Comment on: Double-flanged polypropylene technique: 5-year results

We commend Canabrava and Carvalho for publishing 5-year data on a cohort of 71 eyes undergoing surgery for inadequate capsular support using double-flanged polypropylene suture.1 They reported on 3 techniques using double-flanged 5-0 polypropylene suture to secure intraocular lenses (IOLs) or a capsular tension segment with a median follow-up of approximately 2 years (range 4 months to 5 years). Successful intrascleral placement was achieved for 150 of 173 (86.7%) flanges. Four flanges were internalized and required repeat corrective surgery. A total of 6 of 13 (46.2%) flanges left in the sub-Tenon space had to be surgically revised because of exposure or to prevent exposure. In view of this, it is important to emphasize that any suture, knot, or flange remaining in the subtenon space poses a significant risk for exposure and, therefore, endophthalmitis. There have been a vast number of publications on the topic of surgical management of poor capsular support and secondary IOLs over the years. Indeed, Yuan et al. identified over 900 peer-reviewed articles from 1980 to 2020.2 This is an area of creativity, ingenuity, and constant change, with surgeons striving to achieve less invasive, safer, and more efficient approaches. With new techniques described routinely, long-term safety and efficacy data are key, and only 3% publications in this field report follow-up beyond 5 years.2 Maggi and Maggi should be correctly recognized as the first to present polypropylene flanges in 1997.3 Beginning in 1989, they described creating a new lens with 8-0 polypropylene knotted to 3 Gore-Tex loops in 23 eyes. The needle at the end of the polypropylene is passed ab interno, giving 3 points of fixation. Cautery is used to cut the suture flush with the scleral surface and create a flange. A 2020 report from the American Academy of Ophthalmology concluded that no single best IOL implantation technique exists in the absence of zonular support.4 The various techniques seem to have comparable visual acuity outcomes and safety profiles. Nevertheless, all secondary IOL approaches have their advantages and disadvantages. The Canabrava technique has significant advantages in that there is no conjunctival dissection required, no scleral dissection needed, and it uses readily available materials. The manipulation to dock the polypropylene suture into the needle in the case of the Canabrava technique is also likely less cumbersome for most surgeons than the docking of the IOL haptics into the needle as is required in the Yamane technique. We wonder whether clarification of the data presented in Table 2 is warranted.1 The total of the row describing the sub-Tenon flanges does not sum to 13 as the authors indicate. When accounting for the exposed and irritated flanges within the sub-Tenon group, adding the columns for the flange conditions gives a total of 168 (not 173). Likewise, the exposed and irritated flanges appear to be accounted for twice in the total of the final column. Finally, by our count, the text supports a cohort totaling 167 flanges, rather than 173.

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