Intraocular lens secured with knotless sutures.

Sutureless Scleral Fixation: A Modern Solution for Intraocular Lens Complications

Kai Mendoza in Health & Wellness June 2025 • 4 min read.

"Discover how a knotless technique offers a safe, effective alternative for securing intraocular lenses when traditional methods fall short, ensuring better outcomes and fewer complications."

Posterior chamber intraocular lens (PC IOL) scleral fixation has become a widely accepted method for addressing situations where the natural lens support is inadequate. This technique is invaluable not only during initial IOL implantation when sufficient capsular support is lacking but also in cases of IOL dislocation where repositioning is necessary.

One of the primary challenges associated with traditional scleral fixation is the risk of suture exposure, which can lead to various complications. To mitigate this risk, surgeons often employ techniques such as creating scleral flaps to cover the suture knots. Other strategies involve embedding the knots within scleral tunnels or pockets, or even inverting the knots into the eye.

However, these methods are not foolproof and may not completely prevent suture exposure. Creating scleral flaps can be technically demanding, time-consuming, and challenging in patients with conjunctival scarring or those undergoing concurrent corneal procedures. Moreover, intraoperative hypotony (low intraocular pressure) can further complicate the procedure.

Why Knotless Scleral Fixation Matters: Overcoming Traditional Challenges

Intraocular lens secured with knotless sutures.

In situations where creating scleral flaps is difficult or impossible, alternative techniques are needed to secure the IOL effectively. Several sutureless methods have emerged, including direct scleral insertion, adhesive fixation with tissue glue, and the Z-suture technique. However, these methods can increase the risk of IOL tilting and decentration compared to traditional sutured fixation.

A recent study published in the Journal of the Korean Ophthalmological Society explored a modified approach to sutureless scleral fixation, particularly in cases where scleral flap creation was problematic. The study aimed to evaluate the short-term clinical outcomes of this technique, focusing on IOL stability and complication rates.

The study focused on five patients who underwent sutureless scleral fixation due to difficulties in creating scleral flaps. The key steps of the procedure involved:

Securing the IOL with polypropylene sutures.
Passing the sutures through the sclera at the 5 and 11 o’clock positions.
Reinserting the suture ends under the exposed suture to create tension and secure the IOL.
Covering the sutures with a conjunctival flap to minimize exposure.

Over an average follow-up period of 8 months, the study reported minimal complications. One patient experienced intraoperative ciliary body hemorrhage, and another had IOL tilting due to improper suture tension. However, no suture exposure, IOL dislocation, or progressive decentration were observed. Importantly, IOL astigmatism remained stable and comparable to traditional sutured techniques.

The Future of IOL Fixation: A Step Towards Safer, More Reliable Outcomes

The findings suggest that sutureless scleral fixation is a viable alternative when scleral flap creation is challenging, providing stable IOL fixation and minimizing the risk of suture-related complications. While longer-term studies with larger cohorts are needed, this technique represents a promising advancement in managing complex IOL cases. This method provides a simpler yet effective solution, potentially reducing the learning curve for surgeons and improving patient outcomes in challenging scenarios.

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This article is based on research published under:

DOI-LINK: 10.3341/jkos.2012.53.11.1609, Alternate LINK

Title: Knotless External Fixation Technique For Posterior Chamber Intraocular Lens Transscleral Fixation: A 5-Case Analysis

Subject: Ophthalmology

Journal: Journal of the Korean Ophthalmological Society

Publisher: Korean Ophthalmological Society

Authors: Dae Joong Ma, Mee Kum Kim, Won Ryang Wee

Published: 2012-01-01

Everything You Need To Know

What is sutureless scleral fixation, and how does it differ from traditional methods?

Sutureless scleral fixation is a modern technique used to secure Posterior chamber intraocular lenses (PC IOLs) when the natural lens support is insufficient or when the IOL needs repositioning. Unlike traditional methods that rely on sutures, which can lead to complications like suture exposure, this technique aims to minimize these risks. Traditional methods often involve creating scleral flaps or burying suture knots, which can be complex. Sutureless techniques, like direct scleral insertion or adhesive fixation, offer alternatives, although they may carry risks like IOL tilting or decentration.

What are the main challenges addressed by sutureless scleral fixation?

Sutureless scleral fixation primarily addresses the challenges associated with traditional scleral fixation, particularly the risk of suture exposure. Suture exposure can lead to inflammation, infection, and other complications. Furthermore, sutureless techniques become especially valuable when creating scleral flaps is difficult or impossible, such as in patients with conjunctival scarring or those undergoing concurrent corneal procedures. They also provide a simpler alternative, potentially reducing the surgical learning curve.

In which scenarios is sutureless scleral fixation most beneficial?

Sutureless scleral fixation is most beneficial in several scenarios. It is a viable alternative when creating scleral flaps is challenging or not feasible, such as in patients with conjunctival scarring. It is also useful when the natural lens support is inadequate during initial IOL implantation or when IOL dislocation necessitates repositioning. The technique simplifies the procedure, potentially improving patient outcomes in complex cases where traditional methods are difficult to execute.

What are the key steps involved in the modified sutureless scleral fixation technique described in the Journal of the Korean Ophthalmological Society study?

The modified sutureless scleral fixation technique involves several key steps. Firstly, the Posterior chamber intraocular lens (PC IOL) is secured with polypropylene sutures. Then, these sutures are passed through the sclera at the 5 and 11 o’clock positions. The suture ends are reinserted under the exposed suture to create tension and secure the IOL. Finally, a conjunctival flap is used to cover the sutures, minimizing exposure. This approach aims to provide stable IOL fixation while reducing the risk of suture-related complications.

What were the clinical outcomes and implications of the study on sutureless scleral fixation?

The study demonstrated that sutureless scleral fixation is a viable option when scleral flap creation is problematic. Over an average follow-up of 8 months, the study reported minimal complications. No suture exposure, IOL dislocation, or progressive decentration were observed. The findings indicate stable IOL fixation and a reduced risk of suture-related complications. While longer-term studies are needed, this technique represents a promising advancement, potentially improving patient outcomes and simplifying the procedure for surgeons managing complex Posterior chamber intraocular lens (PC IOL) cases.