RetinaLink is pleased to feature Yoshihiro Yonekawa, MD, Massachusetts Eye & Ear Infirmary and Boston Children’s Hospital, who shares his 27-gauge 3-port transconjunctival scleral IOL fixation technique from the ALCON Retina Exchange broadcast.
The technique shown is a modification of a transconjunctival approach. The original five-cannula technique from George A. Williams, MD and the Beaumont group popularized this surgical approach. The five-cannula approach uses three cannulas for the vitrectomy and two cannulas to externalize the haptics in a transconjunctival fashion. Recently, Drs. Aristomenis Thanos, Jeremy Wolfe and Tarek Hassan reported on how to modify the technique to externalize the haptics utilizing only three cannulas from which the vitrectomy is being performed.
“I prefer to use ALCON’s 27-gauge small gauge platform exclusively for these cases because I like to make flanges at the ends of the haptics with hand-held cautery to prevent dislocations. The flanges fit snuggly into the sclerotomies with 27-gauge incisions,” said Dr. Yonekawa.
This patient was a woman in her 80’s, pre-op VA: 20/150 and presented with dislocated 3-piece IOL in the setting of pseudoexfoliation syndrome. Secondary IOL surgery.
First, we place the 27-gauge cannulas in the direction that the haptics will be externalized. So one will be backwards. Toric markers help to make sure the cannuals are exactly 180 degrees from each other, and we use calipers to measure 2.5 mm posterior from the limbus.
The third cannula is status quo. The infusion will be in the normal inferotemporal cannula to start the case.
The vitrectomy begins and Dr. Yonekawa mentions, “I prefer to shave the vitreous base especially where the haptics will be externalized. The ability to do this is one benefit we have as retina surgeons. We utilize the soft tip cannula to lift the IOL atraumatically off the retina then, hand it off to the other hand with the GRIESHABER® MAXGRIP® forceps.”
Then, we use the 27-gauge vitreous cutter to dissect the Sommering’s ring and capsular remnants. The 27-gauge cutter is great in this regard since it is very precise and avoids damaging the haptics.
IMPORTANT NOTE: Next, we exchange the infusion from the inferotemporal cannula to the superotemporal cannula. Now, we’re 180 degrees apart and grasp the very tip of the haptic staying parallel to the haptic. We then remove the cannula up the shaft of the forceps, using countertraction on the sclera. This prevents bending of the haptic. The procedure is repeated for the other side also.
Retreiving the second haptic can sometimes be a challenge and it can help to make a paracentesis wound for another forceps to do hand-to-hand or drop the other haptic down and grasp it under the viewing system. In this case, a one hand approach was successful.
I like to use low temp cautery to make a nice flanges at the tips of the haptics which will prevent the IOL from dislocating. The conjunctiva is smoothed over to ensure that the haptics are secure and flush to the sclerotomy or just inside.
This patient achieved vision at two weeks post-op and she remains 20/20 over a year later.
“This is now my “go-to” technique for scleral fixation of IOL’s,” according to Dr. Yonekawa.
Dr. Yoshihiro Yonekawa can be reached via e-mail – firstname.lastname@example.org