This video demonstrates scleral-fixation of an intraocular lens with GoreTex suture. The surgery was performed by Dr. Ahmed Sallam MD, PhD at the Jones Eye Institute at the University of Arkansas for Medical Sciences. The authors of the video are Victoria Ly, Adam Neuhouser, and Ahmed Sallam MD, PhD.
The Akreos AO60 IOL must be threaded in a “U-shaped” pattern by passing a Gore-Tex suture through one haptic from anterior to posterior, and then through the other haptic on the same side from posterior to anterior. This pattern is repeated on the contralateral side of the IOL with another suture. The suture ends are passed through a corneal incision and pulled out through each of the corresponding trocars using a hand-to-hand technique with forceps. After the suture ends are passed, the Akreos AO60 IOL is folded and inserted into the posterior chamber. Then, the trocars are removed and the suture ends are pulled to centralize the lens. The sutures are tied and the knots are trimmed and buried into the sclerotomy incisions. Last, the sclerotomies, corneal incisions and conjunctival peritomies are closed. After closing the incisions, none of the Gore-Tex sutures should be exposed.
Indications include dislocated IOL, aphakia with poor capsular support, subluxated crystalline lens, traumatic cataract, corneal decompensation, unamenable iris anatomy for iris fixation, concurrent need for pars plana vitrectomy, and uveitis-glaucoma-hyphema syndrome.
Relative contraindications include uveitis, endothelial dysfunction, corneal dystrophy, retinal hole, subretinal fluid, extensive lattice degeneration or major retinal diseases.
Set up requires an inferior infusion cannula, nasal and temporal conjunctival peritomies, and four 27G trocars in the inferior nasal, inferior temporal, superior nasal, and superior temporal positions. Prior to implantation of the lens, a pars plana vitrectomy can be performed.
Preoperative workup includes calculating the IOL power and measuring visual acuity and intraocular pressure.
The advantages of a scleral-fixated IOL include better visual outcomes and a reduced risk of corneal endothelial pathology, peripheral anterior synechiae, and glaucoma. The major disadvantages of a scleral-fixated IOL include surgically-induced astigmatism secondary to large incisions necessary for the surgery, IOL tilt, and suture-related complications. The advantage of using the Akreos AO60 lens is that its 4 haptics achieve a 4-point fixation, which ensures IOL stability, minimizes tilt, and increases tolerance of slight decentration. The advantageous characteristics of Gore-Tex suture are high tensile strength, high visibility due to its white color, and minimal memory, which allows for easier manipulation, minimal inflammatory response, and decreased risk of suture breakage.
No intraoperative complications of scleral-fixated IOLs have ever been reported. Post-operative complications are largely transient and most can be treated medically with topical therapies. Commonly reported complications are vitreous hemorrhage, corneal edema, ocular hypertension, hypotony, cystoid macular edema, and hyphema. Retinal detachment is rare. Ophthalmic use of Gore-Tex has positive visual outcomes without significant complications.
Special thanks to the Jones Eye Institute at the University of Arkansas for Medical Sciences and Dr. Ahmed Sallam MD, PhD.
1. Khan MA, Samara WA, Gerstenblith AT, et al.COMBINED PARS PLANA VITRECTOMY AND SCLERAL FIXATION OF AN INTRAOCULAR LENS USING GORE-TEX SUTURE. Retina. 2018;38(7):1377–1384. doi: 10.1097/IAE.0000000000001692. https://www.ncbi.nlm.nih.gov/pubmed/28492433
2. Patel NA, Shah P, Yannuzzi NA, Ansari Z, Zaveri JS, Relhan N, Williams BK Jr, Kuriyan AE, Henry CR, Sridhar J, Haddock L, Fortun JA, Albini TA, Davis JL, Flynn HW Jr. Clinical outcomes of 4-point scleral fixated 1-piece hydrophobic acrylic equiconvex intraocular lens using polytetrafluoroethylene suture. Clin Ophthalmol. 2018 Oct 23;12:2145-2148. doi: 10.2147/OPTH.S174211. https://www.ncbi.nlm.nih.gov/pubmed/30425449
3. Terveen DC, Fram NR, Ayres B, Berdahl JP. Small-incision 4-point scleral suture fixation of a foldable hydrophilic acrylic intraocular lens in the absence of capsule support. J Cataract Refract Surg. 2016 Feb;42(2):211-6. doi:10.1016/j.jcrs.2015.10.068. https://www.ncbi.nlm.nih.gov/pubmed/27026444
4. Khan MA, Gupta OP, Smith RG, Ayres BD, Raber IM, Bailey RS, Hsu J, Spirn MJ.Scleral fixation of intraocular lenses using Gore-Tex suture: clinical outcomes and safety profile. Br J Ophthalmol. 2016 May;100(5):638-43. doi:10.1136/bjophthalmol-2015-306839. https://bjo.bmj.com/content/100/5/638.short
5. Yalniz-Akkaya Z, Burcu A, Uney GO, et al. Primary and secondary implantation of scleral-fixated posterior chamber intraocular lenses in adult patients. Middle East Afr J Ophthalmol. 2014;21(1):44–49. doi:10.4103/0974-9233.124093. https://www.ncbi.nlm.nih.gov/pubmed/24669145
6. Jacob S, Kumar DA, Rao NK. Scleral fixation of intraocular lenses. Current Opinion in Ophthalmology. 2020;31(1):50–60. doi:10.1097/ICU.0000000000000632. https://www.ncbi.nlm.nih.gov/pubmed/31789971