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EDITORIAL
Intraocular lens implantation in the absence of capsular
support: scleral fixation
© The Author(s), under exclusive licence to The Royal College of Ophthalmologists 2022

Eye (2022) 36:1721–1723; https://doi.org/10.1038/s41433-022-02024-3 receive or might already have been implanted with a PC- IOL
as well.
Not infrequently, poor zonular support occurs in the setting of
Although routine phacoemulsification with simultaneous implan- already established or impending corneal decompensation. The
tation of a foldable intraocular lens (IOL) in the capsular bag presence of a PC-IOL ensures a deeper chamber, enabling surgical
remains the gold standard in uneventful cataract surgery [1], manoeuvres as well as the introduction, manipulation and the
events such as surgical complications or previous trauma may long-term preservation even of the most demanding endothelial
render zonular and/or capsular support insufficient or even grafts like PDEK and DMEK. On the contrary, endothelial grafting
absent, thus leaving the operating surgeon faced with an in the presence of any iris- or angle-supported IOL is not only
important decision regarding the type of IOL and mode of technically more demanding but the proximity of the IOL to the
fixation. Moreover, increasing age as well as a number of ocular graft increases the risk for secondary or even primary graft failure.
pathologies such as pseudoexfoliation or systemic conditions such A relatively common complication of all scleral-fixating techni-
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Marfan syndrome or homocystinuria may lead to late in-the-bag ques is intraoperative and early post-operative haemorrhage as a
IOL dislocation, necessitating secondary fixation of a pre-existing result of conjunctival manipulation, placement of sclerotomies
IOL or IOL exchange. For over a decade the available choices in and/or needles through the well vascularised pars plicata and the
the absence of capsular support included angle-supported formation of scleral flaps. However, it can be up to a degree
anterior chamber (AC) IOLs and scleral-sutured posterior chamber prevented by careful planning and meticulous surgical technique.
(PC) IOLs through a large corneal or limbal incision. Although Maintaining the eye well-pressurised during the procedure and
flexible open-loop AC IOLs have an improved safety record [2] ensuring tight wounds is of paramount importance. Careful
compared to previous closed-loop models, most surgeons nowa- haemostasis of the scleral bed of the flaps in cases of glued PC-
days prefer either scleral- or iris-supported IOLs due to their near- IOL reduces the possibility of intra- and early post-operative
normal anatomical correction and safer profile regarding corneal vitreous haemorrhage and/or hyphema (Fig. 1).
endothelium. Late postoperative AC and vitreous haemorrhage, especially in
Scleral-sutured, glued or intracanal-fixated IOLs placed in the poorly positioned IOLs, may be attributed to continuous chaffing
posterior chamber further from the cornea and all AC structures, of uveal tissues leading to Uveitis-Glaucoma-Hyphema (UGH)
appear to have a higher safety profile compared with a properly syndrome and most likely CMO. These uncommon complications
implanted iris-fixated IOL (angle-supported, iris-sutured or iris- in secondary PC-IOL fixation (11.6% and 14.3%, respectively) [8]
claw IOs) with lower risk of corneal endothelial loss, pupillary are encountered more frequently in secondary iris-fixation and AC
distortion, iris or angle damage, chronic iritis and secondary IOLs [9]. Considering that two major risk factors for the occurrence
glaucoma [3]. This makes a scleral-fixated (SF) posterior chamber of UGH-syndrome are floppy iris syndrome and traumatic aphakia,
IOL the ideal choice in the presence of previous iris trauma, iris the placement of a SFPC-IOL is largely preferred in the setting of
defects such as in acquired or congenital aniridia, glaucomatous concurrent traumatic iris defects, as these would not only make
eyes with or without the presence of a drainage device and eyes the insertion of any iris-fixated or angle supported IOL without
with a compromised corneal endothelium. Where there is history prior iris reconstructive surgery impossible or at least unstable, but
of iritis and/or CMO, the placement of an angle- supported or iris- they would further increase the risk for late postoperative
fixated AC-IOL, with varying degrees of associated iris chaffing and haemorrhage, inflammation and IOP spikes.
blood-ocular barrier breakdown, may lead to a significantly worse Scleral suture fixation in the absence of capsular support has
prognosis compared to a SF- IOL [4–6]. The implantation of a been criticised for the risk of IOL tilt, decentration and even
posterior chamber (PC) IOL in the sulcus is a lot more subluxation especially where IOLs were suspended by two sutures.
advantageous compared to an iris-fixated or anterior-chamber However, newer techniques of PC scleral fixation such as the four-
(AC) IOL in regard to both safety and optical quality. In terms of flanged technique by Sergio Canabrava [10], the double-needle
safety the presence of a stable PC-IOL forms a barrier preventing Yamane technique [11], the implantation of a Carlevale IOL [12]
the migration of inflammatory cytokines and mediators as well as (Fig. 1b, c) and more importantly the glued-IOL described by A.
prolapse of vitreous strands in the anterior chamber, thus Agarwal [13], allow for a more stable and predictable placement
reducing the risk of CMO [7]. Furthermore, it preserves the with a much larger area of fixation, where a part of the IOL haptics
integrity of the AC, preventing eventual damage to corneal acts as an anchor, making IOL decentration and tilt a lot less likely
endothelium, as well as the iris stroma, and angle structures [14]. With regard to iris-fixated IOLs, one may argue that they have
reducing the risk of inflammation, pressure elevation and/or been shown to have a high track record of stability and lack or
formation of peripheral anterior synechiae. Regarding optical very low levels of tilt. Nevertheless, this appears to be largely iris-
quality, PC-IOLs are placed closer to the nodal point of the eye dependent and may not be the case in eyes with traumatic
ensuring better visual quality compared to any iris-fixated aphakia, floppy iris and stromal atrophy. The flaccid iris in those
technique, considering the fact that fellow eyes will most likely cases lacks tone, reducing the stability of the iris-claw IOLs and

Received: 16 January 2022 Revised: 2 February 2022 Accepted: 10 March 2022

Published online: 24 March 2022
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1722

Fig. 1 Scleral fixation intraocular lens implantation examples. a Scleral fixation intraocular lens in situ – notice long suture ends used to
prevent conjunctival perforation. b Carlevale intraocular lens insertion. c Four-flanged technique for intraocular lens fixation. d Three-piece
intraocular lens insertion through scleral flaps.

Table 1. Advantages of scleral fixation.

1. Lower risk for corneal endothelial stress during performance of AC manoeuvers.

2. Lower risk of pupillary distortion, iris or angle damage and chronic iritis.
3. Lower risk for Uveitis-Glaucoma-Hyphema syndrome.
4. Advantageous in cases of iris defects, trauma or iritis.
5. Implanted closer to the nodal point of the eye.
6. Enables future endothelial grafting.
7. New sutureless techniques devoid of suture-related complications and provide stable fixation.
8. Easy to fit through small incisions.
9. Transconjunctival techniques further reduce conjunctival manipulation.

risking an immediate or late dislocation in the vitreous cavity with (Table 1). Eyes with lack of zonular and/or capsular support tend to
detrimental consequences in case of attempted retropupillary iris have multiple comorbidities making the preservation of cornel
fixation. In fact one recent study has shown a disenclavation rate endothelium and the reduction of iris inflammation with resultant
of retropupillary fixated iris-claw IOLs of 9.7% and an older one of CMO that scleral fixation of PCIOL offer, a top priority.
14%, respectively [15, 16].
Intraocular lenses designed for scleral fixation are foldable and Michael Tsatsos1, Georgios Vartsakis 2,
easy to fit through a small incision, thus their insertion does not ✉
Ioannis Athanasiadis 1 , Marilita Moschos3 and Soosan Jacob4
require the large corneal or limbal wound needed in the case of 1
Department of Ophthalmology, Aristotle University of Thessaloniki,
iris-claw or angle supported AC-IOL, maintaining the structural Thessaloniki, Greece. 2Department of Ophthalmology, Sahlgrenska
integrity of the eye and reducing the risk of a post-operative University Hospital, Gothenburg, Sweden. 3Department of
wound leak, endophthalmitis and astigmatism. Moreover, the risk Ophthalmology, National and Kapodistrian University of Athens,
for a suprachoroidal haemorrhage should be considered and Athens, Greece. 4Department of Ophthalmology, Agarwal’s Group of
large incisions should be avoided in high-risk patients. The advent Eye Hospitals, Chennai, India. ✉email: [email protected]
of newer techniques such as the Yamane [11] and the trocar-
assisted scleral fixation [17] minimise the need for conjunctival
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COMPETING INTERESTS
New surgical approach for sutureless scleral fixation. Eur J Ophthalmol.
The authors declare no competing interests.
2020;30:612–5.
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