Commentary: When in a fix, rely on four-point intraocular lens fixation.

Abstract

This study[1] on Observation of the curative effect of scleral suture fixation technique with four loop foldable intraocular lens is appreciable as it deals with a difficult technique, which has been described and illustrated well in the manuscript. Every ophthalmologist encounters the problem of inadequate capsular support, whether preoperative or intraoperative. It is imperative and crucial to learn how to tackle it and fix an intraocular lens (IOL) to provide good postoperative vision. As polypropylene sutures are non-absorbable, the 9-0 sutures used in this study have the advantage of a greater diameter and cross-sectional area than 10-0 polypropylene suture and will provide permanent wound support; the color blue helps in easy identification and the tensile strength is excellent.[2] Published studies on the use of 9-0 polypropylene sutures in scleral fixation of IOLs are very few.[3] The four-point IOL fixation to fixate the four haptics has been reported to provide a variety of advantages, including enhanced IOL stability and centration, avoidance/minimal of IOL tilt or postoperative pupil capture, and posterior segment complications.[4,5] However, there are a few concerns: The follow-up appears to be too short, with a range of 3–12 months, compared to other studies.[6,7] In eight eyes of this study, having elevated IOP, no medication was used though the IOP stabilized within a week. It may have been better to lower the IOP in the initial stages to prevent any damage. The central corneal thickness and applanation tonometry for the corrected IOP would have added further value. In one patient, it is mentioned that one side of the IOL was dislocated into the vitreous, yet another IOL was implanted and secured by the same technique. In statistical analysis ;newer version of SPSS formula would have been better to use instead of SPSS 16.0. The measurement of IOL tilt has been done at only one month postoperatively in the study. The postoperative endothelial count could have been compared to the preoperative count to provide more valuable insight. The postoperative UCVA was 0.09 ± 0.09, which was significantly better than the preoperative UCVA (t = 13.28, P < 0.001). The quality of vision further improved on correction, and postoperative BCVA was 0.08 ± 0.07, which was significantly better than preoperative BCVA (t = 6.89, P < 0.001). The potential drawback of the type of IOL used is that it is made of a hydrophilic acrylic material, in which opacification can occur. Cases having inadequate capsular support are not only complicated but require skill, expertise, and mentorship. When a surgeon is faced with such a patient, the onus lies only on them to give the best outcome. The importance of the study lies in the management of a complication or condition that can cause a devastating effect on vision. The difficult yet effective procedure described and analyzed is a valuable tool to a solution in a challenging situation.