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Glued IOL Technique Gaining Support

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Glued IOL Technique Gaining Support Clinical Update CATARACT Glued IOL Technique Gaining Support by linda roach, contributing writer interviewing amar agarwal, mbbs, frcophth, lisa b. arbisser, md, robert a. eden, md, and michael e. snyder, md or most cataract surgeons, Preparing to Glue the process of securing an intraocular lens in an eye 1A 1B with weak zonules or a torn capsule means either Fimplanting an anterior chamber (AC) IOL or suturing a posterior chamber (PC) IOL into the ciliary sulcus. But interest in a newer way to secure IOLs in these problem eyes is on the rise. The full name of the procedure is some variation of “sutureless, fibrin glue–assisted PCIOL implantation with 1C 1D intrascleral tunnel fixation.” However, “glued IOL” is the shorthand label that stuck, even though glue isn’t used until the last step (see “How Do You Glue?”). The first such implant was per- formed in 2007 by Amar Agarwal, MBBS, FRCOphth, director of Dr. Agarwal’s group of eye hospitals in India and professor of ophthalmol- ogy at Ramachandra Medical College in Chennai, India.1 Since then, he has (1A) Two scleral flaps are prepared 180 degrees from each other. (1B) As the modified his technique. For example, three-piece IOL is implanted, the leading haptic is grasped with the glued IOL he now secures the haptics inside forceps. (1C) With the haptic still held in the forceps, the IOL is allowed to un- scleral tunnels rather than solely under fold completely in the anterior chamber before the leading haptic is externalized. scleral flaps. His method is beginning (1D) Trailing haptic is externalized. to gain traction with cataract surgeons. For instance, at the Academy’s 2012 exfoliation, or other factors have glaucoma-­hyphema syndrome, and Spotlight on Cataract Surgery Session, damaged the posterior capsule or cystoid macular edema; with malposi- 7.2 percent of the audience members weakened the zonules. These patients tioned or unstable PCIOLs, complica- indicated that they would use a glued may have subluxations; have crystal- tions may include pigment dispersion, PCIOL when faced with deficient cap- line lens fragments or a dislocated IOL pupillary capture of the optic, and iris sular support.2 in the vitreous; have visual problems chafing and inflammation.) from decentration; and sometimes In these patients, a surgeon would Why Go Sutureless? need a secondary implant because of typically suture a PCIOL to the iris Extracapsular fixation is needed by IOL-related complications. (With AC- or the sclera, said Dr. Agarwal. But patients in whom traumatic injury, IOLs, potential complications include this creates its own set of challenges, amar agarwal, mbbs, frcophth mbbs, agarwal, amar posterior capsular rupture, pseudo- endothelial decompensation, uveitis- he said. That’s because, despite three eyenet 31 Cataract decades of refinements in IOL suturing Human blood products. Fibrin glue emerge, he said. “I believe the glued techniques, sutures remain problem- also contains human blood products, scleral-fixated method has not yet atic. Possible complications include which raises the issue of viral trans- stood the test of time.” postoperative inflammation, erosions mission. A patient’s informed consent Dr. Arbisser was more optimistic: over the sutures, induced astigmatism, must be obtained before using any “The only real question is whether the and suture breakage in the years after blood product, including fibrin glue, haptics will erode the scleral tunnel, surgery, he noted. said Robert A. Eden, MD, assistant and they may not. We’ve been doing professor of ophthalmology at Albany scleral buckles for years, and it’s very Considerations for Fibrin Glue Medical College in Albany, N.Y. And rare for them to erode.” Fibrin glue has two main components this may not be possible if an unan- that occur naturally in the blood: ticipated surgical complication neces- Experiences in the OR fibrinogen and thrombin. They are sitates extracapsular fixation. As with any new procedure, the learn- kept separate before use; once they are Three hands needed. In Dr. Agar- ing curve for glued IOLs yields intrigu- mixed, the thrombin promotes rapid wal’s original technique, the maneu- ing case reports and observations. conversion of fibrinogen to fibrin, pro- vers to grasp the IOL, remove vitreous, No room for error. In one case, Dr. ducing a local fibrin clot. and externalize the haptics required Arbisser planned to orient the glued This glue has been used in a grow- an assistant to hold the first haptic IOL vertically, with the haptics and ing number of ophthalmic procedures, while the surgeon worked on the trail- scleral flaps 180 degrees apart at 12 such as replacing sutures in conjuncti- ing haptic with two hands. “I have the and 6 o’clock. (Dr. Agarwal’s technique val autograft for pterygium and lamel- fortune of having residents and a clini- now calls for a horizontal orientation lar keratoplasty, and sealing LASIK cal fellow available to assist in surgery, only in eyes with a horizontal white- flaps to prevent epithelial ingrowth. Its since early on this technique requires to-white measurement of 11 mm or more recent role in IOL fixation comes three hands,” Dr. Eden said. less. If it is more than 11 mm, the lens with both pros and cons. Dr. Arbisser, who views the need should be oriented vertically, in order The healing process. Theoretically, for a third hand as “very impractical,” to assure adequate fixation of the hap- the thrombin in the glue also interacts said that she expects to see continued tics in the sclera.) with endogenous fibrinogen in the improvements in the procedure over This patient had a subluxated IOL, sclera, raising the possibility that this time. In fact, several surgeons have no capsular support, iridodialysis, would jump-start the fibrotic healing recently reported on modifications for and a blown pupil, and the lens was that Dr. Agarwal counts on to hold the two-handed surgery.4,5 slightly back in the vitreous, Dr. Ar- haptics in place after the glue degrades. bisser recalled. However, she found out This hypothesis has not been tested, What About the Haptic Bond? the hard way that a vertical procedure however. (Macrophages and fibroblasts Michael E. Snyder, MD, said that he requires sufficient unscarred “scleral fully resorb fibrin glue in about two will continue relying on Gore-Tex real estate,” which this eye lacked. “I weeks.3) sutures (an off-label use) for scleral made a scleral flap that was only 300 One of the major benefits of using fixation of PCIOLs in problem eyes. μm deep because the patient had a glue, said Dr. Agarwal, is that, unlike He uses an ab externo suture loop re- previous cataract incision superiorly, sutures, it produces no inflammation. trieval and scleral fixation technique. where the flap had to go because of Expense and handling. Fibrin glue Dr. Snyder, who is in private prac- the large horizontal white-to-white,” has several drawbacks, one of which is tice at the Cincinnati Eye Institute she said. “But when I brought the flap its expense. “Glue is expensive. It only and is a voluntary assistant professor up, I was staring at bare choroid. I had keeps so long in the freezer, and once of ophthalmology at the University of to sew the flap down watertight for you thaw it you can’t refreeze it,” said Cincinnati, is skeptical that the fibrotic the three-port vitrectomy that I had Lisa B. Arbisser, MD, who practices healing in the sclera can keep the planned to precede the gluing of the in Bettendorf, Iowa, and is clinical haptics from migrating over the long IOL. And I ended up sewing the lens to adjunct associate professor of ophthal- term. “Fibrosis doesn’t stick to PMMA, the repaired iris.” mology at the University of Utah. “You and haptics are made from PMMA.” A case of dislocation. Dr. Arbisser have to be really quick to use it. If you He speculated that the haptics described a second case, which in- wait too long, it will glue up the appli- might migrate externally, to the ocu- volved a dislocated in-the-bag lens, as cator tip.” lar surface as the sclera remodels or, “the most challenging case I’ve ever, Dr. Agarwal suggests avoiding the potentially, slide along the internal ever done, for fear of dropping the lens rush by keeping the fibrinogen and tunnel and eventually intrude, releas- or parts of the haptic.” She added that thrombin in separate cannulas; the ing fixation. As with the problem of the glued IOL approach “is not an easy fibrinogen is applied first, and the polypropylene suture lysis, it might procedure. I’m not convinced this is thrombin is placed only when the sur- take more than the current five years any less traumatic for a bag lens dis- geon is ready to seal. of follow-up for this complication to location than a lasso technique, espe- 32 may 2013 Cataract cially because of the large vitrectomy required.” How Do You Glue? Dr. Arbisser recounted some of the problems she encountered in this case Although a complete description is beyond the scope of this article, the following and the solutions she now recommends: steps provide a brief overview of the glued IOL procedure (see also Figs. 1A-D): 1) She had trouble inserting her 1. Two scleral flaps and sclerotomies, as well as two scleral tunnels or pockets un- usual 20-gauge anterior chamber der the flaps, are created exactly 180 degrees from one another, at either 3 and 9 maintainer. Her solution: Use a o’clock or 6 and 12 o’clock; a scleral marker is used to ensure precise positioning. 23-gauge maintainer. (See discussion of proper orientation in “No room for error” on page 32.) Fluid 2) In removing the bag, she lost a should always be kept in the eye during the surgery, using a trocar cannula or AC small piece of Soemmering’s ring into maintainer.
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