The double-needle, small-incision, sutureless, transconjunctival scleral fixation technique was first described by Yamane et al in 2017.1 It uses small-gauge sclerotomies and a small clear corneal incision. The Yamane technique is associated with a quick visual recovery and a low risk of postoperative hypotony. Neither capsular nor iris support is required, and suture-related complications are avoided.
It is important to note, however, that only short-term data on the safety and efficacy of this technique are available. Moreover, because this is a two-point fixation technique, there is a risk of IOL decentration and tilt, and great precision is required to decrease this risk (watch a related video above). Additionally, the learning curve is steep.
TWELVE POINTERS
Below are 12 tips and tricks to help with mastering this technique.
#1: Use the TSK thin-walled special 30-gauge needles. Make sure to loosely attach the needles to a non–luer-locking tuberculin syringe filled with balanced salt solution. This fill prevents bubbles from entering at the tip of the needle, which can make threading the haptic difficult.
#2: Implant the most appropriate IOL. The CT Lucia 602 (Carl Zeiss Meditec) is the ideal three-piece lens to use for the Yamane technique because its PVDF haptics resist kinking and breakage.
#3: Keep an eye on the pressure. An anterior chamber maintainer or an infusion cannula is vital to maintaining IOP and ensuring that both sclerotomy passes are similar in length and location.
#4: Check for adequate support. If iris support is inadequate and the IOL is in danger of being lost posteriorly during the procedure, a small amount of a miotic agent injected intracamerally will constrict the pupil slightly. This helps create a platform on which to rest the leading haptic. I like leaving the trailing haptic of the three-piece lens outside the wound.
MORE ON THE YAMANE TECHNIQUE
#5: Prevent postoperative tilt and decentration of the IOL. The needles must be inserted exactly 180º apart and 2.5 mm posterior to the limbus unless the axial length of the eye is extremely short or long. Also, the sclerotomy tunnels must be equal in length.
#6: Be prepared for chemosis and subconjuctival hemorrhage. If chemosis or a subconjunctival hemorrhage develops, especially in combination cases, it is best to perform a limited peritomy to ensure that the sclerotomy passes are performed correctly.
#7: Stabilize the globe. A good tip is to place toothed forceps near the marked point of needle insertion during the scleral insertion.
#8: Thread the trailing haptic with care. The most technically difficult step of the Yamane technique is threading the trailing haptic into the needle. I recommend creating a paracentesis approximately 180º away from the sclerotomy to optimize the direction of the intraocular 25-gauge Grieshaber Maxgrip forceps (Alcon) so that the haptic can be grasped parallel to its span and more in line with the 30-gauge needle. Alternatively, the wound may be created slightly to the left of the 180º meridian.
#9: Look for proper centration of the IOL. Slowly remove both needles simultaneously and observe the optic’s centration. It is important to look for decentration and tilt before cauterizing the haptics.
#10: Recenter the IOL if necessary. If IOL centration is poor or the IOL is tilted and the needle insertions are not 180º apart or not located the same distance from the limbus, then one of the haptics must be reinserted into the eye and refixated with a new needle pass. If IOL centration is poor because the scleral tunnels differ in length, one or both haptics can be trimmed and then cauterized to improve centration.
#11: Avoid pupillary capture of the iris. Insert the needle 2.5 mm instead of 2 mm posterior to the limbus. Alternatively, a peripheral iridotomy may be performed.
#Target slight myopia. Choose a refractive target of -0.50 to -0.75 D to avoid a postoperative hyperopic surprise.2
1. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology. 2017;124(8):1136-1142.
2. McMillin J, Wang L, Wang MY, et al. Accuracy of intraocular lens calculation formulas for flanged intrascleral intraocular lens fixation with double-needle technique. J Cataract Refract Surg. 2021;47(7):855-858.
