?

• AC IOL: an anterior chamber IOL would work but remember that this patient is young and the secondary IOL must last for 50+ years. There is loss of corneal endothelial cells associated with AC IOLs, as well as glaucoma, and these may not be suitable for long-term stability in young patients.
• A sulcus PCIOL is not possible because there is no sulcus. The entire zonular apparatus has broken and the original IOL along with the capsular bag were found on top of the macula.
• Iris sutured PC IOL is possible and can do well, but keep in mind that it will be sutured with 10-0 polypropylene which has a finite lifetime.
• Scleral sutured PC IOL with 2-point fixation can work, but it allows the IOL to tilt and twist like a hammock since it is only fixated at two points. Also the typical 10-0 polypropylene suture is not expected to last many decades.
• The glued IOL technique pioneered by Amar Agarwal MD is a good option. This is similar to a technique described by Scharioth where the haptics of a three-piece IOL are placed into intra-scleral tunnels. It does offer more stability and better longer term results than the 2-point scleral fixation technique. I have used this technique and found it to be quite good.
• Using 9-0 Gore-Tex suture, which is anticipated to last many decades, an Akreos lens is chosen due to its design with four looped haptics, is fixated to the sclera at four points. This provides complete stability, resistance to rotation, tilt, and twist.

The above pic shows the post-op day 1 appearance of the eye after 4-point scleral fixation of an Akreos AO60 monofocal IOL using 9-0 Gore-Tex suture. The white line a few mm nasal to the limbus is one of the Gore-Tex sutures.

In the sneak preview video shown here, Dr. Pradeep Prasad uses 9-0 Gore-Tex suture to scleral-fixate the Bausch & Lomb Akreos AO60 IOL.  A more detailed video with a full interview of Dr. Prasad is coming in the near future.