Eyeworld

36 | EYEWORLD | SEPTEMBER 2023 ATARACT C Relevant disclosures Kim: None Pettey: Carl Zeiss Meditec Nakatsuka: None If there is retinal or corneal damage, such as a retinal tear, CME, or corneal endothelial decompensation, Dr. Kim said these conditions must be treated before IOL replacement or scleral refixation. "As long as there is no permanent damage, when the IOL is replaced and scleral refixation is properly executed, the patient can have an excellent outcome," Dr. Kim said, adding that he's been referred patients like these and they have done well after surgery. More advice on avoiding complications Dr. Kim said it's important to practice intrascler- al haptic fixation on artificial eyes, by attending skills transfer courses, and/or by finding and working with an experienced mentor. "I would also be cautious and selective when choosing which technique. Whether you try Dr. Yamane's original technique or some other variant, ask yourself, does this cause undue stress on the haptics? Although the PVDF haptics are strong, they are not indestructible, so I would be wary of techniques that exert significant stress on the haptics. Are you having trouble with certain steps such as cannulating the trailing haptic? Find a safe technique that flattens the learning curve," Dr. Kim said. Dr. Kim said many surgeons have person- alized the intrascleral haptic fixation technique with their own approach. He said he began us- ing the Sensar IOL (Johnson & Johnson Vision) a few years ago when access to the CT LUCIA 602 was limited. "With my modifications to the technique, I have been able to completely transition to the Sensar with excellent results despite the delicate PMMA haptics because of my gentle approach," he said. "Since I use the Sensar and not the CT LUCIA 602 as my primary IOL, I have been able to avoid the recently described rotisserie optic tilt complication. The surgeons who adopted my techniques in response to this problem have informed me that it has helped them switch to the Sensar. To be clear, the PVDF haptics of the CT LUCIA are the most forgiv- ing, thus the best IOL to use when learning the technique. However, once you master it, I would strongly advise trying other IOLs so you aren't trapped with just one lens." "If there is a flagpole sign, this means the optic is sagging posteriorly within the vitreous space, which would induce optic tilt and astigmatism. A self-check to know the IOL is placed correctly is when you observe the haptics are lying flat to the sclera when the needles are pulled out." Hypotony: Dr. Pettey and Dr. Nakatsuka said the Yamane technique requires the use of thin gauge needles (30 gauge) and long, oblique tunnels, but they are still prone to leaking. "On the extreme end of the spectrum," they wrote, "Marfan patients or others with very long axial length have thin sclera and are considerably more prone to leaking. Additionally, we often do these cases combined with retina providers, whose ports may not consistently seal." Recently Dr. Nakatsuka had a patient with a completely collapsed eye after the procedure, which he thought was likely due to a small leak from a retina port in combination with aqueous suppression that can occur with ciliary body trauma. "Hypotony is a more frequently en- countered complication and most often resolves as small leaks self-seal. However, long-term hypotony may lead to secondary complications, such as hypotony maculopathy. Initial medical treatment includes topical steroids, cycloplegics, or surgical closure of persistent leaks." Other complications: CME, ocular hyper- tension, iris trauma, and retinal trauma are common complications of any secondary lens replacement, regardless of technique, Dr. Pettey and Dr. Nakatsuka wrote. CME, they said, can be managed with topical NSAIDs and steroids or, if needed, intravitreal anti-VEGF or steroid injections. The Yamane technique, according to Dr. Pettey and Dr. Nakatsuka, is susceptible to retained viscoelastic, which can cause elevated IOP. Dr. Nakatsuka has experienced this in up to 20% of cases and usually treats it prophylacti- cally with oral acetazolamide or topical anti-hy- pertensives. As for retinal trauma, Dr. Kim said if nee- dles are positioned too posteriorly, in theory, they could pierce the peripheral retina and cause a retinal tear or detachment. Dr. Nakat- suka said extra care should be taken with small eyes that may have a shorter pars plana and a more anterior retina insertion leaving the retina vulnerable to puncture and trauma. Contact Kim: docdbk100@gmail.com Pettey: jeff.pettey@hsc.utah.edu Nakatsuka: Austin.Nakatsuka@hsc.utah.edu continued from page 35

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