Suturing technique expands options

Albena Dardzhikova, MD, described this surgical technique that was introduced by Howard V. Gimbel, MD, MPH, in September 2006. Dr. Dardzhikova is a fellow in anterior segment and refractive surgery, Gimbel Eye Centre, Calgary, Alberta, Canada, and a research fellow, Gimbel Eye Foundation. Dr. Gimbel is professor and chairman, department of ophthalmology, Loma Linda University, Loma Linda, CA, and medical director, Gimbel Eye Centre.

Dr. Dardzhikova reported outcomes from a series of seven eyes of six patients ages 44 to 82 years old. Three eyes had a decentered IOL in the capsular bag or sulcus, three had a mobile sulcus IOL, and one eye was undergoing secondary IOL implantation for aphakia. Follow-up after the secondary procedure ranged from 7 to 42 months with a mean of 31 months.

"In 1976, Dr. Gimbel sutured the loops of a Binkhorst lens to the capsule," Dr. Dardzhikova said. "More than 30 years later, he brought this idea full circle in his technique of suturing the haptics of a modern IOL to the fibrotic capsular membrane.

"In eyes with a decentered/dislocated IOL where the capsular bag cannot be reopened, there are a number of alternatives for achieving secondary IOL fixation that are generally preferable to simply leaving the IOL in the sulcus," Dr. Dardzhikova added. "In eyes where there is no membrane opening or the opening is too large, the positive outcomes in this series indicate capsule membrane suturing is a viable option to consider."

Dr. Gimbel first implemented the technique when performing secondary surgery for a dislocated IOL. Because the capsular membrane was fibrotic and not amenable for performing the membrane optic capture technique, he decided to suture the IOL to the membrane instead. Details of the procedure appear in a published article (Clinical and Surgical Ophthalmology. 2008;26:42-47).

Dr. Dardzhikova provided an overview of the capsular membrane suturing technique. Because the decision on managing decentered/dislocated IOLs is very case-specific, she noted that maximum pupil dilation must first be achieved to enable a thorough assessment of the state of the residual capsule and zonular support.

When performing the capsular membrane suturing procedure, the haptics are sutured to the area of maximum capsular support using 10-0 Prolene suture on a CTC-6L spatula needle (Ethicon). After the suturing is finished, a Sinskey hook is used to confirm the stability of the fixation and IOL centration.

One of the cases presented by Dr. Dardzhikova involved an eye with a mobile, sulcus-placed, 3-piece PMMA lens and intact posterior capsule membrane. Suturing of each of the haptics to the fibrotic elements of the capsule membrane was done using the McCannel suture fixation technique performed through a temporal 2-mm clear cornea incision.

"In tying the suture, care must be taken to avoid exerting excessive tangential pressure that can cause a membrane tear," said Dr. Dardzhikova.

The second case she presented involved a decentered, single-piece, sulcus-placed IOL. The eye had a large capsule membrane opening, which precluded performing membrane optic capture. In this case, the Siepser slip knot technique was used for suturing and the procedure was performed through the paracentesis incision.

"Part of the beauty of the suture fixation technique in this case was the ability to perform the entire procedure without the need to create a large incision," Dr. Dardzhikova said.

fyiHoward V. Gimbel, MD, MPH
E-mail: hvgimbel@gimbel.com

The authors have no financial interest in the material.