Intraocular lens-sling 2.0: A safer modification for implanting foldable intraocular lens following complicated cataract surgery

Dear Editor, We had earlier published the “Intraocular lens (IOL)-sling technique: A safe approach for lens implantation in complicated cataract surgery and secondary intraocular lens implantation” in your esteemed journal.[1] This was an innovative idea of using a suture material (9-0 or 10-0 nylon) through the dialing hole of a three-piece rigid intraocular lens (IOL), to reduce the risk of IOL drop following complicated cataract surgery. One of the major limitations was that it could not be used while implanting foldable IOLs since they do not have dialing holes. Here, we share a modification that is specifically adapted for use with foldable three-piece IOLs during sutureless scleral-fixated IOL (SFIOL) implantation or for sulcus placement in those with deficient capsular support. After injecting the three-piece IOL into the anterior chamber, while the trailing haptic lies outside, a 9-0/10-0 nylon suture is used to loop around the trailing haptic twice. After implantation, when the IOL is found to be stable in sulcus or haptics tucked inside the intra-scleral tunnel in SFIOL,[2] the sling can be removed by cutting one end.[1] [Fig. 1, Video 1].Figure 1: Steps of implanting a foldable scleral-fixated intraocular lens (IOL) by Gabor’s technique with IOL sling 2.0. a. After the foldable IOL is placed into the eye, the first loop of 10-0 or 9-0 Nylon is made over the trailing haptic, which lies externally. The trailing haptic of a 3-piece IOL is placed externally even when the IOL is injected with a cartridge. b. Another loop is made over the trailing haptic. c. The loop is pushed so that it stays at the junction of the inner one-third and outer two-thirds of the trailing haptic to avoid loosening or displacement. d. Note that the two ends of the IOL sling lie externally. e and f. The trailing haptic is exteriorized using the handshake technique. g. One end of the sling is cut, and the sling is removed gently. h. The IOL position is centered and stabilized {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_vcj8d9nv"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} This allows us to attempt IOL placement in the sulcus even when anterior capsular support is deemed borderline. An unstable IOL can be easily removed. During sutureless SFIOL placement, the slippage is more likely while exteriorizing the trailing haptic. The IOL sling helps to safely manipulate the IOL back to the pupillary plane, where the haptic can be regrasped, thus acting like the surgeon’s third hand. There is always a risk of IOL drop while implanting IOL in capsule-deficient cases, especially by novice surgeons.[3] We believe that the “IOL Sling 2.0,” an additional step to the various SFIOL techniques or during sulcus placement, will enhance the safety of surgical techniques used in aphakia management. Authors’ contributions Manas Nath: Concept, Design, Manuscript editing; Annamalai Odayappan: Design, Definition of intellectual content, Manuscript editing; Koushik Tripathy: Design, Manuscript preparation; Josephine Christy: Concept, Manuscript preparation; Sivagami Nachiappan: Concept, Manuscript preparation. Financial support and sponsorship: There was no funding received by any of the authors for the purpose of the study. Dr. Annamalai Odayappan was a Research scholar at the Kellogg Eye Center, University of Michigan, USA, supported by a grant from NIH/Fogarty International Center (D43TW012027). Conflicts of interest: There are no conflicts of interest.