Eyeworld

EW INTERNATIONAL 106 October 2017 videos, doing wet labs, talking to ex- perts, and performing first cases with an experienced mentor proctoring. Dr. Safran also thinks it's im- portant to do a peripheral iridotomy prophylactically in these cases to prevent reverse pupillary block. Confidence in sutured techniques Dr. Ouano's preferred ISHF is a Gore-Tex sutured technique with an Alcon CZ70BD lens through reverse Hoffman scleral tunnels. These tunnels, made superiorly and inferiorly, spare the conjunctiva for future glaucoma surgery, if needed, and Gore-Tex, which he switched to about 10 years ago, is well known for its high tensile strength and biocompatibility. "Many times, people have been turned away from the Hoffman scleral tunnel because they have the impression that it bleeds. If properly done," he said, which involves using a calibrated diamond knife making a 350-µm deep peripheral corneal incision, dissecting the tunnel at least 3.4–4 mm posteriorly, "it does not bleed because it's only an intras- cleral pocket and there's nowhere for blood to go. I think the most common error in creating Hoffman tunnels is making them too thin." Dr. Ouano finds this technique appropriate for all cases needing ISHF, but especially for aniridic patients, younger patients who need long-term lens implant security, and for those who need conjunctival preservation for future glaucoma surgery. "This technique is my fast- ball technique. I don't see any rea- sons why I would [choose] another one over this one because it's univer- sally translatable," Dr. Ouano said. Dr. Safran said that if there is a capsule or zonular defect present, he may supplement sulcus fixation or optic capture with one or two scleral such as a 95-year-old patient with a subluxated IOL due to pseudoexfoli- ation, he would try to fixate the IOL using the least invasive procedure, like lassoing the IOL-bag complex to the scleral wall. In a younger patient with a subluxated crystalline lens due to Marfan's syndrome, however, Dr. Garg would choose a fixation technique that isn't dependent on the long-term stability of the suture material. Rise of sutureless techniques Ten years ago, Dr. Agarwal presented his glued IOL technique, using a posterior chamber IOL whose hap- tics are externalized through scleral flaps and subsequently tucked into intrascleral (Scharioth) tunnels; the flap is then sealed with fibrin glue. Dr. Agarwal said a surgeon can use any acrylic hydrophobic three- piece IOL that is at least 13 mm in diameter with this technique. He recommended the injector tip be within the mouth of the incision and said to avoid using wound-as- sisted injection, which could lead to sudden, uncontrolled entry into the eye and potential IOL drop. Both Dr. Garg and Dr. Jacob said their preferred ISHF technique is this glued technique. Dr. Garg said he uses the Aaren EC3-PAL (Aaren Scientific, Ontario, Canada) in these cases; Dr. Jacob mentioned the SENSAR IOL (Johnson & Johnson Vision, Santa Ana, California), AcrySof (Alcon, Fort Worth, Texas), and STAAR AQ 2010 V (STAAR Surgi- cal, Monrovia, California). Advantages of this glued tech- nique, Dr. Agarwal said, include less pseudophacodonesis, less UGH syndrome, no suture-related compli- cations, and no tilt due to stabiliza- tion of the axial position through externalization of most of the hap- tics. With 10 years of follow-up, Dr. Agarwal said the results of glued IOL patients have been very good. "As long as there is an adequate amount of tuck of the IOL haptic, the IOL is going to remain stable forever," Dr. Jacob said. At the 2016 ASCRS•ASOA Symposium & Congress, Dr. Yamane first presented his flanged intrascler- al IOL fixation with double-needle technique, which involves using 30-gauge needles to externalize the haptics of the IOL, cauterizing each haptic end, and tucking them into intrascleral tunnels. His preferred IOL for this technique is the X-70 (Santen, Osaka, Japan). He now only uses this flanged technique for cases requiring ISHF. Dr. Safran has sutured lenses and has used Dr. Agarwal's glued technique—or the flap-and-groove technique, as Dr. Safran calls it—but now, 99% of his ISHF cases are done using the Yamane double-needle technique. Dr. Safran thinks this technique offers greater fixation than the flap- and-groove (glued IOL) technique. He had a few flap-and-groove cases where the haptics were pulled out of the scleral tunnel, leading him to secure those cases with Prolene su- tures, which are at risk for extrusion. "That doesn't happen with the flanged haptic technique; it's almost impossible to pull that haptic back into the eye," he said, noting that there is little haptic externalized in the flange, making external extru- sion also less likely. Another advantage is that the relatively small, 30-gauge sclerotomy created by the needle in the newer technique fits very securely around the haptic and creates less risk for hypotony, which can be particularly important if the ISHF is combined with other procedures like DSAEK or iris repair or if the patient is a high myope prone to this problem. "I've also seen less tilt and decentration with the double-needle technique than with the flaps and grooves or any other technique I've used," Dr. Safran said. "I think there are rare situations where it's good to know the flap- and-groove technique, but they're becoming less and less," Dr. Safran said later. Dr. Jacob said that while she has not tried the Yamane flanged technique, she thinks it's a good concept. However, she worries about the presence of needles within the eye. She also pointed out that if both haptic ends are not cauterized to equal amounts, it could lead to decentration. In adopting either of these techniques, both Dr. Jacob and Dr. Safran emphasized the importance of good vitrectomy skills, watching Intrascleral continued from page 104 Figure A: Subluxated cataract with the Jacob glued capsular hook (Morcher, Stuttgart, Germany) engaging the rhexis margin. Figure B: Postoperative image showing the hook engaged onto the rhexis rim with a well-centered IOL. The glued capsular hook is not FDA approved. Source: Soosan Jacob, MD Watch Steven Safran, MD, perform the double-needle flanged haptic fixation technique. continued on page 107

• Blank Page
• Blank Page (1)