Glued IOL

Glued IOL or Glued Intraocular lens is a new Surgical technique for implantation of a posterior chamber IOL with the use of biological glue in eyes with deficient or absent posterior capsules (Fig 1). A quick-acting surgical fibrin sealant derived from human blood plasma, with both hemostatic and adhesive properties is used. Glued IOL or Glued Intraocular lens is a new Surgical technique for implantation of a posterior chamber IOL with the use of biological glue in eyes with deficient or absent posterior capsules (Fig 1). A quick-acting surgical fibrin sealant derived from human blood plasma, with both hemostatic and adhesive properties is used. The eye resembles a camera. Just as we take a photograph with the camera, so also the eye takes a photograph of an object seen by it. In the camera, an object is focused onto the film of the camera by a lens. This image is an inverted image and it is developed in the studio and made into an erect one. The same way, an object is focused by the lens of the eye onto the film of the eye called retina. This image is also inverted and is made erect by the brain. Cataract is an opacity in the lens of the eye. The normal lens allows light to reach the retina. When it becomes opaque and does not allow light to reach the retina, we are unable to see clearly. To understand cataract better, imagine photographing through a camera with grease smeared onto its lens. In such a case, the image formed is very hazy and blurred. Similar to grease smearing onto the lens of a camera, if the lens of the eye gets opaque, the image formed on the retina will be blurred and one will not see clearly. There is no medical treatment for cataract. The only treatment is surgery. When a person has a cataract and the decision is made to operate, then the diseased lens is removed and replaced by an artificial lens called an Intraocular lens or IOL. Once the cataract is removed, there is no focusing ability of the eye as there is no lens in the eye. So one has to use the IOL to get the object focused onto the retina. For an intraocular lens to be placed in the eye one needs some support which is given by the capsule of the lens which is left behind. But in some cases there is no capsule and in such cases the alternative is to fix a glued IOL (Fig 2). The other alternative is to suture the IOL to the eye or fix it in some other place like an anterior chamber IOL. To understand why the glued IOL works better compared to a sutured IOL or AC IOL, let us think of a camera. If we break the lens of the camera and fix it back to the camera body with sutures and take photos the picture quality will not be good as the lens would be moving. This is what happens in an eye with a sutured IOL as there is movement of the IOL (pseudo phacodonesis). Imagine if we would glue the lens to the camera body both the lens and the body of the camera would move in unison. This is what happens in a glued IOL and there is no movement of the IOL (pseudo phacodonesis) which gives a better picture quality. Maggi and Maggi in 1997 were the first to report sutureless scleral fixation of a special IOL. Sutureless intrascleral fixation of posterior chamber IOL was first described by Dr.Gabor Scharioth from Germany. This technique was further modified by making scleral flaps and creating scleral pockets for tucking the haptics. The flaps are then reattached to the bed with the help of Glue. On 14 December 2007, at Dr. Agarwal's Eye Hospital, Chennai, India the first glued Intraocular lens (IOL) surgery was done. For the first time in the World, tissue glue had been used to fix an intraocular lens in an eye. This new surgical procedure was invented & performed by Prof. Amar Agarwal, Chairman, Dr.Agarwal's Eye Hospital, Chennai. Subsequently, the first child in whom glued IOL was performed was a patient Anandhi who had a history of injury in her right eye 3 months ago while bursting crackers. She underwent emergency surgery for lens removal due to severe injury to the lens and sutured IOL, which was specific for such cases. After 1 month, when the child came for follow up, it was found that there was a decenteration of IOL. The parents noted the child's difficulty in performing activities in right eye. Under general anaesthesia Prof. Amar Agarwal removed the already existing IOL and placed the IOL using the Glued IOL technique. Glued IOL can be done both as a primary and as a secondary procedure in cases in which the lens capsule is deficient or absent . As a primary procedure it can be done in all cases of intraoperative posterior capsule rupture. It can also be done in all cases of subluxation or dislocation of lens e.g. Marfans syndrome, traumatic dislocation of lens etc. As a secondary procedure it can be done in all the aphakic cases or can also be done as a part of IOL exchange following an anterior chamber IOL, subluxated or dislocated IOL. Fibrin glue has been used previously in various medical specialties as a hemostatic agent to arrest bleeding, seal tissues and as an adjunct to wound healing. It is available in a sealed pack that contains freeze-dried human fibrinogen (20 mg/0.5 ml), freeze-dried human thrombin (250 IU/0.5 ml), aprotinin solution (1,500 KIU in 0.5 ml), one ampoule of sterile water, four 21-gauge needles, two 20-gauge blunt application needles, and an applicator with two mixing chambers and one plunger guide.Preparation of glue:The vials are placed in a water bath which is preheated to 37 degrees for 2 to 3 minutes. 0.5 cc of distilled water is then added to thrombin vial whereas aprotinin is mixed with fibrinogen. Both the components are then filled in separate syringes and a 26 G needle is attached to it. The glued IOL technique consists of making two partial thickness scleral flaps exactly 180° apart approximately 2.5 mm by 2.5 mm followed by a sclerotomy with a 20-gauge needle 1 mm from the limbus. A 23 G vitrectomy cutter is introduced from the sclerotomy site and thorough vitrectomy is done removing all the vitreous tractions. A corneal tunnel is fashioned and then a 23-gauge Glued IOL forceps is passed through the sclerotomy site and the tip of the leading haptic of IOL is grasped, which is then externalised and brought out onto the ocular surface (Fig 3). Similarly the trailing haptic is then externalised using the handshake technique. Scleral pockets are made at the edge of the flap with a 26-gauge needle just parallel to the sclerotomy site, into which the two haptics are then tucked for additional stability (Fig 4). The scleral flaps are then glued back into place using biological glue. The IOLs that can be used are the three-piece foldable IOLs with slightly firm haptics or a three- piece non-foldable IOL. The glue is then used to seal the conjunctival closure.