intraocular lens ( iol ) implantation in an eye without sufficient capsular support has been accomplished by using an anterior chamber iol , an iris - fixed iol , and a transscleral - fixed posterior chamber ( pc ) iol through the ciliary sulcus or pars plana.1,2 despite the development of these techniques , transscleral iol fixation is associated with several suture - related complications such as inflammation , suture degradation , delayed iol dislocation owing to broken sutures , and suture exposure - induced endophthalmitis.3,4 sutureless techniques for intrascleral fixation of a pc iol have recently become increasingly popular.513 we describe here a modified simple intrascleral fixation technique that provides good iol fixation with reliable wound closure . we retrospectively reviewed the medical records of patients who had had sutureless intrascleral iol fixation performed at the department of ophthalmology , kumamoto university hospital , between april 2012 and may 2013 and who had been followed up for at least 18 months . all patients were informed about the procedure and its possible complications and gave their consent to review their record later . the study was conducted in accordance with the declaration of helsinki , and the institutional review board of kumamoto university approved this retrospective review and analysis of patient data ( reference number : 186 ) . at all pre- and postoperative visits , all patients had a standard ophthalmologic examination including measurement of best - corrected visual acuity ( bcva ) with a landolt chart , slit - lamp examination , measurement of intraocular pressure ( iop ) , and dilated indirect slit - lamp biomicroscopy . the density of endothelial cells in the cornea was measured with a specular microscope ( em-3000 ; tomey , nagoya , japan ) preoperatively and 3 months postoperatively . a sclerocorneal incision of 2.83.2 mm was made with the patient under retrobulbar anesthesia , and an infusion cannula or anterior chamber maintainer was inserted . a sclerotomy was made 2.0 mm to the limbus with an angled 25-gauge microvitreoretinal ( mvr ) knife ( figure 1a [ 13 ] ) . the angled mvr knife was used to create the scleral tunnel 3.03.5 mm long and approximately 50% of the scleral thickness , which was made parallel to the limbus and was started at the sclerotomy ( figure 1b [ 13 ] ) . lamellar scleral dissection , 1.0 mm long , was then performed at an outer wall of the scleral tunnel ( figure 1c [ 13 ] ) . this lamellar dissection of the limbus - parallel scleral tunnel can simplify the forceps - assisted introduction of the haptics into the scleral tunnel . same sclerotomy , scleral tunnel , and lamellar scleral dissection were made 180 from the other site . we used a three - piece iol ( nx-70 ; santen pharmaceutical , tokyo , japan ) with an xj-70 injector . the iol was 13.2 mm long and had a 7 mm diameter optic , and the haptics were composed of flexible polyvinylidene fluoride . the iol was inserted into the anterior chamber , and the trailing haptic was kept outside to prevent the iol from falling into the vitreous cavity . the tip of the haptic was then grasped with a 25-gauge forceps ( maxgrip ; alcon - grieshaber , fribourg , switzer - land , or iol haptic gripping forceps ; geuder , heidelberg , germany ) , pulled through the sclerotomy , and externalized on the left side ( figure 1d ) . after the trailing haptic was inserted into the anterior chamber with a 25-gauge forceps held in the right hand , the other forceps was used to hold the haptic in the left hand ( figure 1e ) . then , the haptic tip was grasped with the forceps , pulled through the sclerotomy , and externalized on the right side ( figure 1f ) . the tip of the haptic was then inserted into the limbus - parallel scleral tunnel with the forceps , and the iol was positioned and centered ( figure 1 g [ 13 ] ) . the conjunctiva was closed with 80 polyglactin ( surgical technique , video s1 ) . for statistical analyses , the decimal bcva value was converted to the logarithm of the minimum angle of resolution ( logmar ) . the statistical analyses were performed via jmp , version 9 ( sas institute inc . , cary , nc , usa ) . we retrospectively reviewed the medical records of patients who had had sutureless intrascleral iol fixation performed at the department of ophthalmology , kumamoto university hospital , between april 2012 and may 2013 and who had been followed up for at least 18 months . all patients were informed about the procedure and its possible complications and gave their consent to review their record later . the study was conducted in accordance with the declaration of helsinki , and the institutional review board of kumamoto university approved this retrospective review and analysis of patient data ( reference number : 186 ) . at all pre- and postoperative visits , all patients had a standard ophthalmologic examination including measurement of best - corrected visual acuity ( bcva ) with a landolt chart , slit - lamp examination , measurement of intraocular pressure ( iop ) , and dilated indirect slit - lamp biomicroscopy . the density of endothelial cells in the cornea was measured with a specular microscope ( em-3000 ; tomey , nagoya , japan ) preoperatively and 3 months postoperatively . a sclerocorneal incision of 2.83.2 mm was made with the patient under retrobulbar anesthesia , and an infusion cannula or anterior chamber maintainer was inserted . a sclerotomy was made 2.0 mm to the limbus with an angled 25-gauge microvitreoretinal ( mvr ) knife ( figure 1a [ 13 ] ) . the angled mvr knife was used to create the scleral tunnel 3.03.5 mm long and approximately 50% of the scleral thickness , which was made parallel to the limbus and was started at the sclerotomy ( figure 1b [ 13 ] ) . lamellar scleral dissection , 1.0 mm long , was then performed at an outer wall of the scleral tunnel ( figure 1c [ 13 ] ) . this lamellar dissection of the limbus - parallel scleral tunnel can simplify the forceps - assisted introduction of the haptics into the scleral tunnel . same sclerotomy , scleral tunnel , and lamellar scleral dissection were made 180 from the other site . we used a three - piece iol ( nx-70 ; santen pharmaceutical , tokyo , japan ) with an xj-70 injector . the iol was 13.2 mm long and had a 7 mm diameter optic , and the haptics were composed of flexible polyvinylidene fluoride . the iol was inserted into the anterior chamber , and the trailing haptic was kept outside to prevent the iol from falling into the vitreous cavity . the tip of the haptic was then grasped with a 25-gauge forceps ( maxgrip ; alcon - grieshaber , fribourg , switzer - land , or iol haptic gripping forceps ; geuder , heidelberg , germany ) , pulled through the sclerotomy , and externalized on the left side ( figure 1d ) . after the trailing haptic was inserted into the anterior chamber with a 25-gauge forceps held in the right hand , the other forceps was used to hold the haptic in the left hand ( figure 1e ) . then , the haptic tip was grasped with the forceps , pulled through the sclerotomy , and externalized on the right side ( figure 1f ) . the tip of the haptic was then inserted into the limbus - parallel scleral tunnel with the forceps , and the iol was positioned and centered ( figure 1 g [ 13 ] ) . for statistical analyses , the decimal bcva value was converted to the logarithm of the minimum angle of resolution ( logmar ) . the statistical analyses were performed via jmp , version 9 ( sas institute inc . , cary , nc , usa ) . table 1 shows the baseline characteristics of the 48 eyes of 47 consecutive patients in this study . the mean follow - up period was 26.7 months . the mean postoperative bcva improved significantly at 3 months ( p=0.02 ) and no bcva value that worsened by at least 0.30 logmar was seen . there was no significant change in the mean iop ( preoperative iop , 11.62.4 mmhg ; postoperative iop , 12.32.1 mmhg ) . two eyes ( 4.2% ) demonstrated an absolute prediction error of more than 1.5 d. no other complications , such as iatrogenic distortion or breakage of the iol haptic , spontaneous iol decentration that caused the refractive change , endophthalmitis , or retinal detachment , were detected during the follow - up period . in addition , the iol haptics were completely incarcerated in the scleral tunnel , and different views of the haptics can be seen , depending on the depth of the tunnel ( figure 2 ) . no conjunctival erosion or inflammation several investigators have reported on the techniques for sutureless intrascleral fixation of pc iols.512 these techniques have some advantages over transscleral suturing , which can cause suture - induced inflammation , iol tilt related to inaccurate placement of the fixation sutures , delayed iol dislocation owing to suture degradation or breakage , and suture exposure - induced endophthalmitis.2 techniques with or without the use of a scleral flap have been reported . the technique without a scleral flap is simpler , takes less time , and requires neither sutures nor fibrin glue . however , inserting the iol haptic into the scleral tunnel , as described by gabor and pavlidis,6 is not easy because the sclerotomy and scleral tunnel are so close to each other . therefore , to resolve this difficulty , we added a lamellar scleral dissection , approximately 1.0 mm long , at the outer wall of the scleral tunnels . as a result , the haptic can be easily grasped and introduced into the scleral tunnel with the forceps . in this study , all eyes were followed up for at least 18 months , with the mean follow - up period being 26.7 months . no iol dislocation or tilt was observed during this follow - up period , which indicated good intermediate - term iol stability with our technique . even if iol decentration occurs after surgery , it can be easily corrected by reopening the incision in the conjunctiva and sclera and adjusting the position of the iol haptic . several new techniques , including a trocar - assisted,11 a sutureless 27-gauge needle - guided,12 and a y - fixation intrascleral iol implantation technique,13 were recently reported . these techniques do not require a large lamellar scleral flap and fibrin glue , and nor does our technique . in addition , our technique may provide minimal invasion to the surrounding tissues without using a trocar,11 even small scleral flap,12 and relatively difficult needle technique.13 our study has certain limitations , including a small sample size , intermediate follow - up period , and no control group . the lamellar dissection of the limbus - parallel scleral tunnel can simplify the forceps - assisted introduction of the haptics into the scleral tunnel and seems to be a safe technique . longer follow - up is needed to determine the long - term results and safety of our technique .
purposeto report the results of sutureless scleral fixation of a posterior chamber intraocular lens ( iol ) by using our developed simple technique.methodswe retrospectively reviewed the medical records of 48 eyes of 47 patients who underwent sutureless intrascleral iol fixation by using our modified technique . 
 a 25-gauge microvitreoretinal knife was used to perform sclerotomies and create limbus - parallel scleral tunnels with lamellar dissection in which the haptics were fixed.resultsthe iols were fixed and centered well . 
 the mean follow - up period was 26.7 months . 
 postoperative complications included smooth vitreous hemorrhage in four eyes ( 8.3% ) , cystoid macular edema in two eyes ( 4.2% ) , and iris capture of the iol in two eyes ( 4.2% ) . 
 no other complications , such as breakage of the iol , spontaneous iol dislocation , or retinal detachment , were detected during the follow - up period.conclusionthe lamellar dissection of the limbus - parallel scleral tunnel can simplify the forceps - assisted introduction of the haptics into the scleral tunnel , and this technique seemed to be safe .