Eyeworld

75 EW FEATURE October 2015 Complex cataract cases patients. If you put an anterior chamber lens in the eye, over the next 70 years this can move and create damage, Dr. Agarwal pointed out. "If you put in a sutured lens, the suture can break after some time," he said. "The advantage of a glued IOL is it remains steady." There are many others who can benefit, he said. He pointed to cases of pseudoexfoliation in which mea- sures such as the use of endocapsular rings may only buy time, but don't fix the problem of progressively loosening zonules. "We take out the whole cataract and fix a glued IOL inside," he said. In gluing the lens here, Dr. Agarwal uses what is known as the handshake technique. With this ap- proach, the tip of the haptic is exter- nalized by first grasping it with one glued IOL forceps and then hand- ing it off to another. Once the first haptic has been externalized and the lens fully inserted, the practitioner moves on to the second. Again the handshake technique is used, transferring the haptic from hand to hand until it is fully externalized on the other side. Each of the haptics is then tucked into a separate intras- cleral pocket on opposite sides and the glue is applied to seal the pocket and subsequently ensure that the conjunctiva adheres over this, Dr. Agarwal said. When gluing the IOL in place, it is important to have fluid, not viscoelastic, in the eye, he stressed, adding that without a capsule, any viscoelastic will fall on the retina. Dr. Agarwal uses an instrument he designed called the trocar anterior chamber maintainer, which inserts fluid through the sclera into the anterior chamber during the proce- dure. Dr. Agarwal has also recently started using the glued IOL tech- nique in conjunction with pre-De- scemet's endothelial keratoplasty (PDEK) in which 25 microns of tissue are transplanted from one pa- tient to another. When combining the techniques, Dr. Agarwal will first perform the glued IOL technique and then perform the PDEK proce- dure. "Now the glued IOL works like a trampoline, so when I inject air inside the eye it pushes against the graft," he said, adding that corneas become clear, making for happy patients. Overall, there can be a bit of a learning curve with the techniques, Dr. Agarwal acknowledged. He advised practitioners to watch videos of the procedures first. Dr. Hoffman recommended becoming versed in a variety of approaches for non-cap- sular IOL fixation. "There are certain instances where a particular tech- nique might be better or easier to do, so it's nice to be able to do them all or at least be aware of them all," Dr. Hoffman said. EW Editors' note: Dr. Agarwal and Dr. Hoffman have no financial interests related to this article. Contact information Agarwal: dragarwal@vsnl.com Hoffman: rshoffman@finemd.com Iris fixation using Dr. Hart's innovation, which makes pupil ovalization less likely. Source: Richard Hoffman, MD Scleral tunnels created adjacent to sclera flaps for IOL haptic capture in a case involving the glued IOL technique Source: Amar Agarwal, MD " There are certain instances where a particular technique might be better or easier to do, so it's nice to be able to do them all or at least be aware of them all. " –Richard Hoffman, MD

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