Eyeworld

36 | EYEWORLD | FALL 2025 ATARACT C Contact Crandall: dacrandall@gmail.com Hart: j.c.hartjr@sbcglobal.net get Z syndrome with a Crystalens (Bausch + Lomb), it's difficult to fix. They often need to be explanted, and Z syndrome causes damage to zonules. He also noted that using a Yamane tech- nique, you may need to look out for the risk of tilted IOLs or rotisserie syndrome (optic twisted on haptic). "This is definitely a rescue. This is not re- fractive surgery," he said. "People come in with multifocal or toric lens, and in those situations, it's a lot more challenging to properly put that in from an intrascleral haptic fixation stand- point than to suture it in place." This takes patient counseling, he said. If the patient has a lot of astigmatism, taking out a toric that's correcting a large portion of that can be a big issue for them. Even with multi- focal lenses, people get used to them. There's no 3-piece alternative to do intrascleral haptic fixation with. "Since I do all of them, from a techni- cal standpoint, fixation with sutures is easier technically than intrascleral haptic fixation," Dr. Hart said. "I think for people looking to pick something up, it's well within their skillset." Physicians often want to learn this in case something happens during cataract surgery, he said, adding that he explains that during cataract surgery is not usually when you want to perform this. "The calculations are differ- ent. Implants are different. It's going to take you longer. You want to take your time. It's not topical anesthesia anymore because it's going to take longer. For most of these, I like to do gen- eral anesthesia so I know the patient is comfort- able and will wake up seeing well." Dr. Hart added that he usually schedules secondary IOL fixation cases for the first case of the day. "I schedule them for an hour, but that's counting the fact that I'm using general anes- thesia," he said. "These are things that can be planned. In the past, people were told, 'Just put in an anterior chamber lens or throw in whatev- er lens you can after the cataract surgery,' and I don't think that's the way we feel anymore because in a lot of cases, you're going to be compounding the error." through the pars plana or in that area, you always have that risk. For intrascleral haptic fixation, it's required that you do a thorough vitrectomy, he said. The recommendation is that you do a pars plana vit- rectomy, but you can do an anterior vitrectomy because the implant is going to be dangling into the vitreous cavity, and you don't want it to be caught up in vitreous. It's also very important to be able to recog- nize dead bag syndrome, he said. If it is a dead bag, the lens and bag should be removed, and you should do intrascleral haptic fixation. He added that when he first started doing secondary IOL fixation, he saw a lot more cases where there were problems with the lens in the sulcus and the haptics of the sulcus-fixated lens had eroded through the zonules. In those situations, we were suturing to the iris. "The downside is there's a somewhat higher rate of CME," he said. There are all kinds of special circumstances, Dr. Hart said. "Some lenses create more prob- lems than others." For example, he said if you continued from page 34 Relevant disclosures Crandall: None Hart: None Dislocated single-piece IOL and Cionni CTR in the bag Source: John Hart Jr., MD

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