Eyeworld

APRIL 2020 | EYEWORLD | 57 C A relatively new IOL fixation technique might offer some specific advantag- es, but it also requires unique surgical maneuvers, according to surgeons. At the 2016 ASCRS ASOA Annual Meeting, Shin Yamane, MD, PhD, introduced this new method for intrascleral IOL fixation, using a transcon- junctival approach without sutures or glue. Since learning this technique, Nicole Fram, MD, has found it particularly useful when she wants to preserve conjunctiva and use small incisions. "In addition, we have found in our series that there is a lower incidence of vitreous hem- orrhage, as fewer sclerotomies are being made compared to scleral suture-fixated IOLs," Dr. Fram said. However, Dr. Fram noted that the proce- dure's two-point fixation requires the surgeon to understand unique surgical maneuvers to avoid tilt, pupillary capture, and decentration. "For this reason, counseling the patient pre- operatively that they may need a second surgery is warranted for surgeons early in the learning curve," Dr. Fram said. Brandon Ayres, MD, said haptic fixation has become his practice's most commonly used technique for IOL fixation. Dr. Ayres said he counsels patients about the various options for IOL fixation and tells them he will use the technique he thinks will work best for them. His use of suture fixation has become limited to situations where he needs to remove a large PMMA IOL or ACIOL, which already require a large wound. "The Yamane technique allows us to keep wound size smaller and is a faster technique, but there are still problems with centration and tilt," Dr. Ayres said. "When it comes to cen- tration and accuracy, I still think suture-fixated IOLs outperform haptic fixation, and in young patients with no sign of retinal pathology, I may still opt for a Gore-Tex-fixated IOL." IOL selection and fixation technique Dr. Yamane recommended using a 30-gauge thin-wall needle (TSK Laboratory), needle stabilizer (Geuder), and Yamane forceps (Kat- alyst Surgical), but other tools can also work to perform this fixation. Dr. Yamane recommends IOLs with PVDF haptics for this technique but any three-piece IOL could be used. Dr. Ayres described some of the differences in haptic materials. "Most of the three-piece IOLs use PMMA for their haptic material, and the PMMA is easy to kink and break," Dr. Ayres said. "The IOL from Carl Zeiss Meditec has haptics made of PVDF and are much more durable. For a sur- geon new to the haptic fixation technique, I'd stick with the CT Lucia 602 [Carl Zeiss Med- itec]; for more experienced surgeons it matters less what IOL you use." Dr. Fram said limited availability of the CT Lucia 602 has made that option less feasible. She also uses a 30-gauge thin-walled needle (Delasco), 25-gauge forceps (MicroSurgical Technology), anterior or posterior infusion, and a proper pars plana-assisted anterior vitrectomy technique. A vitrectomy is necessary for this technique, if not already performed in a prior surgery. The tools Dr. Ayres identified include a 27-gauge or thin-walled, 30-gauge needle, AC maintainer, micro-anterior segment forceps, anterior chamber or posterior chamber infu- sion, marking pen, caliper, and low-temperature cautery. He also mentioned the Scleral IOL Fixation Solutions Pack (MicroSurgical Tech- nology), which includes all needed equipment for the procedure except the IOL. IOL power considerations Dr. Yamane said the IOL power or A-constant considerations with the technique are almost the same as those for in-the-bag fixation. He calculates a 0.3 D myopic shift. by Rich Daly Contributing Writer Keys to intrascleral haptic fixation About the doctors Brandon Ayres, MD Cornea Service Wills Eye Hospital Philadelphia, Pennsylvania Nicole Fram, MD Clinical instructor Stein Eye Institute University of California, Los Angeles Los Angeles, California Shin Yamane, MD, PhD Assistant professor Department of Ophthalmology Yokohama City University Medical Center Yokohama, Japan continued on page 58 SKILL FOCUS

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