TECHNIQUE

Glued intraocular lens scaffolding

for Soemmerring ring removal in aphakia
with posterior capsule defect
Priya Narang, MS, Amar Agarwal, MS, FRCS, FRCOphth, Dhivya A. Kumar, MD

We describe using the glued intraocular lens (IOL) scaffolding technique to remove Soemmerring
ring during secondary IOL implantation in aphakic eyes with associated posterior capsule defect
following previous pediatric cataract surgery. Vitrectomy is performed, and the remnants of the
posterior capsule are removed from the visual axis. A 3-piece foldable IOL is injected below the
Soemmerring ring, and glued transscleral haptic fixation of the IOL is performed. The Soemmer-
ring ring is dislodged from the periphery with a Sinskey hook and brought into the center of the
pupil over the surface of the IOL optic, where it is emulsified with the phacoemulsification probe.
The optic of the preplaced IOL acts as a scaffold and prevents dislodgement of Soemmerring ring
material into the vitreous cavity during emulsification. Placement of a secondary IOL can be suc-
cessfully accomplished in selected patients.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2015; 41:708–713 Q 2015 ASCRS and ESCRS
Online Video

Soemmerring ring formation is a special type of sec-
ondary cataract, and various techniques have been
described for in-the-bag secondary intraocular lens
(IOL) implantation following removal of Soemmer-
ring ring.1–4 Glued IOL scaffolding5 has been
described to facilitate nuclear emulsification in cases
of inadvertent posterior capsule dehiscence with inad-
equate sulcus support for IOL implantation. In this
technique, the nuclear fragments are levitated into
the anterior chamber and a glued IOL procedure6 is
performed and followed by emulsification of the nu-
clear fragments by the phacoemulsification probe, as
Submitted: September 5, 2014.
Final revision submitted: October 19, 2014.
Accepted: November 26, 2014.
From the Narang Eye Care and Laser Centre (Narang), Ahmedabad,
and Dr. Agarwal’s Eye Hospital and Eye Research Centre (Agarwal,
Kumar), Chennai, India.
Corresponding author: Amar Agarwal, MS, FRCS, FRCOphth,
Dr. Agarwal’s Eye Hospital and Eye Research Centre, 19,
Cathedral Road, Chennai- 600 086, India. E-mail: dragarwal@
vsnl.com.
in the IOL scaffold technique.6,7 We describe the appli-
cation of the glued IOL scaffold procedure in cases of
aphakia associated with the presence of Soemmerring
ring that are complicated by posterior capsule dehis-
cence and inadequate sulcus support that would limit
successful IOL implantation.
SURGICAL TECHNIQUE
The preoperative preparations are the same as those in
a normal cataract procedure, and the surgery is per-
formed under peribulbar anesthesia. The site where
Soemmerring ring is apparently less dense is chosen
to frame the scleral flaps for glued IOL surgery
(Figure 1, A). This is done to facilitate the subsequent
sclerotomy incision and to prevent accidental
dislodgement of ring material with the tip of the nee-
dle. As in a normal glued IOL procedure,5 2 partial-
thickness scleral flaps are made 180 degrees opposite
each other. Infusion is introduced into the eye, and a
20-gauge needle is used to create a sclerotomy incision
1.5 mm behind the limbus under the scleral flaps. A
23-gauge vitrectomy cutter is introduced from the scle-
rotomy incision or from the side-port incision, and
vitrectomy is done by switching the vitrector between

708 Q 2015 ASCRS and ESCRS http://dx.doi.org/10.1016/j.jcrs.2015.02.020

Published by Elsevier Inc. 0886-3350
 TECHNIQUE: GLUED IOL SCAFFOLDING FOR SOEMMERRING RING REMOVAL 709

Figure 1. Intraoperative details depicting the method of creation of scaffold with IOL for Soemmerring ring. A: Two partial scleral thickness flaps
made 180 degrees opposite each other. Infusion introduced into the eye. B: Vitrectomy done to clear the vitreous from the anterior chamber and
to release the adhesions around the pupil. C: A 3-piece foldable IOL loaded into the cartridge and introduced from the corneal tunnel. Tip of the
leading haptic is grasped with the glued IOL forceps that is introduced from the sclerotomy incision. D: The IOL is unfolded slowly while the tip
of the haptic is grasped. E: The leading haptic is externalized, and the trailing haptic is flexed inside the eye. F: The trailing haptic externalized
from the right sclerotomy incision.

cutting and aspiration modes to clear the vitreous from
the anterior chamber and release adhesions of the
capsule to iris tissue if present (Figure 1, B).
A 2.8 mm corneal tunnel is created, and a 3-piece
foldable IOL is loaded on the cartridge. The IOL is
slowly unfolded in the eye (Figure 1, C), and simulta-
neously a glued IOL forceps is introduced from the
sclerotomy site. The forceps grasps the tip of the
leading haptic and after the entire IOL has unfolded
(Figure 1, D), the leading haptic is pulled and external-
ized (Figure 1, E). The trailing haptic is flexed and
introduced inside the eye. The handshake technique8
is then performed to externalize the trailing haptic, be-
ing careful that the tip of the haptic is pulled so the IOL
optic forms the base of the Soemmerring ring, bringing
it above the surface of the IOL into the anterior cham-
ber. After both haptics are externalized (Figure 1, F),
Scharioth scleral pockets5,9,10 are created with a
26-gauge needle and the haptics are tucked. Vitrec-
tomy is done at the sclerotomy sites to cut any protrud-
ing vitreous strands.
In cases of intraoperative pupillary constriction, iris
hooks are used (Figure 2, A) to enhance visualization
of the Soemmerring ring, which is located peripherally,
and also in cases with inadequate pupil dilation. The
entire Soemmerring ring material is dislodged from
the periphery (Figure 2, B) using a Sinskey hook and
brought into the center (Figure 2, C). In cases with cen-
tral dislodgement of Soemmerring ring, iris hooks may
not be required but their use is still beneficial as they
eliminate the chance of missing ring material in the pe-
riphery. In these cases, the Soemmerring ring material is
pushed aside above the surface of iris along the anterior
chamber angle and the glued IOL procedure is per-
formed. This ensures that the ring material does not
interfere with the intraoperative view around the pupil
margin. The iris hooks are removed (Figure 2, E), and
the phacoemulsification probe is introduced into the
anterior chamber (Figure 2, F); the Soemmerring ring
is emulsified under low-flow settings.
In cases of widely dilated pupils,11 after Soemmer-
ring ring material is dislodged into the center of the
pupil, the pupil should be constricted with intracam-
eral pilocarpine. Depending on the surgical scenario,
narrowing the pupil size by removing the iris hooks
or using pilocarpine at this stage prevents inadvertent
loss of ring material from and around the edges of the
IOL into the vitreous cavity.
Stromal hydration is done to seal all the corneal
incisions, and the infusion cannula is removed from
the eye. Fibrin glue is then applied beneath the scleral
flaps, followed by sealing of the conjunctival perito-
my incision. To secure closure of the corneal wound,
a 10-0 suture with nylon is recommended.

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710 TECHNIQUE: GLUED IOL SCAFFOLDING FOR SOEMMERRING RING REMOVAL

Figure 2. Dislodgement and emulsification of Soemmerring ring. A: Iris hooks are introduced to dilate the pupil and facilitate visualization of the
Soemmerring ring. B: Soemmerring ring material is dislodged from the periphery with the help of a Sinskey hook. C: Soemmerring ring is
brought into the center of the pupil. D: Iris hooks are removed. E: Phacoemulsification probe is introduced inside the eye, and the Soemmerring
ring is emulsified. F: Soemmerring ring is emulsified completely.

At the end of surgery, a subconjunctival injection of there was no statistically significant reduction in the
0.5 mL gentamicin and 0.5 mL dexamethasone is in- cell count after surgery (PZ.109).
jected into the inferior fornix away from the site of In 1 eye with a long axial length, an anterior sclerot-
scleral flaps and sclerotomy (Video 1, available at omy had to be made because the length of the external-
jcrsjournal.org). ized haptic available for tucking was too short. During
this procedure, an iris defect occurred in the periphery
of the iris (Figure 3, A), which was subsequently
RESULTS
sutured by pupilloplasty with 10-0 polypropylene
The glued IOL scaffolding technique was performed in
3 eyes of 3 patients for postoperative aphakia with
Soemmerring ring and associated posterior capsule
defect (Table 1). In all 3 cases, the extent of the Soem- Table 1. Demographic data and postoperative outcomes of the
merring ring was more than 5 clock hours. The mean glued IOL scaffolding in eyes with Soemmering ring.
preoperative and postoperative corrected distance vi-
sual acuity (CDVA) at the 3-month follow-up was Demographic/Outcome Case 1 Case 2 Case 3
0.38 G 0.9 (SD) and 0.55 G 0.09 (Snellen decimal equiv- Age (y)/Sex 26/M 19/M 34/M
alent), respectively. The mean postoperative specular Preop*
microscopy cell count was 2506 G 77.7 cells/mm2. UDVA 0.02 0.02 0.05
Two of the 3 eyes maintained the preoperative CDVA 0.33 0.33 0.5
CDVA, and 1 eye gained 1 line after surgery. There Postop CDVA at 3 months* 0.5 0.5 0.66
was no loss of CDVA in any eye. Lack of further Preop IOP (mm Hg) 11 12 11
improvement in CDVA in the cases was due to preexist- Postop IOP (mmHg) 12 10 11
ing amblyopia. There was no significant change Specular microscopy
(PZ.655) in intraocular pressure and no incidence of Preop (cells/mm2) 2744 2445 2566
Postop (cells/mm2) 2561 2417 2540
intraocular hyphema or Soemmerring ring segment
drop into the vitreous cavity. Postoperatively, the IOL CDVA Z corrected distance visual acuity; IOP Z intraocular pressure;
was clinically well centered in the 3 eyes and the cor- Preop Z preoperative; Postop Z postoperative; UDVA Z uncorrected
distance visual acuity
neas were clear. Although specular microscopy showed *Snellen decimal equivalent
a cell loss of 2.9% G 3.2% in the postoperative period,

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 TECHNIQUE: GLUED IOL SCAFFOLDING FOR SOEMMERRING RING REMOVAL 711

Figure 3. Iris defect created because of anterior sclerotomy in an eye with a long axial length. A: Iris defect seen. B: Pupilloplasty to seal the
iris defect.

(Prolene) (Figure 3, B) using a modified Siepser slip-
knot technique.
DISCUSSION
In aphakic adult patients who have cataract surgery in
childhood, the Soemmerring ring can often be dense as
the lens substance in young eyes has greater regenera-
tive capacity, which favors the formation of a dense
ring.12
In 1999, Wilson et al.1 described a technique that
used a vitrector probe to remove Soemmerring ring
material. In 2008, Gimbel et al.2 described a method
in which an anterior capsulotomy was performed
with a cystotome peripheral to the fibrosed original
capsule opening, followed by removal of the
Soemmerring ring and placement of the IOL haptics
in the capsular bag. In 2012, Grewal and Basti3
described a modified method for removal of Soem-
merring ring using viscoexpression and a 2-handed
maneuver to divide it. Our method differs from previ-
ously described techniques in that the vitrectomy
probe is used to cut the synechias and perform
adequate anterior vitrectomy to cut the protruding vit-
reous strands and the residual posterior capsule. This
is done carefully so the posterior capsule supporting
Soemmerring ring is not disturbed and does not
dislodge Soemmerring ring into the vitreous cavity.
A 3-piece foldable IOL is positioned in the eye using
the glued IOL scaffold technique, followed by emulsi-
fication of the Soemmerring ring with the phacoemul-
sification probe. The IOL optic acts as a scaffold and

Figure 4. Preoperative and postoperative images. A: Preoperative image demarcating the edges of a posterior capsule defect (yellow arrows) and
the synechias (red arrows). B: Image of the same eye on the third postoperative day.

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712 TECHNIQUE: GLUED IOL SCAFFOLDING FOR SOEMMERRING RING REMOVAL
Figure 5. A: Soemmerring ring with posterior capsule defect. B: Centrally displaced Soemmerring ring.
facilitates the emulsification procedure. This technique
effectively compartmentalizes the eye and almost
eliminates the chance of inadvertent entrapment of
the vitreous strand in the phacoemulsification probe
during the suction and emulsification phase of the pro-
cedure. It also maintains the advantages of a closed-
chamber technique adopted for cataract surgery. The
subsequent phacoemulsification eliminates the chance
of dislodging the Soemmerring ring material from the
space around the edges of the IOL optic into the vitre-
ous cavity.
Techniques have been described to mobilize the
dense Soemmerring ring material and manually
fragment it followed by viscoexpression with the
profuse use of an ophthalmic viscosurgical device
(OVD).3 Introducing continuous infusion in the
eye with the trocar or an anterior chamber
maintainer helps to maintain the stability of the
globe throughout the procedure. If an anterior
chamber maintainer is introduced, care is taken so
the fluid does not flow directly over the Soemmer-
ring ring material. Although in the later stage,
adequate coating of the endothelium can be
achieved with an OVD during emulsification, the
advantage is that the anterior chamber is formed
as the optic occludes the opening of the posterior
capsule and prevents OVD seepage into the
vitreous cavity.
In the cases we saw in our center, pediatric cataract
surgery had been performed in the children at various
ages (between 1 year and 6 years). The patients were
left aphakic, and they had a history of wearing correc-
tive glasses intermittently and contact lenses at a later
age. In 1 case, we found a partial Soemmerring ring
that resembled a crescentic sausage (Figure 4, A), as
J CATARACT REFRACT SURG - VOL 41, APRIL 2015
described by Stokoe.12 In a second case, there was an
annular ring-like formation (Figure 5, A) that was
nearly complete and in the third case, a central
dislodgement of the Soemmerring ring (Figure 5, B).
No proliferation of cells was detected on the anterior
vitreous face.
Wilson et al.1,13 suggest that during secondary
IOL implantation, if Soemmerring ring is present
in focal areas only and is enclosed between the ante-
rior and posterior capsules, it can be left in place.
However, if focal areas of the ring are associated
with the presence of a posterior capsule dehiscence,
the ring must be removed without being dislodged
into the vitreous cavity. The situation is worsened
when the sulcus support is inadequate. Application
of a glued IOL scaffold technique at this stage helps
to restore the benefits of small-incision cataract sur-
gery along with successful implantation of an IOL
and proper evacuation of the Soemmerring ring
(Figure 4, B).
Difficulty in visualizing the haptic because of the
presence of a Soemmerring ring was not encoun-
tered in any case. Careful disposition of the Soem-
merring material into the angle or over the surface
of iris in the anterior chamber can be done to solve
this problem if it occurs during the surgical
procedure.
To conclude, unique to our technique is the use of
the glued IOL scaffold procedure to prevent inadver-
tent partial or complete loss of Soemmerring ring
into the vitreous cavity in the presence of an open pos-
terior capsule. In addition, performing the glued IOL
procedure initially helps to create an artificial posterior
capsule that facilitates safe emulsification of the ring
material by the phacoemulsification probe.
 TECHNIQUE: GLUED IOL SCAFFOLDING FOR SOEMMERRING RING REMOVAL
WHAT WAS KNOWN
 Glued IOL scaffolding is a technique to emulsify the nu-
clear fragments safely in eyes with posterior capsule
dehiscence with inadequate sulcus and iris support that
restricts the preplacement of an IOL, as in an IOL scaffold
technique. Nuclear fragments are levitated into the ante-
rior chamber, and the glued IOL procedure is performed
initially, which acts as a scaffold for the subsequent nu-
clear emulsification.
 Many techniques have been described for in-the-bag
placement of an IOL in cases of aphakia associated with
Soemmerring ring.
 A technique has not been described for cases of Soem-
merring ring associated with posterior capsule rupture,
secondary aphakia, and inadequate sulcus support for
the safe placement of an IOL.
WHAT THIS PAPER ADDS
 Glued IOL scaffolding was performed in eyes with second-
ary aphakia and Soemmerring ring associated with poste-
rior capsule defect with a favorable outcome.
 If performed carefully, it a safe technique and the IOL optic
acts as an artificial posterior capsule, preventing loss of
Soemmerring ring material into the vitreous cavity during
the procedure.
 The technique allowed proper placement of an IOL even
when there was inadequate sulcus support.
REFERENCES
1. Wilson ME Jr, Englert JA, Greenwald MJ. In-the-bag second-
ary intraocular lens implantation in children. J AAPOS 1999;
3:350–355
2. Gimbel HV, Venkataraman A. Secondary in-the-bag intraocular
lens implantation following removal of Soemmering ring
contents. J Cataract Refract Surg 2008; 34:1246–1249
3. Grewal DS, Basti S. Modified technique for removal of Soem-
merring ring and in-the-bag secondary intraocular lens place-
J CATARACT REFRACT SURG - VOL 41, APRIL 2015
713
ment in aphakic eyes. J Cataract Refract Surg 2012; 38:739–
742
4. Agarwal A, Jacob S, Agarwal A, Narasimhan S, Kumar DA,
Agarwal A. Glued intraocular lens scaffolding to create an artifi-
cial posterior capsule for nucleus removal in eyes with posterior
capsule tear and insufficient iris and sulcus support. J Cataract
Refract Surg 2013; 39:326–333
5. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A,
Srinivasan S. Fibrin glue–assisted sutureless posterior chamber
intraocular lens implantation in eyes with deficient posterior
capsules. J Cataract Refract Surg 2008; 34:1433–1438
6. Kumar DA, Agarwal A, Prakash G, Jacob S, Agarwal A,
Sivagnanam S. IOL scaffold technique for posterior capsular
rupture [letter]. J Refract Surg 2012; 28:314–315
7. Narang P, Agarwal A, Kumar DA, Jacob S, Agarwal A, Agarwal A.
Clinical outcomes of intraocular lens scaffold surgery; a one-year
study. Ophthalmology 2013; 120:2442–2448
8. Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S,
Agarwal A. Handshake technique for glued intrascleral haptic
fixation of a posterior chamber intraocular lens. J Cataract
Refract Surg 2013; 39:317–322
9. Gabor SGB, Pavilidis MM. Sutureless intrascleral posterior
chamber intraocular lens fixation. J Cataract Refract Surg
2007; 33:1851–1854
10. Jacob S, Agarwal A, Agarwal A, Narasimhan S. Closed-cham-
ber haptic reexternalization through fresh sclerotomy for poste-
riorly displaced sclerotomy and inadequate haptic tuck in glued
posterior chamber intraocular lenses. J Cataract Refract Surg
2015; 41:268–271
11. Osher RH, Snyder ME, Cionni RJ. Modification of the
Siepser slip-knot technique. J Cataract Refract Surg 2005;
31:1098–1100
12. Stokoe NL. Soemmerring’s ring; a review and three illustrative
cases. Br J Ophthalmol 1957; 41:348–354. Available at: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC509557/pdf/brjopthal00
474-0048.pdf. Accessed December 13, 2014
13. Wilson ME Jr, Hafez GA, Trivedi RH. Secondary in-the-bag
intraocular lens implantation in children who have been aphakic
since early infancy. J AAPOS 2011; 15:162–166
First author:
Priya Narang, MS
Narang Eye Care & Laser Centre,
Ahmedabad, India