Sutureless intrascleral posterior chamber intraocular lens fixation

In their experimental study, Akimoto et al.1 described their technique for intrascleral fixation of an intraocular lens (IOL) via a catheter. The authors stated that they achieved the aphakia by phacoemulsification following the capsulorhexis they performed but did not give information about the status of the posterior capsule. In these experimental cases, surgical maneuvers are easy to perform if the posterior capsule is intact. However, in our patients, these maneuvers are not as easy because the posterior capsule is not intact and anterior vitrectomy has also been performed. During scleral fixation, the use of a large amount of an ophthalmic viscosurgical device or a maintainer for continuous irrigation of the balanced salt solution into the eye has been necessary to prevent ocular deformation.2,3 Akimoto et al. pointed out that the corneal diameter of the pig eye was 16.5 mm and bigger than the human eye, so the estimated placement of the sclerotomy should be the same as in a human eye (14.5 mm). We think they overlooked a point in the method. They used the same placement (14.5 mm) for both sclerotomy and the clear corneal incision (CCI) the IOL was implanted through.1 It would be more reflective of the reality in daily practice if the authors had placed the CCI between 10.5 mm and 11.5 mm because when performing these operations in human eyes, one does not work in the same plane. We agree with the authors that there are fewer intraocular maneuvers in their method. However, when applying this method to the human eye, more ocular deformation can be expected during surgery for 2 reasons. First, CCIs and sclerotomies are not in the same plane in the human eye. The other reason is the necessity of manipulations in both anterior and posterior chambers. Also, the iris tissue will be in front of the catheter during the process. It appears that Akimoto et al. were working in only the anterior chamber of the pig’s eye. We think it would be more appropriate if they specified the necessity of manipulations in both anterior and posterior chambers and noted that some maneuvers involving the iris could be necessary during the procedure. Additionally, the surgeon will not see the second haptic of the IOL behind the iris while exiting from the human eye. This will cause a surgical difficulty that is not less than in previous techniques in which the haptic is held by a forceps. We think it should be kept in mind that this procedure could damage the tissues around the ciliary body if it was not performed very carefully.