A Novel Custom Bent 27-Gauge Needle–Guided Suture Snare Technique for Scleral Fixation of Posterior Chamber Intraocular Lenses
The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Institutional Review Board of Liyang Hospital of Chinese Medicine. All participants undergoing the procedure provided written informed consent after possible benefits and risks of the procedure were discussed. All patients underwent comprehensive preoperative and postoperative ophthalmologic examination, and age, sex, best-corrected visual acuity, postoperative IOL position, and other data were recorded. Surgical Procedure The procedure was performed by one of the authors (C.C.) and is demonstrated in the Supplemental Digital Content (see Video , http://links.lww.com/IAE/C254 and Figures and ). The procedure was performed under retrobulbar anesthesia, and a three-haptic IOL with a haptic loop was selected. First, the IOL haptic fixation point was positioned, the exit position of the needle from the limbus was planned, and a 27-gauge needle was bent into an arc that made it easy to hold with the fingers and pass the suture through the needle (Figure ). Finally, an 8-0 polypropylene suture was threaded through the needle lumen. The 2-mm incisions were made in the ocular conjunctiva at the three fixation sites, exposing the sclera. The IOL was implanted in the anterior chamber. A hand-held needle was threaded into the eye 2 mm outside the limbus and passed through the IOL haptic loop and out the limbal incision with the assistance of a blunt, round, and hollow needle (viscoelastic needle). The suture was pulled out, and the needle was advanced into the eye again (without withdrawing the needle) by the same limbal incision, bypassing the haptic loop. The suture was threaded through the needle lumen once again, and the needle was withdrawn from the eye, thereby completing fixation of the IOL haptic loop. The same procedure was used for fixation of the other two IOL haptic loops. External scleral fixation was performed using an “overhand friction knot” technique to bury the knot in the stroma of the sclera. The tightness of the sutures at the three fixation points was adjusted at the time of securing the knot to keep the optical site of the IOL centered on the pupil. The small conjunctival incision was either not sutured or it was closed with a single 10-0 nylon suture. 

The procedure was performed by one of the authors (C.C.) and is demonstrated in the Supplemental Digital Content (see Video , http://links.lww.com/IAE/C254 and Figures and ). The procedure was performed under retrobulbar anesthesia, and a three-haptic IOL with a haptic loop was selected. First, the IOL haptic fixation point was positioned, the exit position of the needle from the limbus was planned, and a 27-gauge needle was bent into an arc that made it easy to hold with the fingers and pass the suture through the needle (Figure ). Finally, an 8-0 polypropylene suture was threaded through the needle lumen. The 2-mm incisions were made in the ocular conjunctiva at the three fixation sites, exposing the sclera. The IOL was implanted in the anterior chamber. A hand-held needle was threaded into the eye 2 mm outside the limbus and passed through the IOL haptic loop and out the limbal incision with the assistance of a blunt, round, and hollow needle (viscoelastic needle). The suture was pulled out, and the needle was advanced into the eye again (without withdrawing the needle) by the same limbal incision, bypassing the haptic loop. The suture was threaded through the needle lumen once again, and the needle was withdrawn from the eye, thereby completing fixation of the IOL haptic loop. The same procedure was used for fixation of the other two IOL haptic loops. External scleral fixation was performed using an “overhand friction knot” technique to bury the knot in the stroma of the sclera. The tightness of the sutures at the three fixation points was adjusted at the time of securing the knot to keep the optical site of the IOL centered on the pupil. The small conjunctival incision was either not sutured or it was closed with a single 10-0 nylon suture. 

A total of 10 eyes in 10 patients (8 males and two females) were included. The mean age of the patients was 61.5 ± 7.6 years (range: 52–76 years). Indications for surgery were as follows: 6 cases of traumatic lens dislocation, 1 case of IOL dislocation, and 3 cases of aphakia after vitrectomy. The IOL used was the Zeiss CT ASPHINA 603P PCIOL（Carl Zeiss Inc, Perigny, France). There were two cases of transient minor ciliary body hemorrhage during needle puncture. No other intraoperative complications were observed. There was one case of postoperative complications in an eye with transiently elevated intraocular pressure, which was treated with topical antiglaucoma medication. The mean follow-up period was 8.5 ± 5.6 months (range: 3–16 months). The logarithm of the minimum angle of resolution (logMAR) corrected visual acuity was 0.73 ± 0.55 (Snellen 20/107). The logMAR corrected visual acuity at the final follow-up was 0.24 ± 0.27 (Snellen 20/35); the t -test showed that the difference was statistically significant ( P < 0.05). The IOL was well-positioned in all patients (Figure ), and the mean postoperative PCIOL tilt was 2.78 ± 1.32°. There were no cases of pupillary capture, suture loosening, suture erosion, scleral atrophy, or retinal detachment at the time of the final follow-up. 

Implantation of PCIOL without capsular support is generally performed in two ways: sutureless intrascleral fixation using the Yamane technique, which has become popular in recent years, or scleral suture fixation. However, the only IOL that is suitable for this technique is the three-piece IOL, which is difficult to learn using a double-needle technique, especially for IOL haptics that withdraw into the needle lumen. Many types of IOLs can be selected for scleral suture fixation, including two-haptic (including three-piece IOLs), three-haptic, and four-haptic IOLs. The bent needle-guided suture snare technique is particularly appropriate for IOLs with a haptic loop, as the snare and suture can form a “cross-buckle” fixation that remains in place. In particular, stable trocar fixation can be created for subluxated IOLs and capsular bag complexes. The bent needle-guided suture snare technique requires a 27-gauge needle with appropriate hardness, a needle body length of 38 mm, which is much longer than the diameter of the ciliary sulcus, and a puncture opening that is self-closing, with the scleral puncture entrance and the limbal exit planned first. The needle is bent into the corresponding arc shape, which facilitates stable hand-held operation, enables more direct control of the needle tip, and facilitates changing the angle and direction of the needle. The use of blunt, round, and hollow needles (viscoelastic needles) pushes away the iris tissue or pivots the IOL to expose the IOL haptic loops. This facilitates passage of the 27-gauge needle from inside and outside the IOL haptic loop and serves as a “trocar” to guide the needle out of the limbal incision, enabling the IOL haptic suture snare to be completed easily even in cases of small pupils. In some special cases where IOL haptic fixation is required at the 6-o'clock position, the length of the bent portion of the needle can be shortened to avoid interfering with the eyelid distractor or lower eyelid. Fixation of the IOL haptic is a major step in this procedure. Our technique requires only one scleral puncture, and the needle is passed through the limbal incision twice to complete fixation of the IOL haptic loop. Alternatively, in the case of a two-haptic IOL, a cow-hitch suture knot can be used for fixation. , This maintains the integrity of the sutures and reduces the damage caused by clamping of the sutures with forceps. The conventional technique is to use a needle holder to clamp a long straight needle for puncture. , However, this can lead to kinking and twisting of the needle, resulting in potential tissue damage, especially when operating in directions other than 3 o'clock and 9 o'clock (because of interference with the eyelids or eyelid distractor). The sutures are knotted on the IOL haptic with a free end, which can potentially abrade the uvea and cause glaucoma, recurrent uveitis, cystoid macular edema, and other complications. , Some researchers have used trocars to create ports to deliver sutures into the anterior chamber before IOL implantation, using retinal forceps to enter the eye to pull out sutures and even widen the incision and manually fold the IOL for implantation. , In addition to increasing the complexity of the operation, there is potential to cause leakage from the ports and hypotony. Reliable external scleral fixation is necessary for fixation of the IOL. We used the “overhand friction knot” technique to bury the knot in the stroma of the sclera, which eliminates the need for a conjunctival or scleral flap. The conventional method is burial of suture knots in a scleral flap, which may abrade and irritate local tissues leading to complications such as scleral atrophy and exposure of suture knots. Meanwhile, suture breakage and secondary IOL dislocation remain significant problems that cannot be ignored. The long-term stability of the 10-0 polypropylene suture in common use is controversial. , To reduce the risk of suture breakage because of its material properties, some researchers have experimented with a relatively thicker suture for IOL fixation, and 8-0 polypropylene suture is currently being used more and achieving good results in clinical practice. , The follow-up period of the present study was 8.5 ± 5.6 months, and no suture-related complications were observed. In summary, the custom bent 27-gauge needle–guided suture snare technique for scleral fixation of PCIOL facilitates smooth operation. The use of the normal surgical incision for IOL implantation for cataract surgery eliminates the need for additional conjunctival and scleral flaps, thereby allowing for a minimally invasive operation. In addition, it is suitable for scleral suture fixation of multiple types of PCIOLs, subluxated IOLs, and capsular bag complexes. Our experience demonstrates that this technique is safe and results in satisfactory patient outcomes. The limitations of the present study include the few cases, the short observation period, and the lack of observation of long-term effects and comparison with other methods. 

