EyeWorld Asia-Pacific June 2020 Issue

EWAP JUNE 2020 19 SECONDARY FEATURE “I tend to place my IOLs more «œÃÌiÀˆœÀ ̅>˜ œÌ…iÀ ÃÕÀ}iœ˜Ã]» Dr Ayres said. “I like to place “Þ " à >««ÀœÝˆ“>ÌiÞ Î ““ posterior to the limbus. We have found that 50% of our patients with this technique are within 0.5 D of intended target, [and] those that fall outside 0.5 D tend to be œ˜ ̅i “Þœ«ˆV È`i°» Eye marking and incision placement The best way to mark the eye is through use of diathermy, Dr. Yamane said, but dyes are also acceptable. He then creates the main wound at 1:00 and the scleral tunnel at 3:30 and 9:30. Dr. Ayres uses a centration guide, like an LRI or toric marker, to ensure 180-degree placement of the scleral tunnels. He creates sclerotomies at 12 o’clock and 6 o’clock. “My preference is to make them 3 mm posterior to the limbus, and I make my sclera Ì՘˜i Ó ““ ˆ˜ i˜}̅]» Dr. Ayres said. Preventing decentration Decentration occurs when the marks and subsequent scleral tunnels are not 180 degrees apart and centered, Dr. Fram said. Tilt occurs when tunnel lengths are not symmetric or the distance from the limbus is not equal on each side. Insertion angle of the needles is important to control tilt. The needle stabilizer helps to make the insertion angle constant. “Decentration can be dealt with sometimes by trimming œ˜i…>«ÌˆV ŜÀÌiÀ]» Åi Ã>ˆ`° “However, if it is severe, then you can pick the side that looks better centered and redock the other side at the true 180 `i}Àiið /…i…>«ÌˆV y>˜}i V>˜ be cut on a bevel and checked that it will feed into a new 30-gauge, thin-walled needle. The haptic is pulled back into the eye using 25-gauge forceps and placed on the iris. This haptic can then be and redocked in the new 30-gauge needle at a proper 180-degree location for LiÌÌiÀ Vi˜ÌÀ>̈œ˜°» To prevent tilt, Dr. Fram maintains the side with the proper haptic tunnel and entry. Additionally, the shorter pass should be redocked with a more symmetric tunnel length or distance from the surgical limbus. “For pupillary capture, a peripheral iridectomy should be >ÌÌi“«Ìi` wÀÃÌ]» À° À>“ Ã>ˆ`° “An ultrasound biomicroscopy should also be performed to evaluate tilt. If it’s amendable, a [peripheral iridectomy] may Li ÃÕvwVˆi˜Ì° v ˜œÌ] ̅i˜ ̅i persistent optic capture of the pupil can be resolved by ÀiwÝ>̈˜} ̅i…>«ÌˆV VœÃiÃÌ to the side of the pupil that is captured. The new pass should Li “œÀi «œÃÌiÀˆœÀ°» Tips to ease Yamane One tip Dr. Yamane recommends to help surgeons with the ÌiV…˜ˆµÕi ˆÃ ̜ wÀÃÌ «À>V̈Vi inserting the haptic in the needle. “After that, pay attention to the positional relationship LiÌÜii˜ ̅i ܜ՘`Ã]» Dr. Yamane said. Dr. Fram urged meticulous marking, moving the main incision temporally, and keeping ̅i «ÀœÝˆ“>…>«ÌˆV œÕÌÈ`i œv the eye prior to docking. “Understanding the tunnel length (1.5 mm) and orientation (20 degrees to the limbus) was also critical to shortening my i>À˜ˆ˜} VÕÀÛi]» À° À>“ Ã>ˆ`° “I recommend practicing with a simulation model, such as -ˆ“Տ 9 Q ˜Ã 9 ÌR°» Dr. Ayres agreed practice of the technique is critical and mentioned courses offered by ASCRS and the American Academy of Ophthalmology. “Don’t forget to keep the eye formed, using an AC maintainer is critical in these V>ÃiÃ]» À° ƂÞÀià Ã>ˆ`° º/>Žˆ˜} the case through with a surgeon iÝ«iÀˆi˜Vi` ˆ˜ ̅i ÌiV…˜ˆµÕi ˆÃ >Ãœ…i«vՏ°» EWAP Editors’ note: Dr. Ayres is in the Cornea Service of Wills Eye Hospital, Philadelphia, Pennsylvania, and declared relevant interests in Alcon, Carl Zeiss Meditec, and MicroSurgical Technology. Dr. Fram is a clinical instructor at Stein Eye Institute, University of California, Los Angeles, California. Dr. Yamane is assistant professor, Department of Ophthalmology, Yokohama City University Medical Center, Yokohama, Japan. Dr. Fram and Dr. Yamane FGENCTGF PQ TGNGXCPV ƂPCPEKCN KPVGTGUVU 2016 APACRS Film Festival award winning video on Flanged IOL Fixation with Double-Needle Technique is available for viewing at apacrs.org il i l i i i l I i i i l l i i il l i i . pg 19| 2016 APACRS FF.indd 3 20/05/2020 5:26 PM