Eyeworld

SEPTEMBER 2023 | EYEWORLD | 35 C References 1. Yamane S, et al. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology. 2017;124:1136–1142. 2. Scoles D, Wolfe J. Laser to the Rescue. American Academy of Ophthalmology ONE Network. Dec. 15, 2022. www.aao.org/ education/1-minute-video/ laser-to-rescue-2. its own right and most often requires a revision to address the negative sequela." To avoid UGH, Dr. Pettey and Dr. Nakatsuka said to ensure the lens is centered without tilt after viscoelastic removal. "Always place at least one iridotomy, and consider placing haptics further from the limbus (e.g., 2.5–3 mm instead of 2 mm), especially in cases where the iris is highly mobile and floppy. Although controver- sial, one can consider shortening the haptics," Dr. Nakatsuka wrote. Dr. Kim also said that if the needles are pierced through the sclera too anteriorly, it could cause the haptics to rub the overlying uveal tissue resulting in UGH or CME. IOL decentration or tilt: This complication can occur due to asymmetrical scleral tunnels at different lengths or angles, Dr. Pettey and Dr. Nakatsuka said. To ensure proper centration, Dr. Pettey and Dr. Nakatsuka advised "metic- ulous pre-surgical marking with calipers and a Mendez ring to ensure targets are precisely 180 degrees apart, and mark the center of the cornea. Close observation of the scleral indenta- tion during the docking procedure can alert the surgeon to an asymmetry between each side to ensure symmetric tunnels. Ensure that the globe is firm during the scleral needle insertion and avoid hypotony throughout the procedure. We recommend maximal pupil dilation to facilitate continued on page 36 Figure 3: Lens/optic capture can occur after intrascleral haptic fixation, being more common with floppy irises. Source (all): Jeff Pettey, MD, and Austin Nakatsuka, MD visualization during the docking step." (See Figure 2). Dr. Nakatsuka experienced a few cases of rotation of the haptic at the optic-haptic junction with the CT LUCIA lens (Carl Zeiss Meditec), although it appears to be isolated to a particular batch of these lenses. Dr. Kim also mentioned the recent issues observed with the CT LUCIA lenses, which he described as a "ro- tisserie rotation." "Surgeons have observed that these haptics are not completely fused within the optic, causing them to rotate," he said. "There is a technique called laser-lock, 2 which uses the endolaser to essentially melt the haptic to the optic to address this." Lens/optic capture: Dr. Nakatsuka has experi- enced a few cases where the lens optic moves in front of the iris pupil. Floppy iris appears to be a risk factor for this complication (see Figure 3). In addition to similar pearls for avoiding UGH, Dr. Pettey and Dr. Nakatsuka said that treatment options include miotics, supine positioning with miotics, laser iridoplasty, or surgical pupilloplasty to prevent the lens from coming forward. They said some surgeons recommend multiple peripheral iridotomies but noted the efficacy is still unclear. Dr. Yamane recommends a 7.0-mm optic X-70 IOL (Santen) to avoid pupillary capture of the optic, but Dr. Kim said optic capture can still occur if the IOL is too close to the iris plane. "Rather than placing the needles 2 mm posterior to the limbus, I prefer to place them further back at 2.5 mm and target –0.50 D for a plano refractive result," he said. "With this mod- ification, along with always placing a temporal surgical peripheral iridectomy to avoid reverse pupillary block, I have not experienced any cases of optic capture." Flagpole sign: Dr. Kim said that there needs to be adequate scleral support for the haptics with this technique. "If there is inadequate scleral support for the haptics because the needles are not tunneled through the sclera, the haptics may point up in a more vertical orientation, which I've coined the 'flagpole sign,'" he said.

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