Extraocular Technique of Intrascleral Intraocular Lens Fixation Using a Pair of the Shaft-Bended 27-Gauge Needles

Intrascleral intraocular lens (IOL) fixation is a relatively new technique for the eyes without lens capsule. Currently, there are two techniques for externalization of the haptics of the IOL.1–7 One is using a forceps1–5 and the other is using a needle.6,7 Although the technique using the forceps might be relatively easier, some reports showed the risks of ciliary body and IOL haptic damages.1,2 However, it is difficult to load the tip of the haptics into the lumen of the needle in the small space of the anterior chamber using a needle technique. We report a new extraocular technique of loading the haptics into the needle for intrascleral IOL fixation using shaft-bended 27-gauge needles without any special equipment. Methods Twelve eyes of 12 patients were included. The surgery of this technique of intrascleral IOL fixation was needed for IOL dislocation in seven eyes, trauma in four eyes, and unspecified aphakia in an eye. This pilot study was conducted according to the tenets of the Declaration of Helsinki. Institutional Review Board at Tokyo Women's Medical University approved the study. After informed consent was provided, each patient signed a written consent form that described this technique. The Supplemental Digital Content 1 (see Video, https://links.lww.com/IAE/A510) demonstrates the methods of shaft-bending and the procedure of intrascleral IOL fixation. This technique was performed under subtenon anesthesia. First three-port pars plana vitrectomy was done for all cases. A 3.0-mm sclerocorneal incision for IOL injection and 2 lamellar scleral dissections for the externalizing the haptics of IOL were performed. Two different types of handmade shaft-bended 27-gauge needles (Figure 1A) were prepared so that the needle tip could appear extraocularly from the sclerocorneal incision. Lamellar scleral dissection by the first 27-gauge needle was created 1.7 mm from the limbus, and the needle tip was brought out from the sclerocorneal incision (Figure 1B). A 3-piece IOL (7.0 mm Eternity; Santen, Tokyo, Japan) was folded and loaded in an injector. Plunger of the injector was slightly pushed until the leading haptic appeared outside of the injector. The tip of the leading haptic was loaded into the lumen of the needle at the extraocular space (Figure 1C). As the haptic was curved and the lumen of the needle was straight, the haptic was mildly locked in the needle. The IOL was inserted into the anterior chamber with the injector, and the first 27-gauge needle was pulled back in accordance with the movements of IOL without being completely pulled out. The surgeon should carefully perform a sequence of inserting IOL because 7.0-mm lens is relatively hard and requires strength. Another sclerotomy was made at 180° from the initial sclerotomy with the second shaft-bended 27-gauge needle, and the needle tip was also brought out from the sclerocorneal incision (Figure 1D). The tip of the trailing haptic was loaded into the lumen of the needle at the extraocular space using a nontoothed forceps (Figure 1E). Both the 27-gauge needles were finally pulled out to extraocular space (Figure 1F). Scleral tunnels parallel to the limbus were made by the 27-gauge needle. The haptics were inserted into the tunnels.Fig. 1: Surgical technique. A. Two types of shaft-bended 27-gauge needles. B. The first 27-gauge needle tip appears extraocularly from the sclerocorneal incision. C. The tip of the leading haptic from the intraocular lens injector is loaded into the lumen of the first 27-gauge needle at the extraocular space. D. The second 27-gauge needle tip appears extraocularly from the sclerocorneal incision. E. The tip of the trailing haptic is loaded into the lumen of the second 27-gauge needle at the extraocular space using a nontoothed forceps. F. Both the leading and the trailing haptics are placed extraocularly.Results The haptics were well-fixed and the IOL was centrally positioned in all 12 eyes. The perioperative or postoperative complication, such as the wound leakage, vitreous hemorrhage, serous choroidal detachment, and retinal detachment, was not observed. All 12 eyes in our cases had successful scleral fixation of the IOL in 6 months at least. Discussion In the current study, we report the intrascleral fixation with a new extraocular technique of externalizing the haptics of IOL using the standard 27-gauge needle provided at any operating room. We did this technique accompanied with the three-port pars plana vitrectomy because most of our patients needed the IOL exchange or retinal surgery. We think our technique is also useful with anterior vitrectomy system or anterior chamber maintenance cannula for avitreous and aphakic eyes, although the surgeons have to practice for shaft bending of these needles. Yamane et al7 reported 27-gauge needle–guided intrascleral IOL implantation for 35 eyes of 34 patients. Their technique made sclerotomy smaller and externalization of the haptics easier than previous reports. However, it is not easy to load the tip of the haptics into the lumen of the needle in the small space of the anterior chamber. Nonspecialized surgeons, who have no vitrectomy system, also might hesitate to use their technique because it is possible to be at risk for the IOL dislocation into the vitreous cavity. We do not think the surgeons without vitrectomy system choose their technique. Our extraocular technique might make loading the haptics into the needle easy because it was done at the extraocular space. It is possible to reduce the risk of the IOL dislocation into the vitreous cavity with the usage of this technique. Maybe, the cataract surgeons, even at private clinic without vitrectomy system, can perform the intrascleral IOL fixation with our technique. Takayama et al8 performed a technique similar to ours using 24-gauge catheter and 30-gauge needle. Because our technique does not need any special equipment, anyone could perform in the same way. This is another advantage of our new technique. The current study has several weaknesses, including the small case series and the difficulty of making the shaft-bended 27-gauge needles without previous experience. In addition, our technique has the disadvantages of the necessary of conjunctival opening because it is based on the previous reports of the intrascleral IOL fixation using a needle. However, we believe our technique become common for intrascleral IOL fixation. Because the characteristic point of our technique is to load the tip of the haptics into the lumen of the 27-gauge needles not at the anterior chamber but at the extraocular space without any special equipment, it might be easier and safer than the previous methods of intrascleral IOL fixation.