Eyeworld

EW REFRACTIVE 40 August 2018 Presentation spotlight by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer age while externalizing it. "There is a very low risk. I only lost an IOL into the vitreous cavity one time in 12 years and more than 500 of these implantations, and that was the only case when I did not use a continuous infusion," he explained. The placement of the haptics into scleral tunnels creates a high degree of stability with no risk of losing the IOL. This is achieved with the help of a curved forceps, mak- ing sure that the haptic end is fully covered by sclera so there is no risk of extrusion, late erosion, or late conjunctival damage. "By the time you externalize the second haptic, the IOL is already centered," Dr. Scharioth explained. "This is the only technique where you have the chance for what I call fine-tuning at the end of the surgery. You can aim for excellent centra- tion." IOL calculation in scleral fixa- tion is less reliable than in standard cataract surgery with PCIOL implan- tation, but Dr. Scharioth said that by using the SRK/T formula and calculating the in-the-bag position of the PCIOL, he has had excellent refractive outcomes in the majority of cases. A clever technique stably centers IOLs in eyes with no capsular support T he capsule bag can usually withstand the wear and tear of cataract surgery with phacoemulsification and IOL implantation and remain patent. The cataract surgeon, however, will want to be prepared for scenarios involving weak zonule fibers and a torn or missing cap- sule bag with the knowledge of the safest, most efficient implantation alternative. At the 22nd ESCRS Win- ter Meeting, one session presented a highly reliable technique that has been used to fixate IOLs in eyes lacking capsular support for nearly 12 years. Presenting his technique at the meeting, Gabor Scharioth, MD, Aurelios Augenzentrum Reckling- hausen, Germany, said that his intrascleral, sutureless posterior chamber IOL fixation method allows excellent centration of both three- piece and single-piece IOLs. An early publication describes its implemen- tation for the sutureless fixation of a standard three-piece posterior chamber IOL in the ciliary sulcus in eyes without capsule support with IOL implantation when the capsule is weak or absent Figure 1. Inferior haptic implanted in the limbus parallel intrascleral tunnel with curved Scharioth forceps; note 25-gauge infusion cannula used as anterior chamber maintainer Figure 2. Slit lamp photo of an eye 8 years after intrascleral haptic fixation; no sign of inflammation or erosion subluxated and luxated cataract and for secondary IOL implantation. The technique uses standard IOLs and is independent from iris changes. It could be used even in aniridia cases. Reducing the uveal contact results in less irritation and prevention of uveitis-glaucoma-hemorrhage syn- drome. There is no risk for late dislo- cation due to suture degradation and break. Fixation of the haptics in a limbus parallel scleral tunnel al- lowed exact centration and provided axial stability to prevent distortion. The technique uses uncomplicated standardized maneuvers for stan- dard three-piece fixation without the need for special haptic architec- ture or preparation. 1 A subsequent study that in- cluded 63 consecutive patients who underwent cataract surgery using this technique with eyes lacking capsular support resulted in only two decentrations and 61 stable and well-centered IOLs. There were no recurrent dislocations in the 2-year follow-up period. The study proved that fixation of the posterior cham- ber IOL haptics in a limbus parallel scleral tunnel prevented distortion and subluxation in most cases. 2 Specialized technique The procedure begins by prepar- ing the symmetrical, ciliary sulcus sclerotomies 1.5–2 mm behind the limbus, 180 degrees from each other. Dr. Scharioth does not main- tain a strict distance to the limbus, placing the sclerotomies relative to the anterior chamber depth and the insertion of the iris root. Dr. Schari- oth prefers to place the sclerotomies slightly more anteriorly, moving back a half millimeter, if necessary, based on iris movement, which en- sures that he is in the ciliary sulcus. Using the sclerotomies as starting points, he prepares two 2-mm limbus parallel tunnels using 23-gauge cannulas. Although he originally was able to use 24-gauge cannulas, they made haptic implan- tation difficult due to their small size. He performs either an anterior vitrectomy or a PPV and carries out a capsulotomy. Dr. Scharioth then inserts the IOL using continuous irrigation, such as provided by an anterior chamber maintainer or by means of a 25-gauge pars plana infusion. He uses specialized forceps (Scharioth IOL fixation forceps, DORC, Zuid- land, the Netherlands) to externalize the haptics with a maneuver he calls the "handshake technique," by which he grasps the very tip of the haptic, thereby avoiding any dam-

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