Centering the IOL-bag complex

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Multipoint scleral suture fixation through the fibrotic rim of a continuous curvilinear capsulorhexis results in stable recentration of a dislocated IOL-capsular bag complex

By Cheryl Guttman Krader; Reviewed by Howard V. Gimbel, MD, MPH

Calgary, Alberta-Scleral suture fixation of the entire IOL-capsular bag complex through the fibrotic rim of the continuous curvilinear capsulorhexis (CCC) is an effective technique for achieving stable IOL recentration in cases of IOL-capsular bag subluxation.

In addition, it offers advantages compared with other approaches for managing this late complication, according to Howard V. Gimbel, MD, MPH.

The fixation is performed using 9-0 or 10-0 Prolene double-armed sutures to anchor only the fibrotic CCC to the sclera using a modified Hoffman technique. Depending on the situation, anywhere between 2 and 4 sutures may be passed to center the IOL-bag complex precisely.

“The formation of a fibrous membrane at the CCC margin is a well-described phenomenon that is seen in cases of anterior capsular phimosis.

However, this IOL repositioning technique uses the strength of the fibrotic tissue to the surgeon’s advantage.

In fact, it is amazing how much traction the rim can withstand as the sutures are pulled in different directions to position the IOL-bag complex,” said Dr. Gimbel, medical director Gimbel Eye Centre, Calgary, Alberta, and professor and chairman of ophthalmology, Loma Linda University, Loma Linda, CA.

“Alternative approaches for managing the development of a subluxated IOL-capsular bag complex include suturing of the haptics and capsule to the iris or sclera or removing the IOL and replacing it using different types of lenses and fixation techniques,” Dr. Gimbel said.”

However, suturing the entire IOL-capsular bag complex to the fibrotic CCC rim circumvents the various drawbacks of those techniques as it maintains in-the-bag IOL fixation while avoiding IOL exchange, the need for pupil enlarging techniques, suturing through the Soemmering’s ring, and identification of the haptics,” he said.

Dr. Gimbel said the ideal situation for using the technique he described is when the fibrotic ring around the CCC rim is smaller than the IOL optic to provide a complete ring of fibrosis without the anterior capsule being adherent to the posterior capsule.

A measurement of the white-to-white corneal diameter is made in case a decision is made to convert to implantation of an anterior chamber IOL. If there is vitreous prolapse, a two-port anterior vitrectomy is performed first using triamcinolone for staining. When performing vitrectomy, the IOL may be stabilized using a single-armed 10-0 Prolene suture passed through the capsular membrane.

For the suture fixation technique, a dispersive viscoelastic (OcuCoat, Bausch + Lomb) is injected to maintain the anterior chamber and more instilled as needed. If two fixation sutures are to be used, 3-mm half-thickness scleral tunnel pocket incisions are created superiorly and inferiorly.

“I don’t like the superior incision to be close to the visual axis, and therefore, the groove for the superior scleral pocket is made 2 mm posterior to the limbus,” Dr. Gimbel said. “Inferiorly, the limbus is farther away from the visual axis and the corneal groove can be used to start the Hoffman tunnel.”

Once the scleral incisions are created, the first needle of a double-armed Prolene suture is passed through a paracentesis and the pupil, through the fibrotic CCC rim, behind the iris, and out through the superior scleral pocket.

Then, the second needle is passed in a similar manner, beginning from above the CCC. The sutures are looped out of the tunnel, used to adjust IOL centration, tied, and cut.

“I like to capture just the fibrotic element of the capsule so as to avoid disturbing Soemmering’s ring material in the capsule and causing it to spill out of the capsular bag,” Dr. Gimbel said.

If vitrectomy has been needed, additional triamcinolone is injected and further vitrectomy performed to be sure all vitreous is removed from around the loose IOL-capsular complex.

“Taking a suture across the corneal groove minimizes the potential for inducing astigmatism, especially irregular astigmatism,” Dr. Gimbel said.

Dr. Gimbel noted that he has used this IOL repositioning technique in relatively few eyes over the past few years.

However, occasion to use it may increase in the future considering that advancing age is one of the risk factors for IOL-capsular bag complex subluxation.

“When posterior capsule IOLs first came into use, Professor Jan Worst told me that they were a ticking time bomb with respect to the possibility of posterior dislocation because lens opacification is the first part of the aging process that progresses to increasing zonular laxity,” he explained.

Howard V. Gimbel, MD, MPH

E: hvgimbel@gimbel.com

Dr. Gimbel has no relevant financial interests to disclose.

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