**9.2 Sutureless scleral fixation intraocular lens implantation**

Sutureless techniques have also been developed to avoid potential complications that can rise from suture fixation including knot erosion, endophthalmitis, and suture breakage. Agarwal described scleral fixation with glued haptic fixation [30]. Scleral flaps are created 180 degrees apart and a sclerotomy is made within the flap. The haptics of a 3-piece IOL are then externalized via the sclerotomy and glued into place with the flap closing over the haptic. Several complications can occur with the haptic including extrusion, dislocation, and breakage. Haptic-related complications seen include haptic extrusion, haptic dislodgement, broken haptic and subconjunctival haptic. Most of the haptic-related complications are due to improper scleral tucking [31].

Yamane et al. described a technique whereby three-piece IOL haptics are passed through a 27 gauge needle which guides the haptic through a tunneled sclerotomy [32]. The externalized haptic is than cauterized to create a bulb at the tip of the haptic to allow for improved stability within the scleral tunnel. Short-term outcomes from Yamane's initial study reported no IOL dislocation at 1.5 years. Reported complications include optic capture of the iris (8%), vitreous hemorrhage (5%) and cystoid macular edema (1%). It is important to note that the Yamane technique utilizes the EC-3 PAL three-piece intraocular lens, which has more durable and malleable haptics compared to the 3-piece IOLs commonly used in the United States. Higher rates of IOL dislocation have been reported with the Yamane technique when non-EC-3 PAL 3-piece IOLs are used. Several modified Yamane techniques have been since described including the use of 27 gauge trocars instead of a needle to externalize the haptics. Long-term follow-up has yet to be presented since these techniques have only been introduced in the past decade.
