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Surgical outcomes of sutureless, glueless intrascleral fixation of intraocular lenses: A prospective interventional study
*Corresponding author: Kiran Gagdasbhai Chaudhary, Department of Ophthalmology, M and J Institute, B. J. Medical College, Ahmedabad, Gujarat, India. chaudharykiran2129@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Chaudhary KG, Negi PS, Desai NK, Aggarwal S. Surgical outcomes of sutureless, glueless intrascleral fixation of intraocular lenses: A prospective interventional study. Global J Cataract Surg Res Ophthalmol. doi: 10.25259/GJCSRO_7_2026
Abstract
Objectives:
The objective of the study is to evaluate the visual outcomes and post-operative complications of sutureless, glueless intrascleral fixation of posterior chamber scleral fixated intraocular lenses (IOLs) using a modified 26-gauge needle-assisted haptic exteriorisation technique.
Materials and Methods:
This prospective interventional study included aphakic eyes or eyes with dislocated/subluxated lenses or IOLs undergoing pars plana vitrectomy with sutureless scleral fixation of a three-piece polymethyl methacrylate (PMMA) IOL. The three-piece PMMA IOL (Aurolab) was the preferred lens due to its cost-effectiveness and standard availability in the government hospital setup. All surgeries were performed by a single surgeon between June 2023 and June 2024. Best-corrected visual acuity (BCVA), intraocular pressure and post-operative complications were assessed on postoperative day 1, week 1, month 1, month 3 and month 6.
Results:
A total of 50 eyes were included. The most common indications were aphakia following complicated cataract surgery and dislocated/subluxated IOLs. Mean BCVA improved significantly from pre-operative levels at final follow-up. Early post-operative complications included transient corneal oedema and mild hypotony, which resolved with conservative management. No haptic breakage was noted during implantation, although haptic bending occurred in a few cases. No cases of endophthalmitis or late dislocation were observed during the follow-up period.
Conclusion:
Sutureless, glueless intrascleral fixation of IOL using a modified 26-gauge needle technique is a safe, effective and reproducible method for visual rehabilitation in eyes lacking capsular support. The technique avoids suture-related complications, provides good IOL stability and yields favourable visual outcomes. A common challenge encountered during the early learning phase was the technical difficulty of tucking the haptic into the scleral pocket.
Keywords
Aphakia
Dislocated intraocular lenses
Intrascleral fixation
Pars plana vitrectomy
Sutureless scleral fixated intraocular lenses
INTRODUCTION
Management of aphakia in the absence of capsular support remains a surgical challenge. Available options include anterior chamber intraocular lenses (ACIOLs), iris-fixated IOLs and scleral-fixated IOLs (SFIOLs), each with distinct advantages and limitations. ACIOLs, although technically simpler, are associated with endothelial cell loss, chronic inflammation and secondary glaucoma. Iris-fixated lenses may result in pigment dispersion and uveitis.[1-3]
SFIOL implantation offers a more physiological IOL position closer to the nodal point, minimising corneal and iris-related complications. However, conventional sutured SFIOL techniques are associated with suture degradation, knot erosion, pseudophacodonesis and late IOL dislocation.[4] To overcome these limitations, sutureless intrascleral haptic fixation techniques were introduced, beginning with Gabor and Pavlidis. Subsequent modifications, including glued IOL and flanged techniques, have further refined outcomes.
Gabor and Pavlidis first described sutureless scleral fixation using intrascleral tunnels.[5] Subsequent modifications, including glued IOL and flanged techniques, have improved stability while eliminating suture-related complications. The present study evaluates the outcomes of a modified sutureless, glueless intrascleral fixation technique using 26-gauge needles for haptic exteriorisation, eliminating the need for specialised forceps, sutures or glue.
MATERIALS AND METHODS
Study design
A prospective interventional study was conducted at a tertiary care ophthalmic centre after institutional ethics committee approval. The study adhered to the tenets of the Declaration of Helsinki, and written informed consent was obtained from all participants.
Inclusion criteria
Age 18–70 years
Aphakia following complicated cataract surgery
Traumatic cataract with posterior capsular rupture
Subluxated or dislocated crystalline lens or IOL
Willingness for regular follow-up.
Exclusion criteria
Corneal pathology affecting visual outcome
Posterior segment pathology limiting vision
Uncontrolled glaucoma
Amblyopia or squint.
Pre-operative evaluation
All patients underwent:
Best-corrected visual acuity (BCVA) assessment using the Snellen chart
Slit-lamp examination
Intraocular pressure (IOP) measurement
Dilated fundus examination.
Surgical technique
All procedures were performed under peribulbar anaesthesia by a single experienced surgeon. Pars plana vitrectomy (PPV) was performed, followed by sutureless intrascleral fixation of a three-piece polymethyl methacrylate (PMMA) intraocular lens (IOL) using a modified 26-gauge needle-guided haptic exteriorisation technique.
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A superior conjunctival peritomy was performed from the 3 to 9 o’clock position, followed by cauterisation of the bleeding vessels to achieve haemostasis. Two points were marked on the limbus, 180° apart, with a marker pen, preferably at the 3 and 9 o’clock positions, to serve as guides for subsequent sclerotomies. Two scleral tunnels, one on each side, were fashioned, starting 1.5 mm posterior to the limbus, using a 23-gauge microvitreoretinal blade or a 22-gauge needle. The tunnels were created parallel to the limbus in an anti-clockwise direction at both entry points. Each scleral tunnel measured approximately 3-mm in length, with the starting point located 0.5 mm away from the sclerotomy site, that is, the entry point of the needle or IOL haptic exit point. A superior sclerocorneal tunnel measuring 6 mm was constructed at the 12 o’clock position. Three 23-gauge PPV ports were created: The suprotemporal and supronasal ports were used for endo-illumination and vitrectomy cutter, while the inferotemporal port was used for infusion. PPV was then performed, along with pars plana lensectomy or posterior chamber intraocular lens (PCIOL) explantation, depending on the clinical scenario. Lensectomy was carried out using a 23-gauge vitrectomy cutter or a 20-gauge phacofragmatome, based on the hardness of the nucleus. Triamcinolone acetonide (Aurocort 40 mg/mL; Aurolab, Chennai, India) was used to assist posterior vitreous detachment induction when required. The peripheral retina was carefully examined for retinal breaks and endolaser photocoagulation was performed when indicated. Following completion of vitrectomy, sutureless intrascleral fixation of IOL (SFIOL) was performed using the extraocular needle-guided haptic insertion technique (X-NIT), as shown in schematic form in Figure 1.
Figure 1: Schematic images show the steps of X-NIT technique (a) Two scleral tunnels one on each side, were fashioned, starting 1.5 mm posterior to the limbus (b) A bent 26-gauge needle with a silicone stopper was introduced through the scleral tunnel and directed to exit through the corneoscleral tunnel into the extraocular space, (c) The leading haptic was loaded into the lumen of the 26-gauge needle, (d) which was gradually withdrawn from the sclerotomy while the IOL was simultaneously inserted into the eye, (e) The trailing haptic was externalised using the same technique, (f) A well-centered SFIOL was achieved, with both haptics securely tucked into the preformed scleral tunnels. After completion of PPV, the anterior chamber was entered through the preformed sclerocorneal tunnel. A three-piece PMMA intraocular lens (6-mm optic, Prolene modified C-loop haptics, overall diameter 13.5 mm; Aurolab) was implanted in all cases. A bent 26-gauge needle with a silicone stopper was introduced through the scleral tunnel and directed to exit through the corneoscleral tunnel into the extraocular space. The leading haptic was loaded into the lumen of the 26-gauge needle, which was gradually withdrawn from the sclerotomy while the IOL was simultaneously inserted into the eye. The trailing haptic was externalised using the same technique. A well-centred SFIOL was achieved, with both haptics securely tucked into the preformed scleral tunnels [Figure 2]. The sclerocorneal tunnel was closed using 10-0 nylon suture. Vitrectomy ports were closed with 8-0 vicryl suture. The conjunctiva was repositioned and sutured with 10-0 nylon. A subconjunctival injection of gentamicin (0.5 mL) and dexamethasone (0.5 mL) was administered. Antibiotic steroid Ocupol-Dx eye ointment was applied, and pad-bandage was place.
Post-operative follow-up
Patients were examined on post-operative day 1, week 1, month 1, month 3 and month 6. Outcomes assessed included BCVA, IOP, IOL centration, fundus examination and complications.
RESULTS
Demographic profile
Early post-operative complications included transient corneal oedema and mild hypotony, which resolved spontaneously. No cases of endophthalmitis, chronic inflammation or late dislocation were observed during follow-up. As shown in Table 1, the majority of patients were in the 55 -64 years age group (23 patients, 46%), followed by the 65 -74 years group (12 patients, 24%), 45 -54 years group (8 patients, 16%), 35-44 years group (4 patients, 8%), and 25 -34 years group (3 patients, 6%). The mean age was 55.32 ± 10.95 years.
| Group (years) | n (%) age |
|---|---|
| 25–34 | 3 (6) |
| 35–44 | 4 (8) |
| 45–54 | 8 (16) |
| 55–64 | 23 (46) |
| 65–74 | 12 (24) |
Mean age: 55.32±10.95 years. SFIOL: Scleral fixated intraocular lenses, ±: Standard deviation
Table 2 shows a comparison of BCVA in patients undergoing sutureless scleral fixation of IOL from pre-operative status through various follow-up periods. Preoperatively, 24% had a BCVA of <6/60, and 76% had a BCVA of >6/60. Postoperatively, significant improvements were observed: By 6 months, only 4% had BCVA of <6\60, the rest 96% had BCVA of >6/60. This indicates the procedure’s effectiveness in enhancing visual outcomes over time.
| BCVA | Pre-operative (%) | Day 1 (%) | 1 week (%) | 1 month (%) | 3 months (%) | 6 months (%) |
|---|---|---|---|---|---|---|
| 6/60 | 4 (8) | 2 (4) | 6 (12) | 4 (8) | 6 (12) | 4 (8) |
| 6/36 | 5 (10) | 0 (0) | 3 (6) | 10 (20) | 5 (10) | 7 (14) |
| 6/24 | 6 (12) | 0 (0) | 4 (8) | 5 (10) | 9 (18) | 9 (18) |
| 6/18 | 6 (12) | 0 (0) | 0 (0) | 3 (6) | 8 (16) | 6 (12) |
| 6/12 | 9 (18) | 0 (0) | 0 (0) | 6 (12) | 7 (14) | 8 (16) |
| 6/9 | 6 (12) | 0 (0) | 0 (0) | 5 (10) | 7 (14) | 8 (16) |
| 6/6 | 2 (4) | 0 (0) | 0 (0) | 1 (2) | 6 (12) | 6 (12) |
| CF6M | 1 (2) | 2 (4) | 4 (8) | 7 (14) | 2 (4) | 2 (4) |
| CF5M | 1 (2) | 1 (2) | 6 (12) | 6 (12) | 0 (0) | 0 (0) |
| CF4M | 1 (2) | 4 (8) | 7 (14) | 2 (4) | 0 (0) | 0 (0) |
| CF3 M | 2 (4) | 1 (2) | 5 (10) | 1 (2) | 0 (0) | 0 (0) |
| CF2 | 2 (4) | 5 (10) | 8 (16) | 0 (0) | 0 (0) | 0 (0) |
| CF1 | 1 (2) | 5 (10) | 6 (12) | 0 (0) | 0 (0) | 0 (0) |
| CF0.5 M | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| CFNF | 2 (4) | 20 (40) | 1 (2) | 0 (0) | 0 (0) | 0 (0) |
| HM+PL+PR4+ | 2 (4) | 10 (20) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| HM+PL+PR Def | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Total | 50 (100) | 50 (100) | 50 (100) | 50 (100) | 50 (100) | 50 (100) |
BCVA: Best-corrected visual acuity, SFIOL: Scleral fixated intraocular lenses implantation, HM: Hand movements vision, PL: Perception of light, PR: Projection of rays, CF: Counting fingers, CFNF: Counting fingers near face
DISCUSSION
In this study, the mean age of patients was 55.32 ± 10.95 years, with the majority belonging to the 55–64 years of age group (46%). Similar age distributions have been reported by Agarwal et al. and Baskaran et al., where most of the patients undergoing SFIOL implantation were in the fifth and sixth decades of life.[6,7] This age predilection reflects the higher incidence of complicated cataract surgeries, zonular instability and ocular trauma in this age group.[6,7] Male predominance (58%) [Graph 1] observed in our study is consistent with findings reported by Yamane et al.[8] and Gabor and Pavlidis,[5] who also noted a higher proportion of male patients. This may be attributed to increased exposure to ocular trauma and delayed presentation in males.
Aphakia following complicated cataract surgery was the most common indication (80%) in our study [Graph 2], followed by subluxated lens (10%) and subluxated IOL (8%). Comparable results were reported by Baskaran et al., where aphakia constituted the primary indication in approximately 70–85% of cases undergoing sutureless SFIOL implantation.[7] Trauma accounted for 28% of cases in the present study, which aligns with studies by Scharioth et al. and Canabrava et al., emphasising trauma as a significant contributor to loss of capsular support requiring scleral fixation of IOL.[9,10]
The present study demonstrated a significant and sustained improvement in BCVA postoperatively, with most of the patients achieving functional vision (6/18) by 1 month and maintaining stable vision up to 6 months. These results are comparable to those reported by Agarwal et al.[6] (glued IOL technique) and Yamane et al. (double-needle flanged technique), where a majority of patients achieved BCVA of 6/18 or better.[8] The favourable visual outcomes in our study can be attributed to stable posterior chamber IOL positioning, effective vitrectomy and secure intrascleral haptic fixation. Unlike sulcus-placed or iris-fixated lenses, scleral fixation places the IOL closer to the physiological nodal point, minimising higher-order aberrations.[11]
Transient elevation of IOP was noted in a small number of patients on post-operative day 1 (8%) [Graph 3], which normalised within one week in all cases. No patient had persistent ocular hypertension during the follow-up. Similar transient IOP changes have been reported in studies by Yamane et al.[8] and Baskaran et al.,[7] likely related to postoperative inflammation or residual viscoelasticity. The absence of long-term IOP elevation supports the safety of this technique in preserving aqueous outflow dynamics. The complication rate in the present study was low. Transient corneal oedema and mild post-operative inflammation were the most commonly observed complications and resolved with medical management. Importantly, no cases of endophthalmitis, chronic hypotony, significant IOL tilt or late IOL dislocation were observed during follow-up. Compared to sutured SFIOL techniques, which are associated with suture erosion, knot exposure, late suture breakage and secondary IOL dislocation as reported by Vote et al.[4] as well as Price and Price,[12] the sutureless approach effectively eliminates these long-term risks. In addition, unlike the flanged Yamane technique, our method avoids haptic cauterisation, thereby reducing the risk of haptic weakening and late slippage.
The modified 26-G needle–assisted sutureless technique used in this study offers several advantages over existing methods:
Compared to the glued IOL technique, it avoids fibrin glue, reduces surgical cost and eliminates dependence on biological adhesives
Compared to the Yamane flanged technique, it avoids haptic cauterisation and flange-related complications
Compared to sutured SFIOL, it avoids suture-related long-term complications.
The use of preformed scleral tunnels ensures secure haptic tucking and good centration, similar to the outcomes reported with X-NIT and Scharioth techniques, while maintaining technical simplicity.
The limitations of this study include a relatively small sample size and a follow-up period limited to six months. Longer follow-up is necessary to evaluate late-onset complications such as delayed IOL dislocation, scleral erosion and long-term endothelial cell loss.
CONCLUSION
The modified sutureless, glueless intrascleral fixation of IOL using a 26-gauge needle technique is a safe and effective option for managing aphakia and dislocated IOLs. It provides good visual rehabilitation with minimal complications and avoids suture-related failures.
Ethical approval:
The research/study was approved by the Institutional Review Board at B. J. Medical College; Civil hospital, Ahmedabad, number 98/2024, dated 31 December 2023.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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