Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

Abstract

To the Editor: In-the-bag intraocular lens (IOL) dislocation is a rare but serious complication, and the difficulty is multiplied if the IOL-capsular bag complex drops completely into the vitreous cavity.1 Recently, we have described a flapless technique using implantable capsular hooks to fixate the capsular bag of subluxated lens for in-the-bag IOL implantation2 and reconstruct the capsular support for out-of-the-bag IOL fixation3 in the vitrectomized eyes, as well as to refixate the dislocated IOL-capsular bag complex.4 This technique is less traumatic and with no requirements of large conjunctival dissections, scleral flaps, or complicated manipulations of suturing and knotting. We now further modified this technique and applied it in a more challenging case of IOL-capsular bag complex dropping completely into the vitreous cavity, using 4-point intrascleral fixation of implantable capsular hooks. SURGICAL TECHNIQUE The capsular hook is made of 5-0 commodity polypropylene thread attached to a curved needle (Prolene, Polypropylene Suture; Ethicon). The hooks were created using the thermoplasticity method by a high-temperature cautery identical to our previous publications.2–4 After trimming core and peripheral vitreous by a standard 3-port pars plana vitrectomy, the dislocated IOL-capsular bag complex laying in front of the posterior pole of retina (Supplementary Digital Content Video 1, https://links.lww.com/APJO/A182) was taken behind the iris plane and held in place using 23-gauge toothed intraocular forceps (Fig. 1A). Two-side paracentesis was created using a 15-degree blade at 2 and 8 o’clock (Fig. 1B), through which 2 iris hooks were inserted to temporarily stabilize the IOL-capsular bag complex (Fig. 1C). The needle attached to the capsule hook was inserted through the side-point incision opposite to the fixation site, then guided out through the sclerotomy by docking its tip into a 27-gauge needle penetrating through the ciliary sulcus at the fixation point of 2.0 mm posterior to the limbus (Fig. 1D). Afterwards, the curved needle was punctured back at the sclerotomy site, passed intrasclerally to the adjacent sclera, and pulled out transconjunctivally, creating a 4.0-mm scleral tunnel parallel to the limbus (Fig. 1E). The hook was then delivered into the anterior chamber. After the fibrotic continuous curvilinear capsulorhexis rim of the IOL-capsular complex was grasped by the 23-gauge forceps, the hook was inserted into the space between the fibrotic anterior capsule and the IOL to engage the capsular band (Fig. 1F). The tension of the hook was adjusted by further pulling the externalized thread until the capsular band was held still. With the same maneuvers, 4 hooks were fixed in the sequence of 9, 3, 6, and 12 o’clock (Fig. 1G). After each fixation, the externalized shafts were pulled and pushed to adjust the tensions of the hooks, to finally make the IOL-capsular complex centered and aligned. The externalized tips of the hooks were trimmed flush to the surface of the sclera using scissors (Fig. 1H). The side incisions were watertight at the end (Fig. 1I). The surgical procedures are demonstrated in Supplementary Digital Content Video 1, https://links.lww.com/APJO/A182.FIGURE 1: The key steps of the surgical procedures. A, The dislocated intraocular lens (IOL)-capsular bag complex laying in front of the posterior pole of retina was taken behind the iris plane and held in place using 23-gauge toothed intraocular forceps. B, Two-side paracentesis was created using a 15-degree blade at 2 and 8 o’clock. C, The IOL-capsular bag complex was temporarily stabilized using 2 iris hooks. D, The needle attached to the capsule hook was inserted through the side-point incision and guided out through the sclerotomy by docking its tip into a 27-gauge needle penetrating through the ciliary sulcus at the fixation point of 2.0 mm posterior to the limbus. E, The curved needle punctured back at the sclerotomy site and passed intrasclerally to the adjacent sclera, and pulled out transconjunctivally. F, The hook was inserted into the space between the fibrotic anterior capsule and the IOL. G, As the fourth hook had been fixated, the tension of the 4 hooks was adjusted by pulling the externalized thread until the IOL-capsular bag complex was centered. H, The externalized tips of the hooks were trimmed flush to the surface of the sclera using scissors. I, The side incisions were watertight.DISCUSSION Innovative techniques to reposition the IOL-capsular bag complex without explantation or exchange of IOL continue to emerge in recent years. However, most of these techniques involve sutured fixation, which are more prone to long-term complications, including suture knot exposure, suture erosion and breakage, leading to IOL tilt, decentration, even recurrent dislocations.5 We have firstly reported a sutureless and flapless technique using intrascleral fixation of implantable polypropylene hooks.2–4 The hook has a high reliability because of long and safe history of within-the-eye biocompatibility, proved safety and stability of intrascleral fixation, and adequate length of the incarcerating tunnel. There are several advantages of this technique: (1) With no flap and minimal or no conjunctival dissection, it is less traumatic; (2) the tension of the hook is adequate and adjustable, which improves the centering of the IOL, and reduces tilt and decentration of the IOL; (3) it enhances stability and avoids the incidence of suture breakage and erosion using suturing techniques. Recently, 4-point scleral fixation has been applied for IOL implantation in the absence of capsular support.6,7 It dramatically increases stability and reduces the possibility to tilt of IOL around to points at which it is sutured, which has been documented more than 10 degrees in 11.4% to 16.7% of cases using traditional 2-point scleral IOL fixation.8 To the best of our knowledge, this is the first study reporting 4-point scleral fixation of complete dislocated IOL-capsular bag complex, which combines the advantages of both capsular hook and 4-point scleral fixation in vitrectomized eye with IOL-capsular bag complex dropping onto the retina. This method provides a more centered and stable IOL-bag capsular complex and avoids the risk of erosion, slippage, or breakage of sutures, finally reduces the incidence of postoperative IOL-capsular bag complex tilt, donesis, or redislocation. This is especially beneficial for vitrectomized eyes whose ocular anatomy altered variously after pars plana vitrectomy, including deep fluctuating anterior chamber, intraoperative miosis, and loss of vitreous support. The application of sturdier 5-0 thread will make the surgical procedures more feasible, clearly visible, and reposit the IOL-bag capsular bag with more stability.