Eyeworld

32 | EYEWORLD | FALL 2025 ATARACT C will lift up the conjunctiva and Tenon's to make sure they are completely free from the bulb." For scleral-sutured lenses, Dr. Crandall primarily uses enVista lenses (Bausch + Lomb) with the opening at the base of the haptic or the CZ70BD lens (Alcon) with the eyelet on the haptic. The CZ70BD lens is PMMA, so it requires a large incision. "I will lean toward this lens if I have a large corneal or scleral incision, often either in a patient who requires an extra- cap or intracap lens removal or a patient who needs an anterior chamber lens removed since they will already have a large incision." When a toric or multifocal lens is an option, Dr. Cran- dall said the enVista platform works well as a sutured lens, so there are more lens options for this technique. It is important not to overtighten the su- tures, he added. "I like to use a slip knot, and slowly tighten each side until the lens is sitting in a good position, then lock the knots and bury them. It is critical to completely bury the knot. Any free ends of this material have a very high risk of causing a conjunctival erosion." Dr. Crandall also noted advantages of Ya- mane fixation, particularly minimal conjunctival manipulation, and once you have experience, it is a much quicker technique. Since there are only small needle passes, there is a lower risk of hypotony, he said. "Advantages of direct scleral fixation are the wider range of lens options, and, in my hands, it has lower rates of tilting or decentration." For both techniques it is important to use infusion, Dr. Crandall said, adding that this can be either pars plana or anterior chamber infu- sion, to make sure the positioning, centration, and tension are right. Marking for lens place- ment is also critical, he said. The entry points of the haptics/sutures need to be directly 180 degrees apart from each other. Dr. Hart noted that choosing the right fixation technique could also depend on where the original cataract implant was placed. "If the original lens was placed within the capsular bag, which is where these are FDA approved to be, and the zonules have given out, that's one issue. That's an in-the-bag IOL dislocation. That's the most common thing we see these days, usually due to pseudoexfoliation syn- drome or trauma," he said. to open the conjunctiva. This is most common in patients who have had glaucoma surgery or retina surgery," he said. However, Dr. Cran- dall noted that he would hesitate to use this technique in very high myopes since the wider distance can put extra tension on the haptics, which can lead to haptic breakage or predispose lenses to rotisserie lens rotation (the lens optic twisting on the haptic). He also said that the scleral passes of the needles need to be of equal length to make sure the entry points are 180 de- grees apart. "Before burying the haptics, I like to keep about 1 mm of each haptic outside the eye and check the lens centration. If the lens is well centered but the haptic ends outside the eye are of unequal length, the longer one can be short- ened until they are equal," he said. "This way, the lens will stay centered when the haptics are buried." Early on, almost everyone makes the bulb of the melted haptic much larger than necessary, he said, adding that it takes very little bulb creation to hold the lens securely. Addition- ally, a large bulb will be more prone to erosion. "I like to push the bulb in until it is completely flush with the sclera," Dr. Crandall said. "I also continued from page 31 continued on page 34 The most common scenario: in-the-bag IOL dislocation due to pseudoexfoliation syndrome; Soemmering's ring cataract in visual axis above dislocated IOL Source: John Hart Jr., MD

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