Surgery: 25g PPV with IOL Exchange and Sutured CZ70BD Lens: A New Technique to Prevent Lens Tilt
In this video, Dr. Riemann demonstrates his preferred IOL suturing technique in the absence of capsular support. An IOL exchange is performed and the new IOL is sutured to the sclera using a four-point fixation technique to eliminate the common complication of IOL tilt when lenses are sutured into the sulcus.
Surgeon: Dr. Chris Reimann, Cincinnati Eye Institute, USA
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DR RIEMANN: So I’d like to talk about my IOL suturing technique. This is really nice. It works. It’s minimally invasive. And I’ve been getting great results. This is a lens that’s headed on its way into the soup, after multiple retinal detachment repairs for zonular problems. We set up for a vitrectomy. Here I’m using 25-gauge. We make a mark, a 7-millimeter wound, I make this triplanar near-limbal incision. Almost a small incision extracap-type wound. We enter the anterior chamber, but don’t open the wound in its entirety. And then very carefully and meticulously, with DisCoVisc, I fill the anterior chamber, injecting into the bubble, to keep the viscoelastic from going posteriorly and keeping it in the anterior chamber. We use suction from the vitreous cutter to mobilize the lens and get it into the anterior chamber. And then we make sure that there’s nothing bad going on in the back of the eye. The eye is previously vitrectomized here. We make two pairs of 20-gauge sclerotomies, right through the conjunctiva here. In the iris plane, we go in about 3 millimeters back, and if I’m in the iris plane, this brings me into the ciliary sulcus. We take Gore-Tex on a — CV8 Gore-Tex — and loop it in one sclerotomy and out the other sclerotomy, using two MST forceps, and then we repeat the same thing 180 degrees away. So, again, here we’re going in one sclerotomy with the Gore-Tex loop, and out through the other sclerotomy. And we open up the cataract wound to the complete 7 millimeters. We drop the intraocular pressure to 5 here, turn intraocular pressure control off, remove the IOL, externalize each of the Gore-Tex suture loops. A little bit of scleral depression takes it and moves it into view. And then the tricky part is we want to make sure to untangle the Gore-Tex suture loop. Make sure there’s no twists in it. And then we set up for the girth hitch. So here on the other one, again, we make sure there’s no twists. And set up for the girth hitch knot. That is a beautiful way to fixate the suture onto the IOL haptic in a way that gives true 4-point fixation, which makes tilt problems completely go away. And we put the lens into the eye. Take up the slack on the Gore-Tex sutures. And make sure to spin the lens, which you can do by pulling on the Gore-Tex suture pairs, so that the lens haptics are both as far counterclockwise as you can get them. Then we go in one conjunctival opening. Remember, we used a 20-gauge MVR blade, so these are easy to find. Out the other conjunctival opening. Passing the suture loop from the more clockwise sclerotomy towards the more counterclockwise sclerotomy. And then we use a 3-1-1-1-1 knot to tie these snugly but not tightly, right on top of the more counterclockwise sclerotomy. Which is where the internal IOL haptic fixation point is. I like this extracap 10-0 nylon closure. I leave the knot exposed, because we pull these usually about a month out from surgery. It’s easier to pull. Again, we’re going in one conjunctival opening and out the other. With the 25-gauge MST forceps. Passing the more clockwise strand to the more counterclockwise sclerotomy. Maintaining tension on the more counterclockwise strand, while snugging it up to the surface of the eye. Again, a 3-1-1-1-1 knot. And we take the 25-gauge MST forceps, and we tuck the knot intraocularly. Not intrasclerally, but intraocularly. Which eliminates the problems of erosion. We do that for both sclerotomies. We clean up some hemorrhage and viscoelastic from the surface of the retina. And from the anterior chamber. Put in an air bubble to prevent postoperative hypotony. And we’re all done. On postop day one, these eyes look beautiful. Here’s the suture knot. You’ll see the cornea is clear. The Gore-Tex is on the surface of the sclera. The lens is perfectly centered, without any tilt.