Transconjunctival Forceps-Assisted Flanged Intrascleral Fixation via a Posterior Approach: Clinical Outcomes of a Modified Technique
This retrospective study of 332 eyes demonstrates that a modified posterior-approach, forceps-assisted flanged intrascleral IOL fixation technique offers a safe, effective, and highly stable alternative for complex cases, including pediatric and Marfan syndrome patients, with significant visual improvement and identifiable risk factors for cystoid macular edema.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
When the eye's natural lens, which focuses light onto the retina, becomes cloudy or dislocated, surgeons often replace it with a clear, artificial plastic lens called an intraocular lens. Normally, this new lens sits inside a delicate, transparent capsule that holds the natural lens in place. However, in cases of severe trauma, genetic conditions, or complications from previous surgeries, this supporting capsule may be missing or too weak to hold the new lens. Without this anchor, the artificial lens can drift, tilt, or fall out of position, leaving the patient blind. For decades, surgeons have struggled to find a way to secure these lenses when the natural support structure is gone, often relying on sutures that can erode over time or placing the lens in the front of the eye where it can damage the cornea.
A significant shift occurred recently with the development of techniques that tuck the ends of the artificial lens directly into the white part of the eye, the sclera, without using stitches. One popular method, known as the Yamane technique, involves guiding the lens ends through the eye using long, thin needles. While effective, this approach requires the surgeon to maneuver blindly inside the eye, which carries risks of damaging delicate internal structures. Researchers have been searching for a way to make this procedure safer and more precise, particularly for complex cases where the eye's anatomy is distorted or the patient is a child.
A team of surgeons at Ankara Bilkent City Hospital in Turkey has now described a modified approach that changes how the lens is secured. Instead of relying on needles to guide the lens from the inside out, they used a specialized pair of forceps, similar to those used in retinal surgery, to grab the lens ends directly under a microscope. By looking straight into the back of the eye through a small opening, the surgeon could see exactly where the lens was and pull it into place with total control. This method, which they call a posterior-approach forceps-assisted technique, avoids the blind maneuvers of older methods and allows for the direct reuse of lenses that have already fallen out of position, saving the patient from needing a brand-new implant.
The researchers applied this technique to 332 eyes from 309 patients, ranging in age from 3 to 91 years old. The patients had various reasons for needing the surgery, including severe eye trauma, genetic disorders that weaken the eye's support structures, and complications from previous cataract operations. In every case, the surgeons first removed any cloudy vitreous gel from the back of the eye to clear the view. They then created two tiny openings in the white of the eye and used the forceps to gently grasp the two arms of the artificial lens. They pulled these arms out through the openings and used a heated tool to melt the very tips of the plastic arms, creating small, rounded knobs. These knobs acted as stoppers, preventing the lens from slipping back inside. In patients with loose or weak eye walls, such as children or those with connective tissue disorders, the surgeons added a few extra stitches to hold the tunnel tight.
The results of this large series of operations were encouraging. In more than 94 percent of the eyes, the artificial lens remained perfectly centered and stable throughout the follow-up period, which lasted from six months to five years. Only a small fraction of patients, about 5.7 percent, required a second surgery to fix a lens that had tilted or slipped. The most common reason for needing a revision was the lens slipping out of its tunnel, a problem that occurred more frequently in patients with Marfan syndrome, a genetic condition that affects the strength of connective tissue. For these specific patients, the surgeons found that adding a suture to the tunnel after the initial procedure prevented further slipping. Despite the high complexity of the cases, the surgery significantly improved vision for most patients. On average, patients gained about seven lines of vision on a standard eye chart, moving from being able to see only large letters at a distance to reading much smaller text.
The study also looked at potential risks and complications. The most common issue was a swelling of the retina called cystoid macular edema, which occurred in about 5 percent of the eyes. The researchers identified that patients with diabetes, those who had previously had retinal detachment surgery, or those who had to wait for a second surgery to remove dropped lens fragments were at a higher risk for this swelling. Fortunately, all cases of swelling resolved with treatment. Other complications, such as bleeding inside the eye or retinal detachment, were rare. The surgeons noted that their method was particularly useful for repositioning lenses that had already been implanted but had fallen out of place, as it allowed them to grab and secure the existing lens without removing it. This capability is a major advantage, as it spares the patient the cost and trauma of a new implant.
The authors conclude that this modified technique offers a safe and effective alternative for securing artificial lenses when the natural support is missing. By using standard surgical tools and direct visualization, the method simplifies a difficult procedure and reduces the risk of damaging the eye. It proved successful even in challenging scenarios, such as in children or patients with genetic disorders, providing a stable solution where other methods might fail. While the study was retrospective, meaning it looked back at past records rather than testing the method in a controlled experiment, the large number of patients and the consistency of the results suggest that this approach is a reliable option for surgeons facing complex cases of lens dislocation.
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