Techniques for scleral fixation of IOLs

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Monteiro et al.¹ propose a variation to the technique of scleral fixation of intraocular lenses (IOLs). Although details are not provided in the body of the paper, the complications of hyphema, vitreous hemorrhage, and choroidal hemorrhage are mentioned in the abstract. We believe these occurrences may be peculiar to their technique of scleral fixation.

Monteiro et al. make 2 entries into the eye in the region of the ciliary sulcus, the first with a 30-gauge needle, followed by the “blunt” end of the double-armed 10-0 polypropylene (Prolene) suture. Considering the vascularity of the ciliary body, 2 penetrations, the second by a blunt instrument, may tear ocular tissue and thereby predispose these eyes to the aforementioned hemorrhagic complications.²

The authors argue that an advantage of their technique is the lack of scleral flaps. In the absence of a scleral bed, the knot of the anchoring suture is buried in the scleral incision. On careful study of the illustrations, we notice that the anchoring suture is subconjunctival at the conclusion of the procedure. This is not the case when scleral flaps are fashioned, as the anchoring sutures are placed in the scleral bed and covered by the scleral flap as well as the conjunctiva.

This difference is important. As the authors point out, suture exposure might lead to endophthalmitis even after several years. In the case of scleral-fixated IOLs, the anchoring suture communicates directly with the intraocular cavity. We believe the anchoring sutures in this technique are in closer contact with the ocular surface because of the absence of scleral flaps and are more likely to erode through the conjunctiva. Even a microscopic break in the overlying conjunctiva could result in bacterial contamination. It would be worthwhile to compare the incidence of endophthalmitis and suture exposure over the long term with the authors' technique and the scleral flap method.

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References 

1. Monteiro M, Marinho A, Borges S, et al. Scleral fixation in eyes with loss of capsule or zonule support. J Cataract Refract Surg. 2007;33:573–576
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2. Snell RS, Lemp MA. Clinical Anatomy of the Eye. 2nd ed.. Malden, MA: Blackwell Science; 1998;132–213
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