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32 | EYEWORLD DAILY NEWS | MAY 18, 2020 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING the needle-haptic complex of the first needle pass. Dr. Basti recommended externalizing the first haptic before making the second needle pass. He also said to ensure adequate depth of the needle track, due to thin sclera. Conjunctival abnormalities, such as chemosis, subcon- junctival hemorrhage, and prior conjunctival surgery can complicate the Yamane proce- dure as well. Dr. Basti said in eyes with chemosis to squeegee with a Q-tip or muscle hook prior to needle passage. You should also temporarily de- crease the infusion pressure/ use a dispersive OVD. If the chemosis co-exists with abnor- mal sclera, such as in Marfan's syndrome, place both needles before opening the eye for IOL insertion, he said. If there is a filtering bleb, avoid that region, but Dr. Basti said it's OK to pass the needle away from the ostium of filter in the shallow portion of the bleb. Find more on these and other presentations in IC-7. Editors' note: Dr. Garg has financial interests with several ophthalmic companies. Dr. Basti has no finan- cial interests related to his presen- tation. by Liz Hillman Editorial Co-Director T here are several advan- tages to the flanged, double-needle intras- cleral haptic fixation technique, often referred to as the Yamane technique for the ophthalmologist who intro- duced it, Shin Yamane, MD, PhD. In an instructional course, Mitchell Weikert, MD, Hous- ton, Texas, detailed the basics of this technique, and was followed by Sumit "Sam" Garg, MD, Irvine, California, who talked about some of the mis- takes made with this technique and pearls to help avoid them. Mistake #1: Not watching videos, attending courses, or practicing before trying the technique in patients. Watch- ing videos online is useful, Dr. Garg said, adding that practicing with a model eye is important as well. Mistake #2: Not discuss- ing the risks of the procedure preoperatively with the pa- tient. "We often become very comfortable doing these procedures," Dr. Garg said, but there are risks, and com- plications do happen. He said he tells patients this technique is off label with the lens and there is not long-term data on the safety and efficacy of the procedure. Refractive target- ing can also be a challenge, he said. One rare complication Dr. Garg specifically mentioned is intraoperative flash fire associ- ated with disposable cautery. "At our institute when we apply heat to the haptic … we ask our anesthesia colleagues to turn off the nasal cannula oxygen," he said. Mistake #3: Using the wrong lens. Dr. Garg recommends the CT Lucia 602 (Carl Zeiss Med- itec) because the haptics are very resilient to damage, being made of PVDF. "This material is less apt to have kinking or breaking intraoperatively," he said. Mistake #4: Orientation of the incision is off. The main incision should be 90 degrees from the sclerostomy sites and, thus, the sclerostomy sites should be 180 degrees apart across the center of the cornea. Mistake #5: Mismarking the eye. This could lead to lens decentration or tilt. Make sure your primary marks are 180 degrees apart and secondary marks allow for proper tunnel- ing of the needle, he said. Mistake #6: Needle-related. One is not checking the hap- tic in the lumen outside the eye before placing the needle. Dr. Garg said he likes to fill the needle with balanced salt solution to avoid an air bubble at the end of the lumen, which could obstruct the view. If you put your needle on a syringe, Dr. Garg said to not tighten the Luer lock too much because if you have to disengage, it can be a challenge. Bend the needle strategically so you can create a backstop that the haptic can hit and guide it into the lumen of the needle. Dr. Garg said he bends the nee- dle for the proximal haptic up toward the bevel. He turns the bevel to the left then bends up on the needle for the distal haptic. This allows for easier placement of the haptic in the lumen, he said. Mistake #7: Underestimating the intraocular gymnastics to get the haptic into the lumen. This can occur if the approach is at the wrong angle, if there is an inadequate tunnel, uneven tunnels, if you're not engaging the haptic far enough into the lumen, and if you're not externalizing the haptic to allow easier placement of the second haptic. Mistake #8: Centration and tilt. Marking is very important to avoid this. If you get decen- tration, you can trim haptics to improve it, Dr. Garg said. Other mistakes include in- sufficient vitrectomy, not using an AC maintainer, touching the haptic with the cautery (get close but don't touch), and not placing a PI. Dr. Garg also said that his preference is to engage the leading haptic while it's still in the injector, externalize haptics sequentially, and cau- terize sequentially. Despite the challenge of the technique, Dr. Garg said it's well worth the effort to learn. Surendra Basti, MD, Chi- cago, Illinois, shared how a modified Yamane technique could be used in unusual clini- cal situations, such as pediatric eyes, eyes with conjunctival abnormalities, and eyes with partial capsular support. In pediatric patients, the sclera is thin and narrow orbital space can make sur- gical maneuvers challenging. The lack of space in these eyes can cause distortion to Yamane mistakes, pearls to avoid them, unusual cases, and more in instruction course Intrascleral fixation with Yamane in pediatric patients is a challenge due to thinner sclera and smaller orbital working space. Source: Surendra Basti, MD, screenshot from presentation

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