Eyeworld Daily News

ASCRS SYMPOSIA ASCRS ASOA ANNUAL MEETING by Rich Daly EyeWorld Contributing Writer Retina forceps are used to grab the trailing haptic and dock it in the needle. Dr. Kieval then withdraws the needles one at a time. "I've had a couple of these go through and a couple I've had to dissect down to the conjunctiva in order to retrieve the haptics," Dr. Kieval said. "So withdraw these while keeping control." Once the haptics are out of the eye, they can be released without worry that they will retract back into the eye. The haptic ends are cauterized to create a 0.5 mm flange. "This is low-temp cautery, handheld, and you're coming a little close to that haptic just to cauterize it," Dr. Kieval said. Then, the flange is inserted fully into the scleral wall. "Some of these have extruded if they are not placed fully into the scleral wall, and they won't otherwise—at least in my experi- ence over the last 9 months," Dr. Kieval said. Finally, the incisions are closed. "This is a minimally invasive technique that allows for small incisions, less risk of trauma," Dr. Kieval said. The approach allows fixation of a pre-existing three-piece lens, it can be combined with a corneal or retina procedure, it has no risk of suture exposure or breakdown, and it offers a shorter operating time. "There is more and more interest in trying to make this intrascleral haptic fixation tech- nique easier and more standard- ized," said Brandon Ayres, MD, Philadelphia. Dr. Ayres noted that a grow- ing number of manufacturers are producing needles specifically for the technique. Editors' note: Drs. Kieval and Ayres have financial interests with various ophthalmic companies. 30-gauge, thin-walled needles. The haptics of the IOL are external- ized with the needles and cau- terized to create a flange of the haptics. Then, the flange of the haptics are pushed back and fixed into the scleral tunnels. To implement the new ap- proach, Dr. Kieval said surgeons need to first mark the limbus 180 degrees apart, 2 mm posterior to the limbus and 2 mm inferiorly on the left and superiorly on the right. Two paracenteses are made 1–2 clock hours beneath the lim- bal marks and a third paracentesis is made for an anterior chamber maintainer. This is followed by a 2.8 mm keratome incision. Dr. Kieval uses two special- ized 30-gauge TSK needles. "Just make sure the haptics fit into your needles," Dr. Kieval said. "Sometimes you do need to use a 27-gauge if you are using a differ- ent three-piece IOL than what I am describing." Then proceed to the scleroto- my. To insert the lens, Dr. Kie- val uses a technique previously described by Brian Kim, MD, which leaves the leading haptic outside the injector and into the lumen of the needle. As the lens is injected, the haptic advances into the needle. "A lot of people will insert or inject the IOL into the anterior chamber and that's reasonable, but I find it an extra step because then you have to go in with forceps and grasp that leading haptic and in- sert it into your 30-gauge needle," Dr. Kieval said. He removes the needle hub, while ensuring that the needle includes balanced salt solution to prevent air bubbles. The next step is for the 30-gauge needle to tunnel through the right sclerotomy. An important point is not to cauterize the leading haptic too early, which ruins the surgeon's ability to rotate the IOL and give themselves more maneuverability for the trailing haptic. Ophthalmology by Shin Yamane, MD, and colleagues. Some refer to the technique as intrascleral haptic fixation with a double needle technique. The presentation was part of a symposium on import- ant clinical and management skills surgeons should aim to acquire in their first 10 years of practice. The goal of the flanged IOL fixation technique is to provide a simple and minimally invasive method for achieving good IOL fixation. It uses two angled inci- sions parallel to the limbus with A surgeon has identified useful implementation steps for an emerging technique for transcon- junctival intrascleral fixation of an IOL. Jeremy Kieval, MD, Lexington, Massachusetts, described his implementation of a technique first reported in a case series in 2017 in the journal Implementing the Yamane technique 36 | EYEWORLD DAILY NEWS | MAY 6, 2019 Dr. Kieval discusses key steps to perform the emerging technique of transconjunctival intrascleral fixation of IOLs.

• Cover