APACRS 2021 Daily News (Saturday, 31 July 2021)

Asia-Pacific Association of Cataract & Refractive Surgeons Saturday, 31 July 2021 MasterClass: Mastering IOL Fixation In the “Mastering IOL Fixation” MasterClass, Soon Phaik Chee, MD, Singapore, presented on the various techniques for iris and scleral suture fixation. With iris suture fixation, Dr. Chee suggests bringing the intraocular lens (IOL) to the plane of the iris root using IOL-grasping forceps, taking only a 1-clock-hour bite of the iris as peripherally as possi- ble, and creating a Siepser sliding knot with the McCannel suture technique with 10-0 polypropylene. In scleral suture fixation, Dr. Chee recommends using Gore-Tex (polytetra- fluoro-ethylene CV-8) for its excellent longevity, though it is considered off-label use. Techniques such as keeping the suture dry, cutting the suture at a 45-degree angle, and in- serting the needle horizontally under the iris while avoiding the capsule were also recommended. Though the easiest technique is iris suturing, Dr. Chee prefers intrascleral hap- tic fixation for patient outcomes. Amar Agrawal, MD, India, described his handshake tech- nique for glued IOLs. The handshake technique is a key step for foldable glued IOLs by transferring the haptic from one “hand” to another. As the IOL is being injected into the anterior chamber (AC), the tip of the haptic is caught with the forceps and the optic is injected. The haptic is then exteriorized while simultaneously withdrawing the injector so that the second haptic is left trailing outside the wound. The first haptic is held by the assistant while the surgeon inserts the second haptic into the AC to the forceps that are introduced through the side port. The result of this handshake technique is a well-centered multifocal IOL even in compromised eyes. Shin Yamane, MD, PhD, Japan, explained how to perfect outcomes using the double needle technique. For Dr. Ya- mane, perfect outcomes entail no complications, no IOL tilt or decentration, and a small refractive error. Intraoperative complications can include haptic deformation or breakage, which can be prevented by aligning the haptic and needle before insertion of the haptic into the needle. If there is an angle between the haptic and needle, there is a risk of leakage of the haptic. IOL tilt is another complication that can be reduced by using special instruments such as the Yamane needle stabilizer and adjusting the haptic length. Mohan Rajan, MD, India, described the iris claw lens that can be fixated onto the iris without sutures. The lens has a relatively simple design of one piece and one material without additional loops. The fixation mechanism is based on enclavating a fold of iris tissue, and enclavation is made easier by using a larger and oval aperture between the op- tic and haptics.Though complications can arise from using iris claw lens (bleeding, optic capture, dislocation, corneal edema), Dr. Rajan believes that the lens is easy to use, effective, and enjoyable. EWAP Daily News - 5 up to three different devices to produce an integrated K that is the mean if two devices are used, the median K if three devices are used. Deriving a mean or median K is helpful in measuring corneal astigmatism for toric IOL calculations as it de-empha- sizes outliers; the improvement for spherical power prediction was modest, but the improvement in predicting postop residual astigmatism was clinically significant—up to 10% in improve- ment. In his practice, Dr. Barrett says he routinely uses three different devices: the IOLMaster700, LenSTAR, and Pentacam. These calculators provide the most accurate predictions for un- usual eyes, such as eyes that had previously undergone refrac- tive surgery, even when no historical data is available; Dr. Barrett believes they are essential tools for mastering toric IOLs. In his lecture closing the MasterClass, Dr. Oshika warned that misalignment can jeopardize the corrective effect of toric IOLs. Based on their experience, he and his colleagues noted that the largest rotation tended to occur within the first hour after sur- gery, but that it was best to perform repositioning about 1 to 3 weeks after toric IOL implantation as before then the IOLs tend- ed to rotate back to same position. Repositioning could then be done under irrigation. One very important tip Dr. Oshika gave to reduce toric IOL rotation is to wait until the IOL has completely unfolded, some lenses being very slow to open. Further, the patient should be in- structed to stay at rest for the critical 1-hour period after surgery. Finally, Dr. Oshika said that newer generation toric IOLs have better rotational stability, and that in any case complete CCC coverage can reduce the risk of toric IOL rotation after surgery.