EyeWorld India June 2020 Issue

18 EWAP JUNE 2020 SECONDARY FEATURE by Rich Daly EyeWorld Contributing Writer This article originally appeared in the April 2020 issue of EyeWorld . It has been UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ permission from the ASCRS Ophthalmic Services Corp. Contact information Ayres: brandonayres@me.com Fram: nicfram@yahoo.com Yamane: shinyama@yokohama-cu.ac.jp A relatively new " wÝ>̈œ˜ technique might œvviÀ ܓi ëiVˆwV advantages, but it also requires unique surgical maneuvers, according to surgeons. At the 2016 ASCRS ASOA Annual Meeting, Shin Yamane, MD, PhD, introduced this new method for intrascleral IOL wÝ>̈œ˜] ÕȘ} > ÌÀ>˜ÃVœ˜Õ˜V̈Û> approach without sutures or glue. Since learning this technique, Nicole Fram, MD, has found it particularly useful when she wants to preserve conjunctiva and use small incisions. “In addition, we have found in our series that there is a lower incidence of vitreous hemorrhage, as fewer sclerotomies are being made compared to scleral suture- wÝ>Ìi` " Ã]» À° À>“ Ã>ˆ`° However, Dr. Fram noted that the procedure’s two-point wÝ>̈œ˜ ÀiµÕˆÀià ̅i ÃÕÀ}iœ˜ to understand unique surgical maneuvers to avoid tilt, pupillary capture, and decentration. “For this reason, counseling the patient preoperatively that they may need a second surgery is warranted for surgeons i>ÀÞ ˆ˜ ̅i i>À˜ˆ˜} VÕÀÛi]» Dr. Fram said. Brandon Ayres, MD, said …>«ÌˆV wÝ>̈œ˜…>à LiVœ“i…ˆÃ practice’s most commonly ÕÃi` ÌiV…˜ˆµÕi vœÀ " wÝ>̈œ˜° Dr. Ayres said he counsels patients about the various œ«Ìˆœ˜Ã vœÀ " wÝ>̈œ˜ >˜` ÌiÃ them he will use the technique he thinks will work best for them. His ÕÃi œv ÃÕÌÕÀi wÝ>̈œ˜…>à LiVœ“i limited to situations where he needs to remove a large PMMA IOL or ACIOL, which already require a large wound. “The Yamane technique allows us to keep wound size smaller and is a faster technique, but there are still problems ܈̅Vi˜ÌÀ>̈œ˜ >˜` ̈Ì]» À° Ayres said. “When it comes to centration and accuracy, I Ã̈ ̅ˆ˜Ž ÃÕÌÕÀi‡wÝ>Ìi` " à œÕÌ«iÀvœÀ“…>«ÌˆV wÝ>̈œ˜] >˜` in young patients with no sign of retinal pathology, I may still opt vœÀ > œÀi‡/i݇wÝ>Ìi` " °» +1. UGNGEVKQP CPF ƂZCVKQP technique Dr. Yamane recommended using a 30-gauge thin-wall needle (TSK Laboratory), needle stabilizer (Geuder), and Yamane forceps (Katalyst Surgical), but other tools can also work to «iÀvœÀ“ ̅ˆÃ wÝ>̈œ˜° À° 9>“>˜i recommends IOLs with PVDF haptics for this technique but any three-piece IOL could be used. Dr. Ayres described some of the differences in haptic materials. “Most of the three-piece IOLs use PMMA for their haptic material, and the PMMA is easy ̜ Žˆ˜Ž >˜` LÀi>Ž]» À° ƂÞÀià said. “The IOL from Carl Zeiss Meditec has haptics made of PVDF and are much more durable. For a surgeon new to ̅i…>«ÌˆV wÝ>̈œ˜ ÌiV…˜ˆµÕi] I’d stick with the CT Lucia 602 [Carl Zeiss Meditec]; for more iÝ«iÀˆi˜Vi` ÃÕÀ}iœ˜Ã ˆÌ “>ÌÌiÀà iÃà ܅>Ì " ÞœÕ ÕÃi°» Dr. Fram said limited availability of the CT Lucia 602 has made that option less feasible. She also uses a 30-gauge thin-walled needle (Delasco), 25-gauge forceps (MicroSurgical Technology), anterior or posterior infusion, and a proper pars plana-assisted anterior vitrectomy technique. A vitrectomy is necessary for this technique, if not already performed in a prior surgery. /…i ̜œÃ À° ƂÞÀià ˆ`i˜Ìˆwi` include a 27-gauge or thin- walled, 30-gauge needle, AC maintainer, micro-anterior segment forceps, anterior chamber or posterior chamber infusion, marking pen, caliper, and low-temperature cautery. He also mentioned the Scleral " ˆÝ>̈œ˜ -œṎœ˜Ã *>VŽ (MicroSurgical Technology), which includes all needed equipment for the procedure iÝVi«Ì ̅i " ° IOL power considerations Dr. Yamane said the IOL power or A-constant considerations with the technique are almost the same as those for in-the-bag wÝ>̈œ˜° i V>VՏ>Ìià > ä°Î myopic shift. Dr. Fram has found that those considerations depend on the selected IOL. She looks at the recommended A-constant of the manufacturer and uses information from doctor-hill. com, as well as the biometry results. Dr. Fram aims for in-the- bag calculations (plano to –0.50 D) and has found the Holladay calculation most reliable. Although Dr. Ayres uses a similar approach, he has iÝ«iÀˆi˜Vi` “œÀi Û>Àˆ>LˆˆÌÞ ÜˆÌ…ÃViÀ>‡wÝ>Ìi` " ð -G[U VQ KPVTCUENGTCN JCRVKE ƂZCVKQP