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Adaptation of extraocular needle-guided haptic insertion technique (X-NIT)

for scleral fixation of three piece foldable intraocular lens Images in…

Article in BMJ Case Reports · April 2022

DOI: 10.1136/bcr-2021-247869

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Adaptation of extraocular needle-­guided haptic
insertion technique (X-­NIT) for scleral fixation of
three piece foldable intraocular lens
Amit Kumar Deb, Sandip Sarkar ‍ ‍, Kaviyapriya Natarajan, Jayasri P

Ophthalmology, Jawaharlal DESCRIPTION

Institute of Post Graduate Implantation of intraocular lens (IOL) in eyes with
Medical Education and weak capsular support or zonular support presents
Research, Puducherry, India
unique surgical challenges.1 Most of the published
literature on scleral fixated lens (SFIOL) implanta-
Correspondence to
Dr Sandip Sarkar; tion describes techniques for the implantation of
​drsandip19@​gmail.c​ om rigid 3-­piece IOLs. Only a few techniques (Takkar
et al2 Can3 Yamane et al4 Francesco Barca et al5
Accepted 7 April 2022 Kumar and Agarwal6) have been described until in Figure 1 (A)Two conjunctival peritomies are created
the literature for implantation of foldable SFIOLs at 3 o’clock and 9 o’clock positions, (B) AC maintainer
as mentioned in table 1. However, all these tech- is started and corneal incision is made, (C) the leading
niques require intraocular manipulation of the haptic of the 3-­piece IOL is tucked into the lumen of the
haptics using the handshake technique, which has 26 gauge needle, (D) the IOL is slowly injected into AC, (E)
a learning curve.7 We now, discuss the steps of the leading haptic is exteriorised and the silicone stopper
foldable SFIOL implantation using an adaptation is guided over it, (F) the trailing haptic is tucked into the
of the extraocular needle-­guided haptic insertion 26 G needle, (G) the trailing haptic is exteriorised and
technique (XNIT) that was originally described both the haptics are tucked into the previously created
for rigid SFIOL implantation.8 In addition, we also scleral tunnels, (H) pars plana port and the peritomies are
describe a small modification in the original XNIT sutured. AC, anterior chamber; IOL, intraocular lens.

copyright.
technique that provides an added advantage of
negating the risk of intraoperative haptic rebound is then brought out through the corneal tunnel
into vitreous cavity. This modified technique can be with the posterior lip of the wound depressed
easily learnt and applied by the novice surgeons as with a McPherson forceps (figures 1C and 2C).
well as the cataract surgeons for performing SFIOL The preloaded foldable 3-­ piece IOL (Aurovue
implantation.9 Multi-­piece preloaded IOL, Model No: HP3600P)
Surgical technique: Under peribulbar anaesthesia, (no financial interests, any other 3-­piece foldable
two markings are made at the limbus 180° apart (3 IOL can be used as well) is then inserted using the
and 9 o’clock positions). Limited peritomy is then needle as guide for the haptic (figure 1C). Around
done adjacent to the limbal markings (figures 1A 3 mm of the leading haptic is injected out of the
and 2A). Two partial thickness 3 mm long scleral cartridge by the injector in the extraocular space.
tunnels (one on each side) are then fashioned. Each The leading haptic is then loaded into the lumen
tunnel commences 0.5 mm farther away (modifica- of the 26 G needle that had already been exterio-
tion from the original XNIT technique) from the rised through the corneal section. An assistant can
future site of sclerotomy (figures 1A and 2A). An help in guiding the leading haptic into the lumen
anterior chamber (AC) maintainer is then secured of the needle with a McPherson forceps to ensure
(figures 1B and 2B). Limited anterior vitrectomy snug fitting and prevent subsequent slippage of the
is then performed either through a paracentesis haptic. The cartridge tip is then inserted gradually
entry or through a single 23 pars plana port. We
have used a pars plana port in the representative
video (video 1). All vitreous strands in the AC,
pupillary area or below the iris are excised. A 3 mm
wide corneal section is then constructed superiorly
spanning 12 0’ clock (figures 1B and 2B). Two half-­
inch-­long 26 gauge (G) needles are used for haptic
© BMJ Publishing Group
Limited 2022. No commercial
loading, IOL insertion and haptic exteriorisation.
re-­use. See rights and One needle is passed through a 2×2 mm silicone
permissions. Published by BMJ. stopper made from a 240 encircling silicone band
similar to the XNIT technique. The needle is then
To cite: Deb AK, Sarkar S,
Natarajan K, et al. BMJ Case bent 1 mm from the hub and inserted into the Figure 2 Animated figure showing the steps of
Rep 2022;15:e247869. ciliary sulcus 1.5 mm behind the limbal marking and three piece foldable SFIOL using an adaptation of the
doi:10.1136/bcr-2021- 0.5 mm farther from the point of commencement of extraocular needle-­guided haptic insertion technique.
247869 the scleral tunnel (figures 1A and 2A). The needle SFIOL, scleral fixated lens.
Deb AK, et al. BMJ Case Rep 2022;15:e247869. doi:10.1136/bcr-2021-247869 1
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Table 1 Summary of ma published foldable SFIOL techniques
Year of No of surgical
Sl no Author details publication cases Surgical methods Surgical outcomes Surgical complications

1. Takkar et al2 2017 11 Foldable IOL was introduced into the anterior chamber with IOL injector. Only the leading haptic BCVA improved from 0.78±0.63 logMAR Intraoperative retinal break noted in
and the optic were injected into the AC while the trailing haptic was left outside the AC. The to 0.37±0.29 logMAR units at 3 months two patients.
leading haptic was held intraocularly with a 25 G end gripping forceps and externalised. The postoperative Postoperative choroidal detachment
trailing haptic was subsequently pushed inside with mcpherson”s forceps, held similarly with 25 seen in one patient
G forceps and externalised. Both haptics were then secured in the scleral tunnels.
2. Can3 2018 8 Flapless and sutureless intrascleral fixation of posterior chamber foldable intraocular lens Visual acuity outcomes were not No complications were noted till
with the help of a scleral fixation guide. Haptics of the IOL were loaded into the scleral guide mentioned 6 months follow-­up
externalised through the corneal incision in the extra-­ocular space.
3. Yamane et al4 2017 34 The haptics of the foldable IOL were threaded intraocularly and externalised using two 27-­gauge The mean preoperative BCVA was The postoperative complications
needles passed through the ciliary sulcus The haptics were then fixed in preformed scleral 0.48 logMAR units, and the mean included iris capture of the IOL
tunnels made by lamellar scleral dissection. postoperative BCVA improved in three eyes, transient ocular
significantly to 0.17 logMAR units at hypertension in two eyes, and
3 months cystoid macular oedema in one eye.
4. et al5 2020 32 Sutureless scleral fixation using a single-­piece foldable acrylic IOL (Carlevale IOL—special Mean preoperative corrected distance Pupillary block-­1 eye
design IOL with two transcleral plugs in the haptics). Scleral plugs held with crocodile tip forceps visual acuity (CDVA) was 0.46±0.29 High IOP-­1 eye
intraocularly and externalised through sclerotomies. logMAR; mean postoperative CDVA VH-1­ eye
improved to 0.22±0.18 log- MAR and
0.13±12 logMAR at 4 and 8 months,
5. Kumaret al6 2013 53 Glued IOL using intraocular hand shake technique. Significant improvement in uncorrected IOL decentration, pigment
visual acuity and spectacle BCVA dispersion, macular oedema

AC, anterior chamber; BCVA, best-­corrected visual acuity; IOL, intraocular lens.

through the corneal section while the needle (with the leading subsequent hypotony. We have described the outcomes of 11
haptic embedded in its lumen) is simultaneously withdrawn back cases operated using this technique in table 2.
into the AC in a co-­ordinated fashion (figures 1D and 2D). As Large incisions may predispose to intraoperative or postop-
the injector is slowly pushed, the IOL gradually unfolds in the erative hypotony, choroidal detachment, postoperative astig-
AC. Care should be taken to push the injector only until the matism, delayed postoperative recovery, etc.10–13 Foldable
optic is released inside the AC. The trailing haptic should not be IOLs eliminate the need for larger incisions for IOL insertion,
injected inside the AC and should be still lodged in the cartridge. thereby, reducing the postoperative astigmatism, hypotony
The needle and the leading haptic are then slowly exteriorised and allows earlier visual rehabilitation.14 Also smaller incision
through the sclerotomy site (figures 1E and 2E). The injector is ensures AC formed during the procedure and reduces endo-
then gradually withdrawn out through the corneal section and thelial cell injury. All the previously described techniques need
the trailing haptic is released in the extraocular space. The exte- intraocular manipulation of the IOL haptic which increases

copyright.
riorisation of the needle through the sclerotomy site and with-
drawal of the injector from the AC should also be co-­ordinated.
Once the needle with the leading haptic is exteriorised, the sili-
Table 2 Patient characteristics
cone stopper is guided over the leading haptic and the needle
removed (figures 1E and 2E). The stopper prevents slippage of Parameters Value
the leading haptic inside the vitreous cavity during manipula- Total no cases 11
tion of the trailing haptic. The second 26-­gauge needle is bent Age (mean+SD) 59.18±9.99 years
and inserted through the opposite side sclera 1.5 mm behind the Sex
second limbal marking. The trailing haptic is threaded into the  Male/female 7/4
needle using McPhersons forceps, exteriorised and tucked into Eyes
the preformed scleral tunnel (figures 1F and 2F). The silicone  Right/left 5/6
stopper is removed and the leading haptic is also tucked into the Cause of aphakia
scleral tunnel (figures 1G and 2G). IOL centration is ensured by  Complication of phacoemulsification
adjusting the haptics. Pars plana port and peritomies are then
  Large PCR 8 eyes
closed (figures 1H and 2H). AC maintainer is removed and the
   Post dislocation of nucleus 2 eyes
corneal wounds are hydrated to prevent wound leakage and
 Closed globe injury with nucleus drop 1 eye
Preoperative BCVA (Log MAR) 1.60+0.956
Preoperative IOP (mm Hg) 13.63±4.78
Surgery performed
 PPV+PPL+ SFIOL 3 eyes
 PPV+SFIOL 8 eyes
Postoperative BCVA (Log MAR)
 Mean+SD 0.318±0.32
Postoperative IOP (mm Hg)
 Mean+SD 14.63±3.55
Immediate postoperative complications
 Transient corneal oedema 2 eyes
 Ocular hypertension 1 eye
Total follow-­up period 3 months
BCVA, best corrected visual acquity; IOP, intraocular pressure; PCR, posterior capsular rent;
Video 1 Showing the steps of foldable SFIOL implantation using an PPL, pars plana lensectomy; PPV, pars plana vitrectomy; SFIOL, scleral fixated intraocular
adaptation of the XNIT technique. lens.

2 Deb AK, et al. BMJ Case Rep 2022;15:e247869. doi:10.1136/bcr-2021-247869

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BMJ Case Rep: first published as 10.1136/bcr-2021-247869 on 22 April 2022. Downloaded from http://casereports.bmj.com/ on April 22, 2022 at India:BMJ-PG Sponsored. Protected by
the risk of haptic breakage, haptic kinking, IOL drop into the Case reports provide a valuable learning resource for the scientific community and
vitreous cavity.15 Moreover, intraocular manipulation has a can indicate areas of interest for future research. They should not be used in isolation
to guide treatment choices or public health policy.
learning curve and often a hurdle for the novice surgeons.
We have adapted the XNIT technique for haptic manipula-
tion in the extraocular space which helps to overcome the ORCID iD
problems associated with intraocular handling of the haptics. Sandip Sarkar http://orcid.org/0000-0002-9882-0407
Our technique of foldable SFIOL implantation provides a
simple, economic and effective option for aphakia manage- REFERENCES
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copyright.
Contributors AKD: design and performed the surgery, SS: manuscript writing, KN: 12 Das S, Nicholson M, Deshpande K, et al. Scleral fixation of a foldable intraocular lens
manuscript review, JP: patient care. with polytetrafluoroethylene sutures through a Hoffman pocket. J Cataract Refract
Surg 2016;42:955–60.
Funding The authors have not declared a specific grant for this research from any 13 Liu H-­T, Jiang Z-­X, Tao L-­M. New two-­point scleral-­fixation technique for foldable
funding agency in the public, commercial or not-­for-­profit sectors. intraocular lenses with four hollow haptics. Int J Ophthalmol 2016;9:469.
Competing interests None declared. 14 Wallmann AC, Monson BK, Adelberg DA. Transscleral fixation of a foldable posterior
chamber intraocular lens. J Cataract Refract Surg 2015;41:1804–9.
Patient consent for publication Consent obtained directly from patient(s).
15 Narang P, Agarwal A. Glued intrascleral haptic fixation of an intraocular lens. Indian J
Provenance and peer review Not commissioned; externally peer reviewed. Ophthalmol 2017;65:1370–80.

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