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Three-Point Scleral Fixation of IOLs Using a 27-Gauge

Microsuture Passer
Simplifying repositioning of dislocated IOLs.
By JEFFREY D. BENNER, MD • DAVID CAMEJO, MD • JAMES A. PETRERA • ZAAIRA M. AHMAD, MD •
CHRISTOPHER LUMPKIN • JEFFREY D. HENDERER, MD • JOHN W. BUTLER, MD
March 1, 2017
10
Recent studies have shown that the incidence of late intraocular lens (IOL) dislocations is rising,
increasing the potential for necessary surgical intervention.1-4 This is not entirely unexpected,
because the number of patients with IOL implants is increasing, and these patients are living longer.
Consequently, the demand for vitreoretinal surgeons who can reposition or replace dislocated IOLs
is expected to increase.

There are many ways to fixate an IOL in the eye when there is inadequate capsular support,
including an anterior chamber IOL, an iris claw IOL, iris fixation sutures, scleral fixation of the IOL,
and anchoring of the IOL haptics inside scleral tunnels. With scleral fixation, the IOL is fixated in the
ciliary sulcus. Traditionally, the dislocated IOL is removed and a new one is implanted with scleral
fixation sutures. The IOL fixation sutures are then passed via an ab externo or ab interno approach
by passing long suture needles into a hollow 27-gauge needle or grasping the suture with
microforceps. The haptics are anchored to the sclera with a nonabsorbable fixation suture.
Alternatively, the dislocated IOL can be salvaged by repositioning it and fixating it to the sclera with
either fixation sutures or by placing the haptics into scleral tunnels.5,6 This approach obviates the
need for a large corneal wound because the dislocated IOL is not removed. However, this technique
is more difficult to master and has a steeper learning curve than the IOL exchange approaches.

Drs. Benner, Ahmad, and Butler and Mr. Petrera are from Retina Consultants of Delmarva,
Salisbury, Maryland; Drs. Camejo and Henderer are from the Ophthalmology Service at Temple
University Hospital, Philadelphia, Pennsylvania; and Mr. Lumpkin is from TruMed Design,
Evergreen, Colorado. This research received no specific grant from any funding agency in the
public, commercial, or not-for-profit sectors. Dr. Benner discloses a financial interest (patent) in the
microsuture passer. The remaining authors report no conflicts of interest. Dr. Benner can be reached
at jffbenner@gmail.com.
Passing scleral fixation sutures through the eye and attaching them to the IOL haptics can be
technically challenging and cumbersome. The introduction of disposable microforceps has helped
with grasping and pulling sutures or haptics in a straight line, but they are not designed for grasping
or passing sutures at a 90° angle and must be bent to the appropriate angle. They can malfunction if
bent too far, and they increase procedure cost. Implantation of the haptics in scleral tunnels has
grown in popularity recently but also presents challenges.6 When the surgeon grasps the old haptics
of a dislocated IOL with microforceps and pulls them out of the sclerotomy or microcannula, the
haptics can break or deform. Additionally, some haptics can spontaneously slip out of the scleral
tunnels, causing lens tilt or redislocation of the IOL immediately after surgery.6 For these reasons,
some surgeons avoid scleral-fixated IOLs and use an anterior chamber IOL for their dislocation
patients.

We have developed a technique that simplifies implantation of scleral-fixated IOLs using a 27-gauge
microsuture passer (TruMed Design) to pass the scleral fixation sutures. It stabilizes the IOL with 3-
point fixation, producing excellent IOL centration without tilt. The suture knots are rotated internally
so that they are not exposed. We have been using this technique successfully in our practice since
1989. This report presents the long-term safety and efficacy of 79 consecutive patients who had
scleral fixated IOLs implanted with this instrument and technique in our practice.

METHODS
After obtaining a waiver of HIPAA authorization from the Institutional Review Board of Temple
University in Philadelphia, Pennsylvania, a retrospective chart review was performed of a
consecutive series of 79 patients with scleral-fixated CZ70BD IOL implants (Alcon Laboratories)
implanted with either 9-0 or 10-0 Prolene polypropylene fixation sutures (Ethicon) using the
microsuture passer instrument in a retinal referral practice between 2004 and 2016. The microsuture
passer used in these cases is designed to pass and retrieve sutures within the eye to fixate an IOL
to the sclera. It has a 27-gauge curved shaft with an eyelet and a handle on the proximal end of the
device (patent pending) (Figure 1). Statistics were measured with JMP, Version Pro 12 (SAS
Institute Inc.). A P value <.05 was considered statistically significant.

Figure 1. The suture passer (TruMed Design) is comprised of a handle and a curved shaft with a
eyelet at the distal end.

TECHNIQUE
After the patient has been placed under anesthesia and prepped and draped, a speculum is placed
to retract the eyelids. A segmental conjunctival periotomy is performed temporally and nasally. An
infusion cannula is placed inferotemporally. A 7.5 mm clear corneal incision is created superiorly
with the keratome. The anterior chamber is not entered. The toric IOL corneal marker is used to
mark the 3 and 9 o’clock positions (Figure 2). At each marked position, 2 sclerotomies are created
with the microcannula trocar or with a 25-gauge needle 1.5 mm to 2 mm posterior to the limbus, 2
mm to 3 mm above and below the marked midpoint line. Each sclerotomy is marked with the
marking pen for easy identification later (Figure 3). The remaining 2 microcannulas are placed in the
traditional locations with care to avoid the fixation suture sclerotomies. A pars plana vitrectomy is
performed. As needed, the retained lens fragments or dislocated IOL are completely removed from
the eye. The CZ70BD IOL implant is now transferred to the field and positioned above the eye on an
instrument wipe. The clear corneal incision is now opened, if not previously done.
Figure 2. A toric corneal marker is used to precisely mark the midpoint at the 3 o’clock and 9 o’clock
positions.

Figure 3. Creating 2 sclerotomies at the 3 o’clock position with a 23-gauge trocar, 2 mm posterior to
the limbus. Each sclerotomy is 2mm to 3 mm from the midpoint line and marked with a purple
marking pen to make it easier to find later.
The first suture is loaded into the microsuture passer (Figure 4). A needle (CIF, Ethicon) is left on
one end of the suture to help weigh it down it while sutures are passed. Starting at the 9 o’clock
position and then repeating at the 3 o’clock position, the loaded suture-passing instrument is passed
through one of the sclerotomies and out through the clear corneal incision (Figure 5). The suture is
grasped with a tying forceps and the suture passer is pulled back through the sclerotomy. The free
end of the suture is then threaded through an eyelet on the IOL haptic. The trailing end is then
passed through the other sclerotomy at 9 o’clock and out through the clear corneal incision to
retrieve the trailing end of the suture. This is passed into the eyelet of the microsuture
passer (Figure 5). The microsuture passer is withdrawn, pulling the suture back through the
sclerotomy. The suture is pulled tight and to the side of the corneal incision to avoid tangling with the
next suture. In an identical way, the second suture is passed through the sclerotomies at the 3
o’clock position and through the eyelet on the opposite haptic of the IOL (Figure 6). The new suture
is also pulled tight and to the side of the corneal incision. The IOL is now inserted into the posterior
chamber, guided into place by the fixation sutures at 9 o’clock (Figures 7-8). The superior haptic is
intentionally left outside of the incision. The first fixation suture is now tightened to secure the IOL’s
haptic to the ciliary sulcus with 3-point fixation. A temporary surgeon’s knot with 3 throws is used to
secure the inferior haptic. The superior haptic is now inserted into the ciliary sulcus and guided into
place by the other fixation suture. This is also temporarily tied with a surgeon’s knot. A corneal
protector is placed on the cornea to prevent phototoxicity. The clear corneal incision is then closed
with 10-0 nylon sutures. The tension on the fixation sutures is then carefully adjusted. The IOL is
usually well centered at this point. The fixation sutures are permanently tied with care not to
overtighten them. The fixation sutures are carefully rotated inside one of the sclerotomies so that the
knot is internalized and not exposed on the outside of the sclera (Figure 9). The microcannulas are
removed from the sclerotomies. The sclerotomies are closed with an absorbable suture. The infusion
cannula is removed from the eye. The conjunctiva is closed with interrupted sutures. Eye drops
containing antibiotic and steroid are administered. A patch and shield are placed over the eye.

Figure 4. The second 9-0 Prolene suture is loaded into the suture passer. The CIF needle is passed
through the eyelet (blue arrow). The black arrows show the first 9-0 Prolene suture that was already
passed through the 2 sclerotomies and the IOL eyelet. The CIF needle is used to weigh down the
end of the first 9-0 Prolene suture.
Figure 5. The 9-0 Prolene suture has been passed through the sclerotomy and out of the corneal
incision (blue arrows). It is grasped with a tying forceps and then the suture passer is withdrawn. The
black arrows show the first 9-0 Prolene suture.

Figure 6. Threading the trailing end of the second 9-0 Prolene suture into the suture passer. The
passer will be withdrawn, pulling the suture out through the sclerotomy. The blue arrows show the
second suture threaded through the superior haptic eyelet on the IOL and the 2 sclerotomies at the 3
o’clock position. The black arrows show the first 9-0 Prolene suture already threaded through the
inferior IOL eyelet and the 2 sclerotomies at the 3 o’clock position.
Figure 7. Insertion of the IOL through the corneal incision. The blue arrows show the 9-0 prolene
sutures exiting from the sclerotomies.

Figure 8. Insertion of the IOL. Note that 9-0 prolene suture is threaded through the inferior eyelet of
the IOL and exits through the 9 o’clock sclerotomies. The blue arrows show the 9-0 prolene sutures
exiting from the sclerotomies.
Figure 9. Rotating the knot internally through one of the sclerotomies. This step eliminates the need
for a scleral flap. The blue arrow shows the knot just before it is rotated internally. The black arrow
shows the other 9-0 prolene with the knot already internalized.

RESULTS
This series included 79 eyes with follow-up of 0.5 years to 11.9 years (mean = 2.1 years). Baseline
characteristics are summarized in Table 1. The mean age of the patients was 68 (age range: 23-89;
28 female, 51 male). The most common indications for requiring a scleral fixated IOL are listed
in Table 2 and include: dislocated-subluxated IOL (42), dislocated lens fragments or crystalline lens
(15), S/P complex retinal detachment repair (13), aphakia (7), and trauma (2).

Table 1. Baseline Characteristics

Total Patients 79

Total Eyes 79

AGE (YEARS)

Range 23-89

Mean 68

GENDER

Male 51
 Female 28

PREOPERATIVE LOGMAR VISUAL ACUITY (SNELLEN)

Range 0.08-3.00 (20/25-20/20000)

Mean 1.41 (20/514)

LAST-RECORDED POSTOPERATIVE LOGMAR VISUAL ACUITY (SNELLEN)

Range 0.03-3.00 (20/20-20/20000)

Mean 0.87 (20/144)

DURATION OF FOLLOW-UP (YEARS)

Range 0.5-11.9

Mean 2.1

Table 2: Visual Acuity Outcomes vs Surgical Indications

INDICATION PREOPERATIVE VISUAL LAST-RECORDED

(NUMBER OF EYES) ACUITY (VA) (LOGMAR) POSTOPERATIVE VA
(LOGMAR)

Overall (79) 20/514 (1.19) 20/144 (0.87) (P<.0001)

SURGICAL INDICATION

Dislocated-subluxated 20/303 (1.19) 29/91 (0.67)

IOL (42)

Dislocated lens 20/1868 (1.98) 20/166 (0.93)

fragments-crystalline
lens (15)

S/P retinal detachment 20 /633 (1.50) 20/873 (1.65)

repair (13)

Aphakia (7) 20/469 (1.38) 20/65 (0.51)

Trauma (2) 20/2000 (2.0) 20/246 (1.10)

The preoperative Snellen visual acuities (VA) of the 79 patients ranged from 20/25 to 20/20000. The
mean preoperative logMAR visual acuity was 1.41 (20/514 Snellen equivalent). The mean last-
recorded postoperative visual acuity improved to 0.86 (20/144 Snellen equivalent) and ranged from
20/20 to 20/20000 (P<0.0001). Many of our scleral fixation IOL patients had serious retinal
conditions that precluded them from obtaining excellent postoperative visual acuities. As expected,
those patients with complex retinal detachments, macular degeneration, ruptured globe, severe blunt
trauma, or a previous macular hole fared worse than those with aphakia, dislocated IOL, or
dislocated lens fragments or crystalline lens (Table 2). The best visual acuity results were in the
aphakic eyes (improving from 20/469 to 20/65), the dislocated IOL eyes (improving from 20/303 to
20/91), and the dislocated lens fragments and crystalline lens eyes (improving from 20/1868 to
20/166). Of the 79 eyes in our review, 23 eyes (28.8%) achieved a post-operative visual acuity of
20/40 or better at the last follow up. The traumatic eyes fared poorly (VA improving from 20/2000 to
20/246) and the complex retinal detachment eyes worsened (from 20/633 to 20/873).

There were no cases of endophthalmitis or malpositioned IOL. Complications included transient

corneal edema in 27 patients (34%), elevated intraocular pressure in 16 patients (20%), transient
hypotony in 12 patients (15%) that resolved spontaneously within the first week, exposed suture tips
which appeared 1-3 months after surgery due to incomplete internal rotation were resolved with in-
office trimming in 10 patients (12.5%), recurrent retinal detachment with proliferative
vitreoretinopathy in 3 patients (4%) and suture breakage with dislocation of the IOL in 2 patients
(2.5%). There were no cases of endophthalmitis, tilted IOL or malpositioned IOL.

For both cases that developed a broken fixation suture with subluxation of the IOL (Table 3), the
IOLs were fixated with 10-0 Prolene sutures (8.3% of the 24 eyes operated on using the 10-0
Prolene fixation sutures). In the first patient, the 10-0 Prolene suture broke at 5 years and 3 months
postoperatively. This dislocated haptic was “lassoed” with a 9-0 Prolene using the suture passer. In
the second patient, the suture broke at 4 years and 2 weeks postoperatively. An IOL exchange was
performed with placement of an AC IOL. There were no broken sutures with the 9-0 Prolene sutures
(0/55) (P<.05). For this reason, we permanently switched to 9-0 Prolene sutures for scleral fixation
after 2007 and have not had any other cases of suture breakage.

Table 3: Incidence of Fixation Suture Breakage

PROLENE SUTURE INCIDENCE OF FIXATION SUTURE NUMBER OF

USED BREAKAGE EYES

9-0 0 55

10-0 2 24

P value <.05

DISCUSSION
Prior to 1986, the choices for a patient with inadequate capsular support were limited to an anterior
chamber IOL, an iris-claw IOL, or an iris-suture fixated posterior chamber IOL.7-9 Complications were
significant and included corneal decompensation, iris atrophy and chafe, chronic uveitis, pigment
dispersion syndrome, glaucoma, hyphema, cystoid macular edema, and pseudophacodonesis.7 In
1986, Malbran et al reported using a “guide” suture for the fixation of a secondary IOL after
intracapsular cataract surgery, ushering in a new era in which IOL implantation in the posterior
chamber/ciliary sulcus was an option for patients with inadequate capsular support.8

Hu et al and others improved upon the Malbran technique in several ways.9-10 They added scleral
flaps to cover the knot and minimize erosion of the suture knot through the conjunctiva, which posed
a significant risk for endophthalmitis.7,9 Over time, however, some of the scleral flaps thinned and the
knot could still erode through both the flap and the conjunctiva in a delayed fashion.11 Hoffman et al
used a scleral tunnel to decrease the risk of conjunctival erosion, knot exposure, and
endophthalmitis.12

Rotation of the knot into the eye reduces the risk of knot exposure and endophthalmitis.13-15 Yuksel et
al reported a 20.6% rate of suture knot erosion with scleral flaps compared to 0% when the knots
were buried in 56 eyes that underwent trans-scleral sutured IOL implantation.16 An advantage of the
technique described here is that it is relative easy to bury the knots and thus there is no need to
create a scleral flap. In 10/79 (12.5%) of the eyes in this series, one of the knots could not be safely
rotated into the sclerotomy at the time of surgery and the knot was left exposed. The exposed knot
tip was either trimmed or shrunk with the laser in the office. There were no cases of endophthalmitis
in our series.

In early cases, some IOLs dislocated because the suture slipped off the haptic. This problem was
circumvented by selecting an IOL with a loop at the end of the haptic or creating a bulb on the end of
the haptic with the heat from a cautery.9 Alcon later introduced the CZ70BD IOL with strategically
placed eyelets at the midpoint of the curve of the haptic.7 This simplified placement and eliminated
slippage of sutures. The CZ70BD was the IOL of choice for scleral-fixated IOLs for nearly two
decades. Recently, Khan et.al reported good results using a 4-eyelet IOL, the Akreos A060 (Bausch
+ Lomb), with Gore-Tex sutures (W. L. Gore & Associates) for scleral fixation.1,17,18 There were no
cases of suture erosion or breakage with a mean follow-up of 325 days.17 The Akreos IOL is acrylic
and foldable, allowing it to be inserted through a 2.8 mm incision. The CZ70BD is PMMA, not
foldable, and requires a 7.5 mm incision. Both the CZ70BD and the Akreos AO60 must be special
ordered before the surgery. Although this paper focused exclusively on the CZ70BD, the microsuture
passer will work well with any IOL that has eyelets, including the Akreos AO60.

A late complication of scleral-fixated IOLs is suture breakage and dislocation of the lens. The
reported rate of dislocation of scleral-sutured IOLs varies from a high of 27.9% to 2.2%. Vote et al
reported a 27.9% rate of suture breakage with dislocation of the IOL in their series of 61 eyes that
received a scleral fixated CZ70BD IOL with a mean follow-up of 6 years. Their surgical technique
used 10-0 Prolene fixation sutures at the 6 o’clock and 12 o’clock positions under half-thickness
triangular scleral flaps.19 Walter et al reported 2 of 89 eyes (2.2%) with suture breakage, also with 10-
0 Prolene suture used for trans-scleral fixation of secondary IOLs during penetrating keratoplasty.20

Although several innovative techniques for scleral fixation of IOLs have been introduced during the
past 5 years, this technique remains a viable option and has several advantages. The 90° curve
simplifies suture passing and retrieval and eliminates the issues associated with bending the
microforceps. Suture tangling and inversion of the IOL during implantation is reduced. The suture
knot can be buried by rotating it inside of the eye in most cases without the need for a scleral flap.
The 3-point fixation (2 sclerotomies and the eyelet on the IOL) holds the curvature of the haptic
securely in the ciliary sulcus. Tilting and posterior subluxation of the IOL are minimized. Malposition
of the IOL can be more problematic with 2-point fixation techniques. The microsuture passer is
gentle on the sutures, with few broken sutures reported. It is less expensive than disposable
microforceps. It can also be used to “lasso” the free haptic of a subluxated IOL. This was used to
salvage and reposition the haptic of the subluxated IOL in one of our 2 patients with a broken fixation
suture.

CONCLUSIONS
The microsuture passer simplifies the placement of scleral fixation sutures for implantation of scleral
fixated IOLs. The suture knots are rotated internally, eliminating the need for a scleral flap. To
minimize the risk of suture breakage, a previously documented complication, 9-0 Prolene sutures
are preferred over 10-0 sutures for IOL fixation. This technique produces good long-term results and
stability for scleral-fixated IOLs, and results in a well-centered IOL without tilt. RP
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Retinal Physician, Volume: 14, Issue: March 2017, page(s): 18-24