“This has really become my go-to technique because I find it not only very effective, but it can be incredibly efficient once the technique is mastered,” said Christina Weng, MD, MBA, about trocar-based sutureless scleral-fixated IOL surgery (aka “modified Yamane”). During Friday’s Retina Subspeciality Day, she shared pearls for her favorite approach to secondary IOL placement in eyes that lack capsular support.
Preoperative pearls. The ideal patient has a healthy, mobile conjunctiva. It’s important to avoid creating a bullous conjunctiva with a retrobulbar block because it can interfere with marking and haptic externalization. Have IOL options, she advised, by getting preoperative calculations for multiple IOLs. Dr. Weng said that she is partial to the CT Lucia 602 but also has had success with the MA60AC and ZA9003.
If you’re externalizing the haptics 2.5 mm posterior to limbus, aim for –0.5 D to plano target. “This will bring about good refractive outcomes in my experience, and it’s also been endorsed by my cataract colleagues,” Dr. Weng said.
Intraoperative pearls. Learning from her own early experiences with the technique, she shared some of her top intraoperative tips.
- Placement of the trocar-cannulas should be considered before starting, she said.
- Marking is the most important step. She tries to get a dry field and centers around the limbus—not the pupil—to make marks exactly 180 degrees apart.
- Depress at the sulcus to remove residual capsule that could contribute to tilt.
- Trocar symmetry is key to avoiding decentration. The 25- and 27-gauge cannulas are both fine, and you can externalize 2.0 mm to 2.5 mm posterior to limbus. But symmetry means more than marks, Dr. Weng explained. It also involves the entry angle and tunnel length.
- The biggest game changer: hand-to-hand technique. Grasp anywhere along the haptic, she explained, and just hand it off to yourself using another forceps via the cannula or corneal wound. Hold on tight until you feel resistance and elevate your cannula up the shaft of externalizing forceps. After internalization, repeat for the superior haptic. Have an assistant protect the other haptic when you externalize the first, and avoid using toothed forceps, said Dr. Weng. Follow the track if you have to replace the cannula.
- Burning bulb ends is the most satisfying part, Dr. Weng said, with a laugh. Before you start burning the ends, the haptics can be trimmed to optimize centration of the IOL if necessary. Elevate the haptic from the ocular surface, and don’t grab too close to the tip. Holding the cautery close to the haptic should be sufficient—no need to make contact. Tuck the bulbs inside the scleral tunnel.
Dr. Weng finishes by constricting the pupil and putting in a peripheral iridotomy to reduce risk of reverse pupillary block. Let the IOL settle and avoid dilation for the first week.
Wrapping up, Dr. Weng noted the need for long-term stability outcomes and optimal IOL formulas.
—Kanaga Rajan
Financial disclosures: Dr. Weng: Alcon Laboratories, Inc.: C; Alimera Sciences, Inc.: C; Allergan: C; DORC International, bv/Dutch Ophthalmic, USA: C; Genentech: C; Novartis Pharma AG: C; Regeneron Pharmaceuticals, Inc.: C; Regenxbio: C.
Disclosure key: C = Consultant/Advisor; E = Employee; EE = Employee, executive role; EO = Owner of company; I = Independent contractor; L = Lecture fees/Speakers bureau; P = Patents/Royalty; PS = Equity/Stock holder, private corporation; S = Grant support; SO = Stock options, public or private corporation; US = Equity/Stock holder, public corporation For definitions of each category, see aao.org/eyenet/disclosures.
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