Gluing posterior IOLs in place

November 1, 2008

Dr Amar Agarwal and team describe a technique for adhering sutureless scleral-fixated IOLs with a biological fibrin sealant glue.

Key Points

Sutured scleral-fixated IOL (SFIOL) implantation carries the risk of multiple complications, including suture induced inflammation, suture degradation, and delayed IOL subluxation and dislocation due to broken suture. The technique also requires surgical expertise and is time-consuming, requiring perfect adjustment of suture length and tension to ensure good centration of the SFIOL.

To prevent the obstacles and complications associated with implanting IOLs in posterior capsule deficient eyes, it is advisable to avoid the use of sutures. To achieve sutureless scleral IOL fixation, Gabor et al placed the IOL haptic in a scleral tunnel,13,14 whereas we devised a technique to attach the IOL using a biological fibrin glue.

The commercially-available quick-acting surgical fibrin sealant we used had both haemostatic and adhesive properties and was derived from human blood plasma.

The sealant is virus-inactivated and is checked for viral antigens with a polymerase chain reaction, hence the chance of transmission of infection is very low. With tissue derivatives, however, there is of course always a theoretical possibility of viral infection transmission,15 therefore obtaining informed consent from the patient prior to the procedure is mandatory.

Fibrin glue has been used previously in various medical specialities as a haemostatic agent to arrest bleeding, seal tissues and as an adjunct to wound healing.16–18 Though the use of fibrin glue in ophthalmology is considered off-label, it has been used successfully in the eye for a long time. Its various uses in the eye include repair of lacerated canaliculi,19 and to seal full thickness macular holes,20,21 cataract incisions,22–25 corneal perforations, and traumatic lens capsule perforations.26 It has also been used for temporary closure of scleral flaps after trabeculectomy in eyes with hypotony,27 conjunctival fistula closure,28 conjunctival autografts,27 and amniotic membrane transplantation.29,30

During our SFIOL implantations, we used scleral flaps as we would in conventional sutured SFIOLs, which makes the learning curve minimal and very simple. An important advantage of this technique is the prevention of suture-related complications:31–33 suture erosion, suture knot exposure or dislocation of IOL after suture disintegration or broken suture. Chances of scleral melt34–36 and haptic exposure are not increased by this technique, except possibly in high-risk patients, such as those suffering from, for example, rheumatoid arthritis.

The fibrin kit we used was ReliSeal (Reliance Life Sciences). It is available in a sealed pack, which contains freeze-dried human fibrinogen (20 mg/0.5 ml), freeze-dried human thrombin (250 IU/0.5 ml), aprotinin solution (1500 kiu in 0.5 ml), one ampoule of sterile water, four 21 G needles, two 20 G blunt application needles and an applicator with two mixing chambers and one plunger guide.