Surgical Modifications Can Avoid Postoperative Hypotonia

Doctor doing an exam or surgery
The technique employs self-resorbable sutures in intraocular lens implantation.

A modified surgical technique to implant the Carlevale (Soleko) intraocular lens (IOL), including the use of 27 G trocars and self-resorbing sutures, can reduce postoperative hypotonia, according to research results published in Retina. 

Implantation of IOLs in eyes that are missing capsular or zonular support are surgically challenging, the report explains. A new on-label hydrophilic acrylic monofocal IOL, Carlevale, was recently introduced to meet this challenge. The report shows a retrospective case series study that advises surgeons on how to employ a sutureless intrascleral fixation technique for the lens.

All surgical procedures were performed using a standard ophthalmic operating microscope. Both 2 o’clock and 8 o’clock positions were marked at the corneal limbus, with a 3 mm to 4 mm conjunctival incision made. One-half to two-thirds thickness scleral mini-frown incisions posterior to the libmus were made to create a scleral tunnel. This flap was lifted to create either 23 G or 27 G lamellar sclerotomy. 

The Carlevale IOL was inserted into the anterior chamber and the scleral flap was lifted and inserted to secure the haptic anchor. The conjunctiva was sutured using self-resorbing sutures. 

Sixteen eyes from 16 patients (8 women, 8 men) were included in this study (mean age, 70 years). No significant differences were found in visual acuity between postoperative and final follow-up measurements of corrected-distance visual acuity (mean, 0.83±0.8 logMAR vs 0.65±0.7 logMAR).

In terms of complications, 44% of patients experienced postoperative hypotonia (IOP <5 mm Hg) during postoperative days 1 through 3. One of these patients required additional tunnel sutures while another required scleral exploration and adjustive sutures. All other patients with hypotension spontaneously regained normal IOP. Other complications included postoperative macular edema 8 weeks post-surgery, temporal and nasal iris root defects, and anterior chamber and vitreous bleeding with tilted IOL.

For the first 7 cases, the surgeons decided to modify the surgical technique, using 27 G trocars in cases that were more complicated. This led to a significant reduction in postoperative hypotony. 


Januschowski K, Boden KT, Macek AM, et al. A modified sutureless intrascleral fixation technique for secondary intraocular lens implantation—a pilot study. Retina. Published online May 27, 2021. doi:10.1097/IAE.0000000000003220