Scleral Fixation of IOL (Scleral Suture Fixation and Intrascleral Fixation)

Key points of this condition

• Sutured scleral-fixated IOL and intrascleral fixation are surgical techniques used to fixate or reinsert an IOL when capsular support is lost, and for optical rehabilitation of aphakia.
• Sutured scleral-fixated IOL uses nonabsorbable sutures to fixate the IOL to the sclera, while intrascleral fixation (Yamane technique) fixates the haptic within a scleral tunnel without sutures¹⁾²⁾.
• Zonular weakness due to exfoliation syndrome is an important cause of IOL dislocation within the capsular bag²⁾.
• Preoperative evaluation includes dilated slit-lamp examination, and if necessary, ultrasound and anterior segment imaging²⁾.
• Network meta-analysis showed that visual outcomes of iris-fixated, transscleral sutured, and intrascleral fixation were generally comparable, but complication profiles differed³⁾.
• In sutured techniques, attention should be paid to suture breakage, late dislocation, and suture exposure³⁾⁴⁾.
• The Yamane technique (reported in 2017) does not use sutures, glue, or scleral flaps, but requires proficiency in precise needle insertion and haptic manipulation¹⁾⁵⁾.
• The surgical technique is selected individually based on capsular support, iris and scleral condition, available IOL, comorbidities, and surgeon experience²⁾³⁾.

1. Scleral Suture Fixation and Intrascleral Haptic Fixation

Scleral suture fixation and intrascleral haptic fixation are surgical techniques used to refixate an intraocular lens (IOL) within the eye when capsular support is lost. They are considered in cases such as posterior capsule rupture, zonular dialysis, IOL dislocation, IOL drop, and aphakia, where capsular support is unavailable ²⁾. Depending on the remaining capsular support and the condition of intraocular tissues, options include IOL repositioning, exchange, iris fixation, scleral suture fixation, and intrascleral fixation.

Scleral suture fixation is a technique in which a non-absorbable suture is tied to the haptic of the IOL and fixed to the sclera through the ciliary sulcus. It can be performed using an ab interno (from inside the eye) or ab externo (from outside the eye) approach.

Intrascleral haptic fixation refers to a group of techniques in which the haptic of the IOL is fixed within the sclera. The representative Yamane technique uses no sutures, adhesives, or scleral flaps; the haptic is passed through a scleral tunnel created with a 30-gauge needle and secured by a flange (bulbous enlargement) formed by cauterization ¹⁾.

This article focuses specifically on the techniques, indications, and selection of scleral suture fixation and intrascleral haptic fixation, differing from articles on the overall pathology and diagnosis of IOL dislocation (“Intraocular Lens Dislocation”) and general secondary IOL insertion procedures (“Secondary IOL Implantation”).

Main Indications

• IOL dislocation: IOL decentration or drop due to zonular dialysis
• Aphakia: No capsular support due to complications during initial surgery or trauma
• Insufficient capsular support: Eyes with partially damaged lens capsule
• Posterior capsule rupture: When in-the-bag insertion is not possible. If accompanied by vitreous prolapse, the risk of cystoid macular edema, retinal detachment, and endophthalmitis increases, and visual prognosis may deteriorate; therefore, evaluate residual capsular support and the degree of vitreous prolapse to select anterior vitrectomy and appropriate secondary fixation.
• IOL exchange: Replacement of an existing IOL due to opacification or refractive error

Indication	Corresponding Surgery
Mild IOL decentration (repositioning only)	IOL repositioning
IOL dislocation / loss of capsular support	Scleral suture fixation or intrascleral fixation
IOL drop (into vitreous cavity)	Vitrectomy + scleral suture fixation or intrascleral fixation
Zonular dehiscence + concurrent PEA	Consider capsular support device or secondary fixation depending on residual capsular support
Posterior capsule rupture (cannot insert in-the-bag)	Select iris fixation, scleral suture fixation, or intrascleral fixation individually

Q What is the difference between scleral suture fixation and intrascleral fixation?

A

Scleral suture fixation is a technique that fixes the IOL haptic to the sclera with non-absorbable sutures; the number of fixation points and the presence or absence of a scleral flap vary by technique. Intrascleral fixation (Yamane technique) inserts the haptic into a scleral tunnel created with a 30-gauge needle and fixes it by cauterizing and flanging the tip ¹⁾. Network meta-analysis showed that visual outcomes were generally comparable, but the types and frequencies of complications differed; selection depends on patient background and surgeon experience ³⁾.

Secondary IOL implantation

Intraocular lens dislocation

2. Main symptoms and clinical findings

Subjective symptoms

The main subjective symptoms of IOL dislocation/drop are as follows.

• Decreased visual acuity / refractive changes: Caused by refractive error due to IOL decentration or tilt, or when the optic portion moves out of the pupillary area
• Monocular diplopia / glare: Occurs when the IOL edge is exposed in the pupillary area
• Oscillopsia: The IOL moves with changes in body position, altering vision
• Visual field defect: Occurs when the optic portion moves out of the visual field due to IOL dislocation or drop
• High hyperopia: When the IOL falls into the vitreous cavity, severe hyperopia similar to aphakia occurs
• Asthenopia: Associated with refractive error and aniseikonia

Clinical Findings

Diagnosis can be easily made by dilating the pupil and confirming the following four items.

1. Position of the IOL optic and haptics
2. Condition of the zonules of Zinn
3. Condition of the lens capsule
4. Presence of IOL oscillation (tremor)

Findings of IOL Dislocation

IOL deviation: Under mydriasis, the IOL haptics are visible in the pupillary area.

Iridodonesis: Suggests relaxation of the zonules of Zinn.

Horizontal shift of the anterior chamber: The IOL tilts nasally or temporally.

IOL oscillation: Presents with tremors associated with eye movements.

IOL dislocation or drop is evaluated under dilated slit-lamp microscopy for position, oscillation, haptic, and capsular support. If the fundus is difficult to visualize or intraocular lens drop into the vitreous cavity is suspected, B-mode ultrasound may be added ²⁾. IOL dislocation into the anterior chamber may be accompanied by corneal endothelial damage or pupillary block glaucoma, and early intervention should be considered based on symptoms and findings.

Q What symptoms occur when the IOL is dislocated?

A

The most common symptom is decreased visual acuity. When the IOL is displaced, the optical part of the lens moves away from the pupil, causing refractive error. Additionally, monocular diplopia (IOL edge exposed in the pupillary area), glare, and oscillopsia with postural changes may occur. When the IOL drops into the vitreous cavity, significant hyperopia occurs as in aphakia. Dislocation into the anterior chamber can be an emergency with eye pain and elevated intraocular pressure.

3. Causes and Risk Factors

The causes of IOL displacement vary by type. Decentration and tilt occur due to extracapsular insertion or asymmetric insertion. Intracapsular dislocation involves posterior sinking of the IOL due to progression of zonular rupture, associated with pseudoexfoliation syndrome, trauma, high myopia, previous surgery, and connective tissue diseases ²⁾. Extracapsular dislocation may occur after intraoperative capsular complications.

The zonules of Zinn pull the lens capsule equator in 360 degrees, serving a dual role of fixing the position toward the visual axis center and maintaining capsule shape through uniform traction. Depending on the degree and extent of rupture, position fixation, shape maintenance, or both may be lost.

Ocular Risk Factors

Pseudoexfoliation syndrome (PXF): Progressive zonular weakness associated with pseudoexfoliative material is the most common cause of late intracapsular dislocation, accounting for over half of cases according to reports ²⁾. The mean period from cataract surgery to dislocation is reported to be approximately 7 to 8.5 years.

After intraocular surgery: Intraoperative zonular damage or long-term decreased capsular support may contribute to dislocation ²⁾.

High myopia: Weakening of the capsule and zonules due to axial elongation and reduced support from vitreous liquefaction.

Anterior capsule contraction (capsular phimosis): Centripetal contraction due to proliferation and myofibroblastic metaplasia of lens epithelial cells after CCC. This places excessive tension on the zonules and contributes to late dislocation.

Systemic and External Risk Factors

Connective tissue diseases such as Marfan syndrome: Associated with zonular weakness or lens displacement. In Marfan syndrome, ectopia lentis occurs in approximately 60% of cases (30–72% depending on reports), serving as a representative systemic factor for zonular weakness ²⁾.

History of trauma (blunt trauma): Zonular rupture due to globe deformation.

History of intraoperative capsular complications: Prior posterior capsule rupture or anterior capsule tear is a risk factor for late dislocation.

4. Diagnosis, Examination Methods, and Surgical Technique Selection

Diagnostic Approach

The basic diagnostic method is slit-lamp examination under mydriasis. If the IOL position may change with posture, evaluation in the supine position is also helpful for preoperative planning, but confirmation under an operating microscope is not mandatory for diagnosis in all cases.

The following assessments are necessary for preoperative diagnosis:

• Dislocation vs. drop (differentiation of the degree of IOL displacement)
• Intracapsular vs. extracapsular dislocation
• How to lift the IOL onto the iris
• Extent of vitrectomy to be performed
• Selection of instruments needed for extraction and fixation

Main Examination Items

Examination Method	Main Purpose
Slit-lamp microscopy (under mydriasis)	Assessment of IOL position and movement, confirmation of haptic position
Observation in supine position	Auxiliary evaluation when IOL position change due to posture is suspected
B-mode ultrasound	Detection of IOL in vitreous cavity, confirmation of posterior segment status
Anterior segment OCT / UBM	IOL evaluation behind the iris, zonule status, detailed haptic assessment
Specular microscopy	Corneal endothelial cell density (preoperative evaluation)
Corneal curvature and anterior chamber depth measurement	IOL power calculation and surgical technique decision
Fundus examination	Exclusion of retinal complications (e.g., detachment)

Surgical technique selection algorithm

Based on the secondary IOL fixation options listed in the AAO PPP, individual consideration is made as follows²⁾.

• Capsular support present → Prioritize ciliary sulcus fixation (3-piece IOL). For intrascleral fixation, use a 3-piece IOL whose haptics can be externalized through the needle lumen to form a stable terminal flange. Polyvinylidene fluoride (PVDF) haptics are considered suitable for intrascleral fixation due to superior flexibility and recovery, whereas PMMA or polypropylene haptics easily bend or break during manipulation. However, microfractures at the optic-haptic junction have been reported even with PVDF 3-piece IOLs, so select after confirming manufacturer details and technique compatibility
• No capsular support, weak zonules → Suture fixation or intrascleral fixation
• Problems with ocular surface, iris, or sclera → Individually evaluate fixation site and technique
• Existing IOL compatible with fixation method → If no damage or deformation, refixation is an option
• Concurrent glaucoma surgery required → Select technique individually considering interference with conjunctival/scleral manipulation. Case reports exist of simultaneous intrascleral fixation and trabeculectomy⁶⁾
• Poor iris/scleral condition, recurrent dislocation → Consider exchange to ACIOL

Factors for surgical technique selection

Evaluation item	Suture fixation	Yamane technique
Learning curve	Established	Requires time to master
Suture breakage/dislocation risk	Present	None
Long-term outcomes	Accumulated over 30+ years	Data being accumulated

Q What tests determine the need for surgery?

A

First, evaluate the IOL position, stability, and zonular status using a slit-lamp microscope under mydriasis. If vitreous cavity drop is suspected, add B-mode ultrasound; use anterior segment OCT or UBM for detailed evaluation behind the iris. If corneal endothelial damage is a concern, specular microscopy results also guide surgical technique selection ²⁾.

5. Standard Treatment

5-1. Overview of Treatment Strategy

Management of a dislocated or dropped IOL varies greatly depending on the degree and condition of the displacement.

• Mild displacement (pupillary capture, capsular capture, loop dislocation into the anterior chamber, early postoperative asymmetric fixation, etc.) → IOL repositioning. Position can be corrected via a side port using a hook or spatula.
• Dislocation/drop → Based on the existing IOL’s shape, material, damage, and remaining capsular support, choose repositioning, refixation, or exchange.
• Dropped IOL → After total vitrectomy, retrieve and remove using vitreous forceps. Subsequent suturing or intrascleral fixation is performed as usual.
• Reuse of existing IOL → Check the IOL’s material, shape, presence of damage, and compatibility with the fixation method; decide individually whether to refixate or exchange.

5-2. Surgical Technique for Dislocated IOL Removal

First, lift the IOL above the pupil, then create an appropriately sized wound and remove it.

• Foldable IOL: Can be cut in the anterior chamber and removed through a small incision 3–4 mm wide.
• PMMA IOL: An incision of approximately 6.5 mm matching the optic diameter is required.
• Dislocated IOL: It can also be floated to the iris plane using liquid perfluorocarbon (LPFC).
• Corneal endothelial protection: Fill with ophthalmic viscosurgical device (OVD) during IOL manipulation and removal.

5-3. Suture fixation (transscleral suture fixation)

Principle: Non-absorbable sutures are tied to the IOL haptic via an ab interno or ab externo approach and fixed to the sclera through the ciliary sulcus. Two-point fixation is standard.

Specific technique using the cow-hitch method:

1. Create a scleral flap at the limbus at the 12 o’clock position.
2. Puncture the ciliary sulcus with a long needle attached to 9-0 polypropylene suture.
3. Puncture from the 6 o’clock position with a 30-gauge pick-up needle.
4. Connect the long needle and pick-up needle to pass the suture.
5. Tie the suture to the IOL haptic using a cow-hitch knot.
6. Insert the haptic into the predetermined ciliary sulcus position.
7. Suture and fixate to the sclera under the scleral flap.

Haptic externalization method: Another method involves inserting the IOL haptic into a 25-gauge needle, guiding it out through a side port, performing a cow-hitch knot, then forming a bulb at the tip using electrocautery and pulling it into a scleral tunnel.

Suture selection:

• 9-0 or 8-0 polypropylene (Prolene) suture is used. Late breakage has been reported with 10-0 polypropylene. The timing of occurrence varies widely; published series averages range from 12 to 122 months (approx. 1–10 years), and in individual cases range from 33 to 170 months (approx. 3–14 years)¹²⁾. Caution is advised with 10-0 use in pediatric cases, where 9-0 should be considered due to superior tensile strength and degradation resistance.
• CV-8 Gore-Tex suture has high tensile strength and is expected to reduce the long-term risk of breakage

Situations to consider capsule preservation: Even in cases with zonular weakness, if capsular support remains, a capsule-preserving technique may be considered. This may reduce vitreous cavity invasion, but evaluation of posterior capsule rupture and long-term stability is necessary; it is determined on a case-by-case basis as a standard procedure.

Main complications:

• IOL redislocation (late dislocation due to suture breakage)
• IOL tilt and decentration
• Intraocular hemorrhage
• Retinal detachment
• Exposure, erosion, or breakage of the suture knot ⁵⁾
• Glaucoma
• Postoperative pupillary capture (more likely because the optic is not covered by the capsule immediately behind the iris)

5-4. Intrascleral fixation (Yamane technique / flanged intrascleral fixation)

Nakagawa S, Ishii K. Secondary intrascleral intraocular lens (IOL) fixation with capsule preservation for IOL dislocation following mature cataract surgery with incomplete capsulorhexis: A case report. Medicine (Baltimore). 2025;104(25):e43030. doi:10.1097/MD.0000000000043030. PMID:40550021. PMCID:PMC12187320. Figure 1. License: CC BY 4.0. https://creativecommons.org/licenses/by/4.0/

Intraoperative course shown in 12 panels from preoperative IOL inferonasal decentration (A) to 30-gauge needle insertion (D/E), 3-piece IOL injector insertion (F/G), and flange formation and scleral fixation using the double-needle technique (H–J). Corresponds to the sequential steps of the Yamane double-needle technique described in section “5-4. Intrascleral fixation (Yamane technique).”

Principle: A scleral tunnel is created with a 30-gauge thin-wall needle, the haptic of a 3-piece IOL is inserted into the needle lumen and pulled out through the sclera, then the haptic tip is cauterized to form a flange (bulbous enlargement). The flange is locked within the scleral tunnel, fixing the IOL. No sutures or adhesives are used. ¹⁾

Specific technique using the Yamane double-needle method:

1. A 30-gauge thin-wall needle is inserted at 2 mm from the corneal limbus at two sites 180 degrees apart
2. Each IOL haptic is inserted into the lumen of each needle
3. The haptic is pulled out through the sclera together with the needle
4. The tip of the haptic is cauterized with low-temperature electrocautery to form a flange (bulbous enlargement)
5. The flange is pulled back into the scleral tunnel and embedded for fixation

IOL selection: In the Yamane method, a 3-piece IOL is used that allows the haptic to be externalized through the needle lumen and a stable flange to be created at the tip. Since the haptic material, diameter, and behavior differ by product, the choice should be made by confirming compatibility with the technique and manufacturer information¹⁾⁵⁾.

Advantages:

• No need for scleral flap creation, making it minimally invasive
• No risk of late dislocation due to suture breakage
• Early visual recovery can be expected
• When combined with glaucoma surgery, the surgical technique should be individually considered to avoid interference with conjunctival and scleral manipulation⁶⁾

Main complications:

• Elevated intraocular pressure
• IOL tilt and decentration¹⁾⁵⁾
• Optic capture
• Vitreous hemorrhage
• Cystoid macular edema (CME)
• Haptic conjunctival penetration/erosion
• Endophthalmitis²⁾

Important note: The surgical technique should be selected individually because the condition of the sclera and conjunctiva, the IOL material, and the position of haptic fixation affect postoperative stability¹⁾⁵⁾.

5-5. Surgical technique comparison table

Nakagawa S, Ishii K. Secondary intrascleral intraocular lens (IOL) fixation with capsule preservation for IOL dislocation following mature cataract surgery with incomplete capsulorhexis: A case report. Medicine (Baltimore). 2025;104(25):e43030. doi:10.1097/MD.0000000000043030. PMID:40550021. PMCID:PMC12187320. Figure 2. License: CC BY 4.0. https://creativecommons.org/licenses/by/4.0/

Anterior segment photographs (A: normal illumination, B: slit-lamp optical section) and anterior segment OCT (C) 3 months after intrascleral fixation. IOL tilt 5.0 degrees and decentration 0.06 mm indicate good centration. This corresponds to the refractive predictability and tilt evaluation after intrascleral fixation discussed in section “5-5. Surgical technique comparison table”.

Item	Sutured technique (transscleral suture fixation)	Intrascleral fixation (Yamane technique)
Fixation principle	Fixation of haptic to sclera with suture	Implantation of haptic flange into scleral tunnel
Suture	Required (e.g., 9-0/8-0 polypropylene)	Not required
Scleral flap	Varies by technique	Not required
Suitable IOL	IOL suitable for suture fixation	3-piece IOL suitable for flange formation
Late breakage risk	Yes (reported with 10-0 polypropylene, etc.12))	No suture breakage
Haptic erosion risk	Low	Yes
Procedure complexity	Moderately high	High (requires proficiency)
Combined glaucoma surgery	Case-by-case	Case-by-case6)
Visual outcomes	Generally comparable across studies	Generally comparable across studies3)

In a network meta-analysis of three methods (iris fixation, transscleral suturing, and intrascleral fixation), best-corrected visual acuity was generally comparable, while complication profiles such as cystoid macular edema, hemorrhage, and corneal endothelial effects differed between techniques³⁾. The AAO PPP lists anterior chamber IOL, iris fixation, and scleral fixation as options when capsular support is insufficient, and selection should be based on ocular condition and surgeon experience²⁾.

5-6. Key points for suturing in zonular rupture

If zonular rupture is detected intraoperatively, assess the extent of rupture, anterior and posterior capsule status, and residual support, and combine capsular support devices, anterior vitrectomy, and secondary IOL fixation as needed. The indication for capsular support devices including the fixation-type CTR and whether to preserve or remove the capsule should be determined on a case-by-case basis²⁾.

Suturing technique (transscleral suture fixation)

Indications: Loss of capsular support, zonular rupture, etc. Select based on IOL shape and ocular tissue condition.

Suture: 9-0 or 8-0 polypropylene. Tie to the haptic using a cow-hitch technique and suture under a scleral flap via the ciliary sulcus.

Advantages: Compatible with multiple fixation methods and IOL shapes. Long-term outcomes have been accumulated.

Disadvantages: Risk of suture breakage (late dislocation). The need for a scleral flap varies by technique. When performed concurrently with glaucoma surgery, the surgical method is selected individually considering interference with conjunctival and scleral manipulation.

Intrascleral fixation (Yamane technique)

Indications: Cases with loss of capsular support where a 3-piece IOL suitable for flange formation can be used.

Fixation method: Scleral tunnel with a 30G thin-wall needle + haptic flange capture. No sutures, glue, or scleral flap required.

Advantages: No risk of suture breakage. A single case of concurrent intrascleral fixation and trabeculectomy has been reported, but general superiority has not been established⁶⁾.

Disadvantages: Requires a learning curve. Risks include haptic erosion, tilt, and decentration¹⁾⁵⁾.

Q Which is better: suture fixation or intrascleral fixation?

A

In a network meta-analysis, best-corrected visual acuity was generally comparable among the three methods, but complication profiles differed³⁾. The surgical technique is selected individually based on capsular support, iris, scleral, and corneal endothelial status, the IOL used, comorbidities, and surgeon experience²⁾³⁾. Since scleral fixation can cause refractive errors due to IOL position, preoperative explanation and postoperative refractive evaluation are necessary.

Q What should I be careful about in daily life after surgery?

A

Postoperatively, IOL decentration, pupillary capture, inflammation, elevated intraocular pressure, and cystoid macular edema may occur¹⁾³⁾⁵⁾. If sudden vision changes, eye pain, or redness occur, seek medical attention promptly. For suture fixation, late redislocation due to suture degradation or breakage should be monitored; for the Yamane technique, haptic exposure/erosion and IOL decentration require long-term follow-up.

Precautions in treatment

• After suture fixation, there is a risk of late IOL redislocation due to suture breakage, requiring long-term follow-up.
• Check for postoperative complications such as pupillary capture, IOL tilt/decentration, inflammation, elevated intraocular pressure, and cystoid macular edema¹⁾³⁾⁵⁾.
• In cases with posterior capsule rupture, assess residual capsular support and the extent of vitreous prolapse, and perform anterior vitrectomy and secondary IOL fixation as needed²⁾.
• In cases where corneal endothelial damage is a concern, evaluate the corneal endothelial cell density before and after surgery.

6. Prognosis and Long-term Outcomes

Visual Prognosis

In network meta-analysis, postoperative best-corrected visual acuity was generally comparable among iris fixation, transscleral suturing, and intrascleral fixation across studies³⁾. However, individual visual prognosis varies depending on the underlying disease, corneal, retinal, and optic nerve status, IOL position, and postoperative complications.

Frequency of Major Complications

Complication	Suture technique	Yamane technique	Notes
Suture breakage/exposure	Present	Absent	Related to late redislocation and infection risk of suture technique
Haptic exposure/erosion	Absent	Present	Confirm fixation position and flange burial
IOL tilt/decentration	Present	Present	Cause of refractive error
Cystoid macular edema/intraocular hemorrhage	Present	Present	Differences in frequency between surgical techniques have been reported3)
Pupillary capture	Present	Present	Check position when vision changes

Complication rates vary widely depending on the target population, fixation method, and follow-up period; therefore, a single rate cannot be applied to all cases³⁾.

Key points for long-term follow-up

• In scleral fixation, long-term regular follow-up is necessary to prepare for late IOL dislocation due to suture degradation
• In the Yamane method, check for conjunctival penetration/erosion of the haptic and changes over time in IOL tilt/decentration.
• Cystoid macular edema (CME) may develop several months after surgery; perform OCT evaluation when visual acuity decreases.

7. Pathophysiology and Detailed Mechanisms

Function of the Zonules of Zinn and Mechanism of IOL Displacement

The zonules of Zinn pull the lens capsule equator in 360 degrees, serving a dual role: fixing the lens in the visual axis center and maintaining capsular shape through uniform traction. Depending on the extent and degree of rupture, either fixation, shape maintenance, or both may be lost.

The mechanisms of IOL displacement by cause are as follows:

• Decentration/tilt: Due to surgical technique issues such as extracapsular insertion, asymmetric insertion, or improper placement during suturing or scleral fixation.
• Intracapsular dislocation: A condition where the IOL sinks posteriorly due to progression of zonular rupture. Associated with exfoliation syndrome, trauma, high myopia, prior surgery, connective tissue diseases, etc. ²⁾
• Extracapsular dislocation: Often occurs after intraoperative capsular complications.
• IOL drop: When intracapsular dislocation progresses to complete zonular rupture, or when the IOL completely separates from the capsule in extracapsular dislocation.

Zonular Weakness in Exfoliation Syndrome

In exfoliation syndrome, exfoliative material deposits intraocularly, which may be accompanied by zonular weakening and poor pupillary dilation, affecting cataract surgery and IOL fixation planning ²⁾.

Late Dislocation Due to Anterior Capsular Contraction

After continuous curvilinear capsulorhexis (CCC), lens epithelial cells at the capsulotomy edge proliferate and transdifferentiate into myofibroblasts. When the centripetal contractile force generated by these cells exceeds the centrifugal traction of the zonules, anterior capsular contraction (capsular phimosis) progresses. Increased weight of the IOL and capsule due to posterior capsule opacification further increases stress on the zonules.

Refractive Characteristics of Sutured and Intrascleral Fixated IOLs

Refractive outcomes after scleral fixation are affected by the effective lens position, tilt, and decentration of the IOL. A 5-year follow-up study of glued IOL evaluated IOL tilt, but it is not a study demonstrating the refractive prediction accuracy of the Yamane technique ¹⁰⁾. The refractive predictability of each surgical technique should be explained based on studies where the target eyes and fixation method match.

Indications for Suture Fixation in Posterior Capsule Rupture

When intraoperative posterior capsule rupture prevents stable fixation in the capsular bag or ciliary sulcus, options such as anterior chamber IOL, iris fixation, scleral suture fixation, and intrascleral fixation should be considered based on residual capsular support ²⁾.

8. Recent Research and Future Perspectives

Important Information for Patients

The following content is currently at the research or clinical report stage and does not represent standard treatment available at general hospitals. It is reference information for professionals regarding future medical developments.

Application of Light Adjustable Lens (LAL) for Scleral Fixation

After scleral fixation, refractive errors may occur due to the effective IOL position. The Light Adjustable Lens (LAL) is an IOL whose power can be adjusted postoperatively with UV irradiation.

Ma et al. (2023) reported a case of a 53-year-old woman with spontaneous bilateral lens subluxation who underwent off-label use of LAL with trocar-based ISHF (intrascleral haptic fixation) ⁷⁾. Postoperative power adjustment was performed targeting micro-monovision, achieving uncorrected visual acuity of 20/20 in both eyes. This single case suggests the potential to reduce refractive error after scleral fixation, but additional studies are needed to establish efficacy and safety.

Simplification of Technique with Trocar-Based Modification

Bever et al. (2021) reported a modification in which the IOL is intentionally dropped onto the retina, and then the haptic tip is directly grasped with a 27-gauge forceps and pulled out through the sclera ⁸⁾. This technique eliminates the need for manipulation at the iris plane and is a safe and efficient procedure for surgeons experienced in vitreoretinal surgery. All 4 cases achieved stable IOL fixation and good centration.

Refixation of Multifocal IOL Using the Cable Tie Technique

Eom et al. (2022) reported four-point flanged intrascleral fixation for subluxated multifocal IOLs with C-loop and double C-loop haptics using the cable tie method with 6-0 polypropylene. ⁹⁾By forming the suture into a cable-tie-like loop, secure fixation to the optic-haptic junction was achieved, and both cases showed good IOL centration and distance and near visual acuity.

4-flange intrascleral fixation

Canabrava (2020) reported a four-point intrascleral fixation method without scleral flaps, knots, or glue, using flanging of the four ends of 5-0 polypropylene monofilament by cauterization ¹¹⁾.

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9. References

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4. John T, Tighe S, Hashem O, Sheha H. New use of 8-0 polypropylene suture for four-point scleral fixation of secondary intraocular lenses. Journal of cataract and refractive surgery. 2018;44(12):1421-1425. doi:10.1016/j.jcrs.2018.08.008. PMID:30314754.
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