The successful placement of Intraocular Lenses (IOLs) during cataract surgery has become synonymous with their positioning in the capsular bag. In these cases, the IOL is positioned within the lens capsule, well-aligned on the pupillary axis, and the lens-capsule complex is supported by the zonules, as this maximizes surgical and refractive outcomes. In the absence of sufficient posterior capsular support, such as in cases of complicated cataract surgery with capsular damage, it is possible to place an IOL in the ciliary sulcus, achieving good visual outcomes [1,2].

Surgical options for eyes without sufficient capsular support include: a) Anterior chamber fixed Intraocular Lens; b) Iris-fixed Intraocular Lens; c) Sclera-fixed Intraocular Lens; and d) Scleral-fixed Intraocular Lens, including suture-free or suture-free fixation. The scleral intraocular fixation position of the IOSFL closely approximates the normal anatomical position of a lens placed within the capsule. It does not impede pupil dilation, unlike an iris-claw IOLs. Furthermore, the incidence of adverse events such as corneal endothelial decompensation, pupillary block, anterior chamber angle closure, and ocular inflammation is lower compared to anterior chamber or iris-fixed lenses. These factors make the IOSFL method the best surgical option compared to other types of interventions [1,2].

In the presented material, we have treated the principles, protocols and different techniques according to the modifications with the results achieved in the placement of Intraocular Lenses Fixed in the Sclerae, methods used with great success in the clinic “Albanian Eyes Center”, Tirana, Albania.

To the aphakic patient, an artificial Intraocular Lens provides correction which best approximates the physiologic process in optical terms and allows the best restoration of all functions, both monocular and binocular. On correction with an Intraocular Lens, the Aphakic patient recovers stereoscopic perception, mainly in near vision, and avoids the well-known problems usually encountered. There are several conditions when the Intraocular Lens cannot be placed in the capsular bag and when scleral fixation is required, including:

• Subluxation / dislocation of the lens (ectopia lens) and where the main causes are: 1/a] Congenital ectopia without systemic signs; 1/b] Ectopia with systemic associations; and 1/c] Marfan syndrome, Weill-Marchesani, homocystinuria, hyperlysinemia, and other acquired
• Insufficient capsular support in which we can list: 2/a] After post-surgical Aphakia due to intracapsular cataract extraction surgery; and 2/b] Complications caused by zonular dialysis or large posterior capsule rupture. In today's contemporary literature there are numerous techniques and operative modifications of IOSFL described by different researchers and scholars, but nevertheless some of the basic considerations remain unchanged [3,4].

According to the protocols carried out by us with the evaluated patients, the following steps were followed:

• Preoperative evaluation, detailed ocular and systemic anamnesis were taken for each of the patients to assess hereditary syndromes, and a complete ophthalmological examination was
• Anesthesia, surgical interventions, were performed with peribulbar block for patients who were cooperative and with general anesthesia for all other patients.
• Time of surgical intervention, the IOSFL intervention was performed as a primary procedure in a planned manner for those cases with a known zonular or posterior capsule defect, as well as for the circumstances of a complicated cataract intervention, the IOSFL intervention was implanted primarily in the same session or for special cases in a second session.

Research and scientific studies have not shown any difference in visual outcome or complication rates between primary and secondary implantation. During the surgical intervention, phacoemulsification or lensectomy and anterior vitrectomy can be performed depending on the case presented to the surgeon [5,6]. Below we will briefly describe two of the most commonly used techniques that are applied in our daily practices at the “Albanian Eye Centre”, Tirana, Albania.

A] Yamane Technique

In today's surgery, the Yamane technique description and outcomes useful for surgical tips and combined procedures [7,8] serves as a flapless and suture less transconjunctival technique, using a 30 G (Gauge) pintle, which is very well known and quite popular and is performed according to the protocol and steps of the following scenario. A three-piece intraocular lens is placed in the anterior chamber using an injector and the trailing haptic is held out to prevent the intraocular lens from falling into the vitreous cavity. An angular sclerotomy is made through the conjunctiva 2 mm from the limbus using a 30 G pintle. The leading haptic is inserted into the lumen of the needle using forceps. A second sclerotomy is then made with one side of a second pintle that is 180⁰ from the first sclerotomy. The trailing haptic is inserted into the lumen of the second pintle. Then, both haptics are externalized into the conjunctiva. The edges of the haptic are cauterized using an ophthalmic cauterizing device to create a flange with a diameter of 0.3 mm. The haptic flange is pushed back and secured in the scleral tunnels [9]. The following steps are followed according to the approved protocol.

Photo 1: 2 mm. marking of the conjunctiva from the limbus (up/down) at 3 and 9 o'clock.

• In this technique, a toreutic marker is used to mark the positions, the conjunctiva 2 mm from the limbus in the upper part at 3 o'clock, and 2 mm in the lower part at 9 o'clock, to have the most accurate placement of the haptics (Photo 1).
• The three-piece intraocular lens is then carefully placed in the anterior
• Trans-conjunctival sclerotomy is performed with the side of the 30 G
• Two 30 G pintles, one on each side, are passed 2 mm from the limbus through the conjunctiva, with an intra-scleral length of 2 mm.
• The leading haptic is grasped with forceps and inserted into the shaft of the 30 G needle on one side.
• After the first haptic is securely fixed in the lumen of the needle, the shaft is released from the holding forceps, allowing the intraocular lens to move in the eye.
• The following haptic is similarly inserted into the 30 G pintle on the other
• With the second haptic, already inserted into the lumen of the needle, it is extracted from the haptic by removing the needle through the transconjunctival sclerotomy, then the haptic is carefully grasped.
• With low-temperature cauterization, the terminal of the haptic is melted from 1-2 mm at its ends to create a flange (bulb), which prevents and allows the exit of the haptic only through the scleral incision made.
• Then move to the other side of the eye at approximately 180°, where the needle still penetrates the sclera, holding the main haptic of the intraocular lens. The needle is withdrawn and the haptic is grasped on the conjunctival surface, melting its edge by low-temperature
• The haptic is prolapsed through the conjunctiva and pushed into the scleral
• The final result should be a three-piece IOLs centered in the posterior segment and completed without sutures [7-9]. as shown in Photo 2.

Photo 2: Three-piece Intraocular Lens centered in the posterior segment without suture.

B]       Canabrava Technique

In the last 10 years, the Canabrava technique has been described as a method of intrascleral fixation with four flanges of the intraocular lens (4-Flanged Polypropylene Intrascleral Fixation of Acerose of Intraocular Lens). Its beginnings date back to 2017, applied by the Brazilian ophthalmologist Sergio Canabrava⁽¹⁰⁾ and in our clinical practices, the steps are carried out according to the following scenario:

• First, the specialist inserts the 6-0 polypropylene suture through the holes of the Acerose to align the Intraocular Lens.
• Then the surgeon continues with the insertion of the suture through the sclera on the left side only, to continue with its insertion on the other side, only after having placed the Intraocular Lens in the eye using The Brazilian specialist explains that the key to this technique is to position the polypropylene on the right side of the eye, preventing the Intraocular Lens from entering the posterior chamber of the eye.
• In the next steps, the first and second flanges are placed from the bottom, and at this point the specialist can better position the Intraocular Lens.
• In the same way, the third and fourth flanges are placed from the top [10,11]. It is important that all 4 flanges are inserted from inside the scleral tunnel to avoid endophthalmitis, steps which are presented in Photo
• In the next steps, the first and second flanges are placed from the bottom, and at this point the specialist can better position the Intraocular Lens.
• In the same way, the third and fourth flanges are placed from the top^(10,11). It is important that all 4 flanges are inserted from inside the scleral tunnel to avoid endophthalmitis, steps which are presented in Photo 3.

Photo 3: Intraocular Lens placement using the Canabrave Technique.

Our study included 36 patients treated with FSIOL at the ophthalmological Clinic “Albanian Eye Centre”, Tirana, Albania. The complications maybe can happen as a result of: a] Temporary corneal edema; b] Postoperative hypotony; c] Ocular hypertension; d] Cystoid macular edema; e] Dislocation or deviation of the intraocular lens; f] Pupillary lens capture; g] Pseudo-phacodonesis; h] Suprachoroidal and vitreous hemorrhage; i] Retinal detachment, especially in high myopia and Marfan etc. In our daily practice at our clinic during the two- year period, February 2022-March 2024, there have been patients who, for the most common reasons, required intraocular lens fixation, their data in % are presented in Table and Graph 1.

Table 1: Motives of Intervention for fixing of Intraocular Lens.

In a total of 36 patients who underwent the surgical procedure with Scleral Fixation of the Intraocular Lens (IOSFL), we studied and analyzed the strategy for the best management of the existing lens at the time of the intervention.

In 28 (87.5%) cases (of patients) with surgical intervention, the lens was replaced by placing a new lens, which is fixed in a scleral manner. These clinical decisions have been necessary only in cases for patients with damaged and luxated Intraocular Lenses in the vitreous cavity, as well as in cases when the model of the existing lens was not suitable for reuse in scleral fixation (13).

In 4 (12.5%) cases (patients) re-implantation of the same lens was performed, meaning that the existing Intraocular Lens ^(13,14) was repositioned and scleral fixed, as its structural condition allowed such management. These data are presented in graph 3.

Graph 3: The kind of Intraocular (IOL) used during the IOSFL procedure.

The following graph 4 shows the distribution of additional interventions performed in combination with IOSFL. In most cases, the IOSFL intervention was not performed as an isolated procedure, but according to the data analyzed for 36 patients, additional surgical interventions were identified which include: a] Posterior Vitrectomy (PPV), this procedure is performed in many cases to remove the gelatinous fluid that fills the vitreous cavity and to ensure a clear visual field during lens implantation. It also helps in the management of IOL luxated in the vitreous cavity. b] Pars plana lensectomy (PP lensectomy), which procedure is performed in cases of Nucleus Drop or complicated cataracts. This procedure removes the luxated lens through the posterior segment. c] Extraction of the previous lens (IOL exchange), in cases where the existing IOL is damaged or not suitable for fixation, it is replaced with a new lens that is fixed scleral. d] Phaco emulsification, in some cases in patients with subluxated cataracts is performed to remove the cataract and prepare for the placement of new lenses with scleral fixation. e] Anterior vitrectomy, used when the operated eye has vitreous invasion into the anterior segment, often after rupture of the posterior capsule. f] Pupiloplasty, this procedure is performed for those cases with ectopic pupils, to restore normal iris position and function [15,16].

Graph 4: Supplementary intervention in favour IOSFL procedure.

Of the 36 patients treated with the scleral fixation intraocular lens technique IOSFL, only 6 patients (18.75%) developed cystoid macular edema in the postoperative period. The remaining 30 patients (81.25%) did not develop any significant clinical complications during the postoperative follow-up. This low complication rate supports the relative safety of the IOSFL technique in the hands of non-professional surgeons, and when surgical protocols are implemented according to strict criteria, especially in patient selection and execution of surgical interventions.

• From the four study cases, the analysis of the basic data confirms the efficacy and safety of the Canabrava technique in difficult anatomical situations, as well as the importance of individualizing the surgical approach in compromised eyes [10,14].
• As new contemporary technologies used to design Intraocular Lenses improve, the need for long-term data relating to the performance of eyes implanted with IOLs also A large proportion of IOL studies have assessed patients over time-spans ranging between 3 months
• [17] and 5 years [18] with fewer studies extending beyond 2 years of follow-up [19]. By our study cases report and analysis we have concluded improvement for long-term period to the performance of eyes implanted by IOLs, which data were in accordance with foreign researchers [15,17,18].
• In this study report, we have presented a variety of clinical assessment by Yamane and Canabrava techniques, mainly used in our Clinic “Albanian Eyes Centre”, Tirana, Albania to evaluate the visual and optical performance of patients implanted with IOLs, for a normal life with highlighting relative advantages and shortfalls. These findings should assist researchers in developing a comprehensive series of investigations designed to evaluate the performance of IOLs [19, 20].

Recommendation

For subsequent interventions, it is recommended to make the appropriate selection and choice depending on the pathologies for each patient ^{(21, 22)}, and what is most essential is to ensure the best possible anatomical and functional results after the placement of the IOSFL after every second additional intervention.

Author Contributions: Conceptualization and methodology: Associated Prof. Ali TONUZI and Ledia DINO, Ph.D. Investigation and resources: Secretary of “Albanian Eyes Clinic”, Tirana, Albania. Data curation and writing to the draft of manuscript: Dr. L. Qafmolla. Writing, review, editing and managing of manuscript Dr. Luan Qafmolla. Both authors have read and agreed to the published version of the manuscript.

Plagiarism: The study research report was designed and written by the authors, presenting a significant contribution with an effort to ensure that the accuracy of the published parts of the cited literature sources is in line with the approved norms, rules and guidance of the Smart Wearable Technology publisher journals. The authors declare that for the drafting and revision of the paper have strictly respected the rules of acceptance, and in terms of references and citations of the literature used in our scientific research, ethical and academic norms have been taken into account and respected.

Acknowledgement: Both authors of the draft manuscript thank Dr. Luan Qafmolla for obligation and regulation of article according the guidance of Smart Wearable Technology publisher journal, as well as for contacting with editorial board of this journal. Also, acknowledgements Prof. Ali Tonuzi and his “Albanian Eyes Centre” for the contribution in data base and treatment of patients in respective clinics.

Declaration of Figures’ Authenticity: All tables and graphs submitted are created and processing by the authors and well-ordered by Dr. Luan Qafmolla, whom confirm that these data are original with no duplication and have not been previously published in whole or in part in other journals abroad.

Conflicts of Interest: The authors declare that they have no financial or non-financial interests to disclose.

Funding: This research received no external funding.

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