Bios

Dr. Fernández is a vitreoretinal surgery fellow at Hospital Dr. Elías Santana, Santo Domingo, Dominican Republic.

Dr. Alfaro is a retina specialist at Centro Laser in Santo Domingo.

Dr. Felfeli is an ophthalmology resident at the University of Toronto. 

DISCLOSURES:
Dr. Fernández
and Dr. Alfaro, and Dr. Felfeli have no relevant finanancial relationships to disclose. 

Shin Yamane, MD, and colleagues in Japan in 2017 described a scleral intraocular lens haptic-fixation technique that didn’t use sutures or glue.1 They originally described the technique using two parallel 30-ga needles at 2 mm distance from the limbus. Since then, a number of subtle modifications of the

Yamane technique have emerged. Here’s ours.


27-gauge trocar cannulas

For our modification, we’ve substituted the 30-ga needles for 27-ga trocar cannulas. After we appropriately mark the entry sites with the Thornton marker, we mark a 2-mm area away from the site. We place the 27-ga trocar cannula in opposite directions (Figure 1).

When placing the cannula, a tunneled sclerotomy is a must so that the haptic can rest without extrusion. When the forceps correctly grasp the haptic, they need to be taken out in the same direction as the trocar cannula. For this step, we favor the
Grieshaber forceps (Alcon) rather than a needle because the forceps are easier to use. This cannula must be removed first followed by the forceps with the haptic grip, so they don’t get trapped inside. 

Now, the flange can be prepared with cautery, as described in the original technique. Bear in mind that the flange must have an appropriate size to rest inside the tunnel. Very large flanges may erode through the conjunctiva over time.

A crucial step in this approach is to verify the optic centration and tilt before closing the sclerotomies. Expect a slight degree of conjunctival edema the day after.

The 27-ga trocar cannulas are placed in opposite directions to externalize the haptics of a three-piece IOL with the help of forceps.

In the case we present, we also did a valved scleral tunnel to remove the nucleus. Our preference is to suture this tunnel to avoid unnecessary postoperative complications. Not all surgeons choose to make a full posterior vitrectomy. In addition to ensuring no peripheral breaks or tears are left unidentified, some have proposed a full posterior pars plana vitrectomy to possibly decrease the risk of postoperative macular edema and vitreous traction.2


Bottom Line

We’ve used this technique in a large number of cases with satisfactory results. The decentration and tilt in our patient population has been slightly higher than with other techniques, but with few or almost no postoperative complications. RS



REFERENCES

1. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology. 2017;124:1136-1142

2. Suren E, Kalayci M, Cetinkaya E, et al. Evaluation of the findings of patients who underwent sutureless flanged transconjunctival intrascleral intraocular lens implantation with or without pars plana vitrectomy. J Ophthalmol. 2021:4617583.