Since the introduction of scleral fixation for intraocular IOL implantation in 1986 [14], researchers have continuously refined surgical techniques over the decades. Improvements have included considerations on whether and how to create a scleral flap, the choice and design of IOLs, suture materials and models, and fixation methods. These advancements have progressively reduced complication rates, including issues such as IOL subluxation and tilt, retinal detachment, hemorrhage, macular cystoid edema, ocular hypertension, and suture erosion or breakage [1, 10, 13, 15]. Building on the techniques of various scholars and incorporating clinical experience, this study introduces an innovative method for scleral fixation IOL implantation: the four-point fixation of the Akreos-Adapt AO IOL using two parallel 6−0 polyglactin sutures and a flanged technique.

This procedure offers several advantages. Firstly, the Akreos-Adapt AO IOL, selected for all patients in this study, is foldable, hydrophilic, aspherical, and equipped with four haptics [8]. This allows for a small corneal incision to insert the IOL and facilitates four-point fixation. Although hydrophilic acrylic IOLs has the possibility of their opacification in contact with air or gas in very specific surgical procedures such as DMEK, DSEAK and posterior vitrectomy via pars plana where they leave gas, postoperative inflammation and the risk of IOL tilt or dislocation can also be significantly reduced, and better prognosis visual acuity can be achieved. Furthermore, the use of four-haptics IOLs substantially decreases the likelihood of iris capture complications, particularly in cases of floppy iris, such as Marfan’s syndrome. Iris capture can result in secondary issues like glaucoma and iritis, which can severely impact the patient’s vision [2,3,4,5, 8].

Secondly, the use of 6−0 polyglactin sutures, known for their superior toughness and resistance to degradation, enhances long-term stability for scleral fixation of the IOL. This significantly reduces the risk of suture breakage, a major complication. Moreover, 6−0 polyglactin sutures are well-suited for this procedure because their diameter matches the inner diameter of a 30-gauge needle. The flange created by the 6−0 polyglactin suture is larger than the scleral puncture made by the 30-gauge needle, which facilitates suture traction and simplifies the surgical process.

Thirdly, this study utilized flange technology for scleral fixation of IOLs, as opposed to other suture fixation techniques such as intrascleral fixation, glued IOLs, or iris-sutured IOLs. This technique, initially described by Yamane et al. and later modified by Canabrava et al., [11,12,13] involves using 6−0 polyglactin sutures with flanges at four scleral sites to secure the IOLs. This method simplifies the procedure, as the suture can be guided into the eye with a 30-gauge needle without the need for tying or embedding, thereby reducing the complexity of scleral fixation surgery and minimizing suture-related complications. Additionally, it avoids the production of conjunctival peritomies and scleral flaps. The four-point scleral fixation enhances IOL stability and reduces the risk of tilt or dislocation. However, in specific cases such as pediatric patients with Marfan syndrome and elastic sclera, the flange structure alone may not be sufficient for stabilization. In these cases, flattened flange structures, which provide increased stability and prevent conjunctival exposure, have been suggested as a safer option [16].

A fourth key advantage of this technology is the ability to independently adjust the length of the two parallel 6−0 polyglactin sutures, a feature not available with other suture fixation methods. The adjustable flange technique enables precise tightening of the sutures to achieve optimal tension and IOL positioning, even after the sutures are fixed, to ensure the IOL optical zone is perfectly centered.

Fifth, this study utilized sutures configured in two horizontal parallel lines, allowing the IOL to be suspended on these sutures. This approach helps prevent excessive tensile deformation of the IOL, which could occur with circular or semi-circular fixation methods used on both sides of the Akreos-Adapt AO IOL.

In this study, all patients showed significant improvement in postoperative visual acuity at the final follow-up, which was more than three months later. There were no intraoperative complications observed during the follow-up period. Thus, this technology proved to be an effective and safe method for managing aphakia. Although we have not observed any IOL movement or iritis in this study, the possibility of these events occurring in a longer period should not be excluded.

Nonetheless, certain limitations of this study have been noted. The sample size of 14 patients was small, and the study focused on a limited number of indicators, and some were not quantified. Further, the follow-up period was short. Long term follow-up studies with a large sample size can be conducted in the future, which can provide more robust data on the long-term efficacy and safety of the technique.