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EW INTERNATIONAL 104 October 2017 by Liz Hillman EyeWorld Staff Writer If the bag is subluxated but otherwise intact, Dr. Jacob described the off-label use of a capsular hook. She makes a scleral flap in the zone of subluxation, inserts the capsular hook through the sclerotomy, under the iris but over the anterior capsule, hooking on the capsulorhexis. The haptic of the hook is then tucked into the sclera. "This is a form of sutureless capsular bag fixation," she said. "It fixes the entire IOL-bag complex to the scleral wall." If a dislocated IOL is a one-piece lens, Dr. Yamane said he would take it out, but if it is a three-piece lens and made of PMMA, he would leave it in and fixate it from there. The management technique could vary depending on the pa- tient's age, not just the type of IOL. Dr. Garg said that in older patients, they find this technique too diffi- cult, refer the case to a more experi- enced surgeon. "If you run into a complication there is no shame or fault in clean- ing up the vitreous, closing up the incision, and either referring to an- other surgeon who can do a second- ary IOL or learning the technique yourself and coming back at a later date and doing it," Dr. Ouano said. Dr. Garg said if the capsulorhex- is is intact and centered, optic cap- ture could be used, but even without optic capture the sulcus can be an acceptable place to situate a three- piece IOL. A one-piece IOL should not be placed in the sulcus. In a posterior capsular rent with intact capsulorhexis, Dr. Jacob said the surgeon could do optic capture with a three-piece IOL, but if there is not a good rhexis, the surgeon could use the same three-piece IOL and convert to glued ISHF (described later in this article). Intrascleral haptic fixation: What do young eye surgeons need to know? W e all have complications. Cataract surgery is a safe procedure with excellent outcomes, but every so often, things go wrong. The rhexis runs out, the posterior capsule tears, vitreous comes forward, your heart sinks. There is much debate about the best and safest technique for IOL placement in the absence of capsular support, when sulcus placement is no longer an option. Some surgeons think that anterior chamber IOL placement or iris fixation are perfectly acceptable options, while other surgeons think scleral fixation is best. Some surgeons think that suture fixation to the sclera is the best approach, while other surgeons raise concerns about suture breakage and erosion. When both the anterior capsule and posterior capsule are damaged, an increasingly popular method is to secure the haptics of a three-piece IOL inside the sclera without the use of sutures. This is known as intrascleral haptic fixation (ISHF). One exciting technique is to secure the haptics in scleral pockets and close those pockets with fibrin glue (the glued IOL technique, introduced by Amar Agarwal, MD). Another new, elegant technique is to dock the haptics internally into needles inserted from externally; the needles are then withdrawn and the externalized haptic ends are melted and nudged back into the sclera (the double- needle flanged haptic technique, introduced by Shin Yamane, MD). This month, we called upon several surgeons with extensive experience per- forming ISHF. Thanks to Dr. Agarwal, Soosan Jacob, MD, Dr. Yamane, Steven Safran, MD, Dean Ouano, MD, and Sumit "Sam" Garg, MD, for sharing their thoughts. Naveen Rao, MD, YES connect co-editor continued on page 106 YES connect Leading experts discuss their preferred techniques E very cataract surgeon, even the most experienced, will experience complications like capsule rupture or IOL dislocation, said Dean Ouano, MD, Coastal Eye Clinic, New Bern, North Carolina. There are several IOL fixation techniques that can be employed in the absence of capsular support or lens dislocation. Some of the world's leading experts on the topic—Amar Agarwal, MD, Dr. Agarwal's Eye Hospital, Chennai, India; Shin Yamane, MD, Yokohama City Uni- versity, Yokohama, Japan; Soosan Jacob, MD, Dr. Agarwal's Eye Hospi- tal, Chennai, India; Steven Safran, MD, Lawrenceville, New Jersey; Sumit "Sam" Garg, MD, medical director, Gavin Herbert Eye Institute, University of California, Irvine; and Dr. Ouano—gave a brief overview of their preferred IOL placement technique in the absence of capsular support, from sutured options to newer sutureless intrascleral hap- tic fixation (ISHF) procedures, and offered surgical pearls and broader perspectives on what could be in a surgeon's toolbox. Anterior chamber lenses, dislocated IOLs, and more If there is a lack of capsular support, such as when there is an anterior and posterior capsule tear with vitreous loss, traditional teaching would say to perform a vitrectomy and place an anterior chamber IOL. However, most of the physicians interviewed for this article said they don't use anterior chamber (AC) IOLs. Dr. Ouano said his ASC doesn't even keep them in stock. Dr. Jacob said AC IOLs involve making a larger incision and can complicate future surgeries, if needed. For example, an already complicated cataract surgery may sometimes be at higher risk of the need for endothelial keratoplas- ty. In this case, the AC IOL would preferably be removed, she said, while other ISHF techniques allow the IOL to remain in place. In this scenario, Dr. Yamane said he would recommend young eye surgeons put a three-piece IOL in the sulcus with optic capture or if Postop results of Dr. Agarwal's glued intrascleral haptic fixation technique Source: Amar Agarwal, MD Preop 1 week after glued IOL 2 months postop after PDEK 6/9 7 months postop after PDEK 6/6

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