MODIFIED DOUBLE BELT-LOOP TECHNIQUE WITH FOUR-POINT FIXATION: EARLY EXPERIENCE AND LESSONS FROM THE FIRST CASE

To describe technical caveats encountered during the first case of the double belt-loop technique for a severely subluxated intraocular lens (IOL) and to report a modification employing four-point fixation that may improve surgical stability and outcomes.

An academic teaching hospital.

A 64-year-old man who had undergone cataract surgery with in-the-bag IOL implantation two years earlier presented with sudden visual deterioration. Examination showed a markedly subluxated IOL with an intact eyelet visible in the pupillary center. The optic zone was misaligned with the visual axis, causing blurred vision.

Given the degree of subluxation and suspected vitreous entanglement around the IOL–capsular complex, pars plana vitrectomy with IOL repositioning was planned, considering possible IOL exchange or scleral fixation of the original lens.

Intraoperatively, the IOL was highly mobile in the supine position and sank into the vitreous cavity during vitrectomy. With the eyelet still visible, a 27-gauge needle preloaded with 6-0 Prolene was inserted 2 mm posterior to the limbus. The IOL was grasped through a paracentesis with intraocular forceps to guide the needle through the eyelet from beneath. The suture was externalized and withdrawn through the paracentesis. A second scleral entry, 4 mm apart and also 2 mm posterior to the limbus, was made. Attempted externalization through the side port failed due to mismatch between needle length and port position, so threading was completed in the anterior chamber.

The opposite end of the suture was brought out through the second bore, completing the first belt loop with two scleral fixation points. With the third point securing the IOL eyelet, a triangular loop provided excellent centration and stability. During manipulation, the remaining zonular support was lost, prompting creation of a second belt loop in a similar manner.

Low-temperature cautery formed knots partially embedded in the scleral tunnel near the entry site. Knot size was optimized to about 3–4 mm of Prolene, and slight over-tightening during cauterization compensated for reduced heat efficiency near the conjunctiva, achieving ideal final tension.

The belt-loop technique provides a straightforward and effective approach for rescuing a subluxated IOL, particularly those with eyelets or looped haptics. The described modification, employing two scleral fixation sites per loop, enhances IOL stability and reduces the risk of ciliary body contact associated with traditional fixation 1.5 mm posterior to the limbus.

This first experience also highlights the importance of planning needle length and paracentesis position, as a mismatch may prevent externalization for threading. Attention to knot size and slight over-tightening during cauterization can help achieve optimal final tension near the conjunctiva. Preoperative ex vivo trials to verify cautery effect, thread compatibility, and knot sizing are recommended to streamline future procedures.