Lecture: Surgical Solutions for Dislocated IOLs

DR MCCABE: All right. Well, it’s exciting to be here. And I want to welcome everybody who is here from all parts of the world. But let me actually stop sharing for just a moment. We’re getting a preview there. So let me look back and fix where we’re at in the talk, and then we’ll share again. All right. Okay. And everybody can see my screen? Here we go. All right. I want to thank everybody for being here today. It’s thrilling to see how many different countries there are represented in our webinar today. And if you want to see who else is here, feel free to go ahead and just introduce yourself in the chat. And I think everybody can see that. Perhaps. And we will begin now. And we’re gonna talk about surgical solutions for dislocated IOLs. And at least in my practice in Florida, in the US, we have more and more dislocated IOLs that I’m seeing. Here are my financial disclosures. Really not relevant to this talk. And some of those reasons are listed here. So it could be that there’s damage to the IOL just during insertion. Sometimes colleagues will say: You know, I’m not interested in doing anything to exchange lenses. If I have a lens exchange, I’m going to refer that to somebody else. But really you can’t avoid it. Sometimes you put the lens in, and it just needs to be taken out immediately. It could be that there’s a significant refractive miss, and you want to improve the patient’s ability to function after surgery. Maybe there’s anisometropia from it. There could be intolerable side effects. This is a bigger issue with all of the premium and multifocal lenses that we now have available. Dysphotopsias, positive or negative, anisometropias, as we mentioned. And dislocation, which has become a bigger and bigger issue. And I think there’s a significant role for that with eye rubbing. So we’re going to have a polling question here for the audience. And I just wondered, in the audience, what is the most common reason you’re exchanging an IOL? Is it for refractive miss, damage to the IOL, intolerable side effects, dysphotopsias, that might be a more premium lens or diffractive optics situation. Sometimes not. Or is it a dislocated IOL, either in the bag or the IOL itself? And we’ll kind of see where everybody is at by all answering this question together. And we’ll have that here in a moment. And then we’ll kind of look at what we’re dealing with. We’re all kind of dealing with the same things, aren’t we? So we want to make sure our patients are happy. They’re able to function the way they need to. Dislocated IOL. Just like my practice… The majority of patients, it’s dislocated IOLs. And frequently, that’s late in the bag dislocations. So let’s see what we can do about that. So oftentimes these late dislocations are from a zonulopathy. So it might be that… Sorry. I’m gonna move this over. It could be pseudoexfoliation, could be they’ve had prior surgery like a vitrectomy. Maybe multiple injections for macular degeneration. That can often be a cause as well. So trauma. Blunt trauma. Or surgical trauma. That can cause all kinds of different problems. Like UGH syndrome. You see in that upper right — and I think you can see my cursor here — you can actually see the outline of the single piece hydrophilic acrylic lens as it’s rubbing against the iris, causing pigment dispersion, maybe even glaucoma. They may get dysphotopsias, corneal edema, lots of things we have to treat to get the patient to function better. When do we exchange? When it’s affecting vision. Decreased visual acuity, decreased quality of vision. If the optic is no longer covering the pupil, it’s clear they’re not gonna see well. Maybe there’s excessive tilt causing increased astigmatism or instability in the refraction. You could have increased intraocular pressure from dispersion or UGH and maybe it’s the wrong power and they’re not able to function well. What are the considerations? Well, you want to look and see first: Is the capsular bag intact? Is that something you’re gonna be able to use to fixate another lens? Or even to put this lens maybe back where it should be? Maybe it wasn’t planted fully within the capsular bag to begin with and you just need to implant it in the capsular bag. What was the length of time since implantation? What’s the age of the patient? Do you see evidence of fibrosis? Is it gonna be hard to get the lens out? And what’s the lens material and design? Is it something that can be in the sulcus, a single piece acrylic lens design with large haptics, et cetera? Sharp — are not good candidates for in the sulcus fixation. And a lot of the same considerations go with an open capsule. However, now you have to deal with vitreous. You have to think about that. Can you tamponade it? Did the patient already have a vitrectomy? What additional tools are you going to need or need to consider? You also want to know what the health history is of the eye. That’s going to also affect your approach. Have they had a trab or a tube? And that was a question somebody submitted ahead as well. We’ll look at a case like that. You can see — the upper left is a patient who has had a trabeculectomy and has a nice elevated functioning bleb there. Have they had a PK? Is there iris pathology you have to deal with, with a surgical solution, at the time of surgery? And you’re gonna look at the preoperative assessment. This is really important for planning purposes during your surgery. What’s the ocular health? What does the ocular surface look like? What does the topography look like? Are the endothelial cells compromised or healthy, if you have the ability to look at that? Even with specular microscopy, looking with your slit lamp, you can get an idea of the health of the endothelium for planning purposes. If you have access to imaging of the macula, here you can see that this patient here has an epiretinal membrane. Some cysts already. Increased risk of macular edema. Here there’s some vitreomacular traction. And again, some swelling and cysts and that is also affecting their vision. And you want to make patients aware of that. So all of these things can be helpful. But they’re not critical in making a plan for the patient. I see just like you do that there are many in the bag IOL dislocations. That seem to be more frequent in my practice. And I think there’s a number of reasons, and there are some publications on this as well. So eye rubbing. That’s a big deal. You can see my father-in-law here is rubbing his eyes. You can imagine I’m telling him not to, of course. Pseudoexfoliation. This is a big deal for us. We have a lot of patients with that. Maybe prior surgery. Axial myopia. Trauma. And then very aggressive capsular phimosis. This is a patient with retinitis pigmentosa. And so you can see very, very aggressive fibrosis can cause — and phimosis — can cause decentration of the IOL. And maybe it was a complication of the primary cataract surgery. So eye rubbing. I really think this is a bigger issue than we’ve ever thought before. Let’s talk about how we do it. Having lots of tools in your tool box is important. One of the tools I like the best is this spatulated cannula. Pretty easy for any manufacturer to make. And these are available in a wide variety of manufacturers. It just has a very tapered tip which makes it easy to get underneath the anterior capsule. And elevate that with a dispersive OVD or viscoelastic. And having lots of dispersive OVD on hand is also important. Iris hooks for good visualization. This spatulated cannula I just talked to you about. Miochol and Miostat, if you’re going to do an iris fixated lens or put it in the sulcus and that’s another reason to constrict the pupil. You want triamcinolone, really great for identifying vitreous and staining it so you’re sure you’re doing a complete anterior vitrectomy. You want to have maybe 23 gauge, 25 gauge, if available, a small gauge vitrectomy unit. With trocars, I prefer, but not always available. Anterior chamber maintainers are very helpful when you’re doing anything that’s much manipulation in the eye. This is one of my favorite things. It’s a Grieshaber maxgrip forceps. I think it’s called a Finesse. It has a fine tip like this in the Duet system by MST. But these are great for being able to manipulate the IOL in the eye and also for suturing. So grabbing the suture with those makes it much more easy. Disposable retinal lenses. Since oftentimes we’re worried about retinal pathology. Maybe the lens is even already back on the retina. And these interchangeable ends for a forceps and scissors are also a really great system to have. You want to have the appropriate needles. So a 30 gauge thin walled TSK needle is something we get from Japan, or 27-gauge long needles, which I’ll show you a technique that makes it less necessary to have some of the fancy forceps that we use. Or short needles. Which allow for intraocular docking of another needle or the suture. I prefer to use 7-0, 6-0, or 5-0 prolene in many of these cases now. Gore-Tex is a great solution as well. Vicryl can be used. Of course, we worry that these smaller gauge sutures can break over time, and it’s another reason I really tell my patients: Don’t rub your eye after having a dislocated lens that’s been sutured. Low temperature handheld cautery allows us to use some of these prolene sutures in a flanged technique, which we’re gonna look at in a little bit. And then intracameral medications. Trying to take some of the responsibility away from the patient and their postoperative care. So antibiotics, steroids, anything we can do to help the patient to function better that way. And then knowing the bag to sulcus conversion, Dr. Hill has that on his website. I have it printed in my OR. And that allows us to make conversions, if we’re not able to put it back in the bag, even if we think we can. Let’s see. There we go. So a torn or damaged haptic. Somebody asked about this. Can you leave a damaged haptic? Well, here’s a case of a patient who had a toric lens implanted. And you can see that the minute it got in the eye, already the haptic was disinserted from the optic. And this had to be removed. So no question. Has to be removed. Sometimes with a three-piece lens, if there’s deformation of one of the haptics, typically the trailing haptic, you can actually reform that, and if it hasn’t been too damaged, actually use the lens and still have it centered. And in a situation where you might not have a backup lens, you could even do an optic capture, a reverse or primary optic capture, in order to center the lens. So we’re gonna talk about techniques for IOL removal in just a little bit. I see there’s a question there. But I’ll show you some techniques in just a moment. So this is a lens that also had to be removed. You can see it’s a toric lens as well. A premium lens. But it had a scratch right in the center of the optic. And so better to remove this lens now than have the patient complaining of dysphotopsias postoperatively, where you actually have to worry about explanting once there’s been fibrosis. So here’s a technique. I generally do like these scissors. These are the McCool forceps. I don’t know which manufacturer makes them. But they have a little gripping surface on the very end of it. You can see it’s almost like a gripping forceps. And then they’re very heavy. So they’ll go through some really tough lenses. And then you can use them as a forceps there, to remove the two halves. So that tends to be my go-to method. But there are others. And I think this is gonna show you a different one. So here what we see is I’m using that spatulated cannula on a dispersive viscoelastic. I’m inflating underneath the anterior capsular leaflet, along the axis first of the optic-haptic junction. And then even everywhere I can, to try to make sure that there’s some viscoelastic behind the optic. But here’s the first area of concern with these lenses. You get a constriction of fibrotic ring — anywhere there’s an enlargement of the haptic. So this actually, even though it’s an AcrySof platform, it does enlarge proximal to the optic, even, and that ring can be removed. I’m now removing a little fibrotic ring from around the terminal bulb. But those can be removed by either using a second instrument like I am here, or I’m also inflating along that axis. And using the spatulated end of the cannula to gently remove that ring from where there is that terminal bulb and that enlargement there, along the axis or along the width of the IOL. And I guess this one I am also cutting with the same McCool forceps. Grabbing with the end of it. I like to already have one of the haptics out, so you’re not bending that, potentially impacting the iris and causing a bleeding or tear. And in this case, I was able to put another lens immediately right back into the same location. Here’s another technique. And this is a modification of a technique that I also used. Especially in a warm lens. So a lens that’s already been in the body. But you can take a lens, any of these lenses, and you can actually just twist your arm, after you’ve grabbed at least 2/3 of the way across the optic. And you can twist it and bring it out. And this modification by putting a cannula there, through a paracentesis, you’re actually protecting the endothelium as well. So that’s another little twist on the twist and out technique. So in the most common things that we see in the US… These two platforms, the Tecnis and the AcrySof or Clarion platform, we talk about this problem. Either the dilation on the AcrySof or the terminal bulb particularly. And in this design there’s an angulated expansion next to the optic and that tends to be fibrosis. But all lens designs have their typical spot. Here again, this is a ReSTOR, I believe, that was being explanted. And you can see yeah, it’s pretty stuck in there. So the other thing you want to do is use lots of viscoelastic. Go slowly. Because pulling on the capsular bag if there is a fibrosis can cause a big zonulopathy, which is not what you want. As you’re trying to decide how you’re going to fixate the lens that you’re replacing this lens with. So slow deliberate movements, lots of viscoelastic, here again there’s that fibrotic ring that’s near the expanded portion in the middle of the haptic. And by coming from another direction, using more viscoelastic in that region, using maybe that spatulated end, I’ll be able to expand it, maybe break through the fibrosis, and that will allow me to more safely remove the haptic without causing zonulopathy over there. So you can see just by putting some viscoelastic in that area, it allowed me to get that. And now there’s this little constriction at the terminal bulb, and I’m going to do something very similar to remove that there. And this works for whatever the lens design is. Thinking in the same manner that by expanding those areas of fibrosis you can alleviate that and you can have a result that isn’t as impactful on the zonules. So this is an example of the other type, a Tecnis multifocal. Where that constriction is right here. You can definitely see that fibrosis. We know it going into the surgery. And we’re gonna spend a lot of time just trying to free that up. Again, similar sort of considerations as before. I’m gonna speed it up just a little bit. Because we have a lot of videos to look at. And here, although it looked like there was a big constriction there, it did actually free up pretty readily. This side — I think we’re gonna see — was a little tougher. And your other option, rather than causing damage there, is to just take some intraocular forceps and disinsert that haptic from the optic. And sometimes that’s the best thing to do. So in this case, again, the same technique of sort of blowing out viscoelastic in the area of constriction, allow this to free up, and come out more readily. And a lot of… We’re going to look a little bit… This is one where it was more difficult. I really just couldn’t get it to free up in this axis. And in the end, it just seemed that it would be easier to disinsert it there. And sometimes you even have the option of backing it out. Moving it away at that point. So that can be the safest way. So here’s a case where… Well, it was a complete in the bag dislocation. You can see it might be a three piece lens in this case. I’m putting in that trocar that we mentioned. It’s a 23-gauge trocar with valves in this case. And I put the infusion trocar there in first. You can see… And here is the one for the vitrector. You always want to visualize the end of the trocar in the pupil, to make sure that there’s no entrapped tissue. Sometimes it can entrap tissue even in the ciliary body and get buried there. So you want to be sure that that end of the trocar is visible before you remove it. I’ve done an extensive vitrectomy, not shown here, of course. For time. But then elevating the whole IOL-bag complex in front of the iris, more vitrectomy, because we just don’t want to pull on vitreous if we can avoid it. Using the same lens cutting forceps, which I do twist them out sometimes as well. But oftentimes, this way. When you take out the lens, you’ll see sometimes a Soemmering cataract is at risk for falling back in the back of the eye. So be aware of that. And then we’re coming up with a solution to put a new lens in, once the whole lens-bag complex is gone. Now, like this case I just showed you — when you have an aphakic patient, what is your favorite or go-to choice? This is going to be an audience response as well. Is it an anterior chamber lens, a posterior chamber lens, and then you have a choice, you could do an intrascleral haptic fixation, like the Yamane technique, or you could glue the haptics, like in the Agarwal technique that’s been used frequently. Or do you take a three piece IOL and fixate it to the iris? Do you suture the eyelet of a closed loop or eyelet containing haptic lens, like the CZ70PD used to be. And there are many designs like that internationally. And that could be with Gore-Tex or prolene. Or do you use the iris claw lens, which we do not use in the US? There are a lot of questions about that. I have no experience with the iris claw lens. We don’t have it available in aphakic powers in the US. And it looks like a lot of people are doing an intrascleral haptic fixation, which has been such a great technique. I’m super happy to have that in my career. I’ve been able to pivot to more of a Yamane technique. And using the principles of flanged IOLs, we’ve been able to do other things that sort of are less invasive, and we’re gonna talk a bit about that. Some of you may know those techniques already, and we’ll cover that here as well. So we’re gonna move on. Let’s see. I’ll close that. And… So traditional methods… We kind of talked about those. Right? You could fixate the IOL-bag complex with 9-0 prolene. The problem with that is that 9-0 prolene tends to break over time. And I feel like this is an increased problem again in patients who rub their eyes. So I’m spending much more time, no matter what the technique is, talking to patients about not rubbing their eyes. And even if they don’t, the knot can erode through conjunctiva if it’s not buried well. And that can create problems. The same is true if you use Gore-Tex suture. So Gore-Tex won’t fail over time. But I’ve definitely seen Gore-Tex erode through conjunctiva before. That can have a lot of the same issues. And you have to take down the conjunctiva. Unless you do a Hoffmann pocket. So other issues with Gore-Tex as well. Maybe not as readily available in some areas. But oftentimes it requires in the past an exchange of the IOL. That would require a vitrectomy. There could be loss of cortical material or Soemmering cataract into the posterior segment. Removing the lens can be traumatic. It can cause damage to the iris. You might lose the lens into the posterior segment. You can have corneal damage as well. And it does require a second IOL. And that is another expense. And especially disappointing to patients who have premium IOLs as their primary lens. Intrascleral haptic fixation. A lot of you are doing this, and that’s been really nice, because we don’t have to disturb the conjunctiva, if you use the Yamane technique. Or if you glue it, it may allow you to keep especially a three piece lens that’s already in the eye. But if it’s not a three piece lens, it can require a new lens. And it can be technically demanding. Especially I find the glued IOL can be a demanding technique as well. So here we’re gonna go over the Yamane technique just a little bit. Because it’s become so popular and many of you are using it. As you know, it was popularized by Shin Yamane in Japan. It typically uses the thin walled TSK needle we talked about that’s 30 gauge, keeping the perforation very small. You make an intrascleral tunnel 2 millimeters posterior to the limbus in the orientation of the haptic as shown on the right. And use a 3-piece IOL. The 3-piece IOL can be a variety of different styles. But the material of the haptic is what’s so important. And you really do want to try, if you’re using a new design. The handheld cautery, to see what the flange will look like, prior to actually putting it in the eye. The needles after the haptics are introduced into the needles, they’re withdrawn, low temperature handheld cautery is used to create a flange that is buried into the sclera. The advantages are: It’s minimally invasive. It’s a small incision procedure. And it fixates the IOL to the sclera, when bag is not present. We find that the CT Lucia lens works best because the PVDF haptics are very resistant to kinking and there can be some manipulation that’s required in order to thread that. And here’s a video. This is actually by Brandon Ayres at Wills. And just nicely demonstrates the technique. In this case, he likes to put the lens in the eye. The leading haptic in the eye, and the optic. You can see putting that bent TSK needle 2 millimeters posterior to the limbus. Creating about a 2 millimeter tunnel. In the orientation of the haptic, before entering in the eye. Once you’ve entered, then you turn the needle, so you can visualize it in the pupil. And the other thing to notice is that he’s done a vitrectomy. There’s some trocars. He also has an AC maintainer in, to maintain pressure. He’s using microforceps. And the pupil is pretty small. Didn’t really have to dilate the pupil in order to do this technique. Of course, the bigger the pupil, always, I think, a little bit easier. But also prevents the IOL from falling posteriorly if it’s small enough. Once the first haptic is threaded into the needle, you can allow that to just sit there. Putting the next needle in, again, a 2 millimeter tunnel, in the direction of the haptic, so I always think about: Which way does the haptic go? And then you’re going to manipulate the optic so you can see the end of the haptic. And then carefully thread that into the needle, really threading it far enough. Because the most disappointing thing I find with this technique is if you withdraw the needle and the haptic is not there. So I try to get as much as I can into the needle. You can do — either withdraw them simultaneously or sequentially, as you see here. And then creating a very small flange. Does not need to be big. And that’s going to be the theme of all these flange techniques. And then you really want to make sure that you’re using something small. Usually I use the end of my Utratas, because they have a small point. And bury that into the superficial layers of the sclera. So nice demonstration of the Yamane technique here. So what are alternatives to exchange? So sometimes you just don’t want to exchange it. I’m just looking at questions here. How do you manage a Soemmering ring in the case of IOL exchange? We did this one. In the case of an IOL exchange, yeah, you’re kind of dealing with that like a cataract, in a lot of ways. A lot of times I’ll either — if we’re doing the belt loop technique, like I’ll show you in a minute — it’s an advantage to have it there. But if I’m removing the IOL and the bag and the Soemmering ring, you’re dealing with it like a cataract. In some instances, it’s as thick and dense as one. I typically elevate it into the anterior chamber, and you may have to use other instruments, even scissors, to try to cut through it and break it into smaller pieces. So the three-piece lens options are rotate it into the sulcus. That sometimes is okay if there’s sufficient capsular support. Can even do that with an optic capture. The Yamane technique, as we just showed. Glued intrascleral haptic fixation. Iris fixation. Scleral fixation. Or an in the bag belt loop with double flange technique that is on the right, actually. So Yamane is on the lower left there, and another example of that. Single piece, you don’t have so many options. You can’t leave it in the sulcus. You could do a scleral suture. With Gore-Tex, even. Or I prefer this in the bag belt loop technique, which I’m going to show you in a little bit. And sometimes there’s the option of a piggyback lens, if you’re looking at a refractive exchange. So flanged techniques have had an evolution. Really the beginning of them was the Yamane technique. So we’ve already talked about that. I want to show you this little variation. This is really how I do it. I like to keep it in the inserter. And then directly put it into the lumen in the needle from the inserter. I find that that’s a little more stable. And then of course the trailing one is the one that’s always a little bit more difficult. And then you want to externalize these. You can do a little adjustment by trimming one end or the other in order to get better centration. So that’s another option. It helps you fine tune the result. But we already saw that. So another double flange technique is to fixate the IOL through an eyelet. And that was actually how Sergio Canabrava, who started using segments of prolene suture, that was his first contribution, was looking at an eyelet fixation with the lens that came with an eyelet to begin with. I think it was a CZ70PD. And here’s another way of looking at that. With the closed loop haptics of the AO60 or Akreos, by Bausch and Lomb. There is under development in India and a couple different places — development of specific lenses for prolene suture fixation with two eyelets. So you can avoid tilt. But that is one way. And that would be in the case of an IOL exchange, rather than keeping the lens. I have developed this technique. The belt loop technique. For in the bag dislocations. And we’re gonna talk about this a little bit. We’re gonna… I’m gonna show you a couple videos. So don’t be too worried about looking at this right now. Because we’ll go over it step by step. But essentially you’re taking a prolene suture segment, making flanges on either side, going through the capsular bag, back out through conjunctiva and sclera, and just using the lens that’s already there. And we’ll talk about why that might be good. Another way is to actually create a fenestration within an IOL that’s already in the eye by using a punch. This is a punch developed by Morgan Micheletti from Texas, and is through Diamatrix. Or you could even just take the needle itself and pass it through the IOL. It tends to cause more damage to the IOL. A little bit of a stellate pass. It would depend on if you have a cutting needle or a tapered needle too. So I’m looking at needle solutions for that technique as well. Sometimes you can elongate the haptic. Just pierce the haptic itself with a needle and put prolene in there. You have to be very symmetric in how you enter the haptic and where on the haptic you’re doing this pass, in order to get good centration with this technique. And then this is an interesting thought as well. Where you’re creating sort of a little round button of the prolene suture and a fenestration there, and then putting the haptic through it, creating a flange, and using that as a longer haptic. So interesting innovations in this area. Let’s talk about the belt loop technique, though. That is actually… Thank you. Something that I’ve developed. And it was all based on this flange technique. It uses — typically for me now — 6-0 prolene. That allows you — and I’m gonna just move this aside so you can see. But that allows you to have a 30-gauge TSK needle, a very small perforation. Only uses handheld cautery. You could use intraocular forceps and do it intraocularly, but also extraocularly with regular forceps. So this is about as low technology as you can get for fixation of a dislocated in the bag IOL. And it’s appropriate for every type of IOL. Every kind of design I’ve done this technique with. And often avoids anterior vitrectomies, which I think is great for the patient. So here is a case. Somebody asked me about: What do you do if you have a trabeculectomy? What would be your solution? So here’s a nice elevated functioning trab and they had a toric IOL. They had a toric IOL, which was nice to want to keep it. But beyond that, I didn’t want to disturb the bleb or the conjunctiva unnecessarily. So I’ve marked 180 degrees apart in the axis of the toric. And I’m bending that TSK needle with the bevel up, and I’m placing it 2 millimeters posterior to the limbus through conjunctiva and sclera. And I’m going to place it through the capsular bag. Right between the haptic and the optic. At the area of the haptic-optic junction. And in these cases, fibrosis of the bag is actually beneficial. It helps keep this prolene suture from sliding. And now I am using intraocular forceps to thread this 30-gauge needle with the 6-0 prolene suture, cutting the bevel. Once it’s externalized, I grab it and create kind of a large flange. I call it a safety flange. It’s just there so I don’t pull it out. Because nothing is worse than pulling out a suture you already placed. Right? So now I’m inflating the sulcus. Bending another 30-gauge TSK needle, placing the other end of the same piece of prolene suture into the anterior chamber, that’s when you cut the bevel, and making sure that this needle goes in front of the haptic and the bag and the optic. So it’s purely in the sulcus now. And I’m taking that other end, threading it into the lumen of the needle, so that now it’s creating a loop, a loop through the capsular bag at the optic-haptic junction in the axis that I want it to be for this toric IOL. And then I’m going to snug that up a little bit. Not all the way yet. Because I’m going to place a similar belt loop, 180 degrees on the other side. Because this had generalized zonulopathy. And this is gonna allow me to very finely tune centration of this lens and the orientation. Because now it’s in the orientation that I want it to be for their toric lens. This is now putting the second pass, the second half of that first piece of — the second piece of prolene suture — creating the second belt loop. From behind the optic. Through the capsular bag. And now around through the sulcus and back out through the conjunctiva and sclera. Now, you can see at the beginning: It looks like this is gonna be decentered. But it’s because this loop actually flipped around. It flips over the wrong way. And so I just pushed in some more of the prolene suture, so that I can grab it, and flip it the proper way, and now centration can happen the way it should. Very small flanges are all that’s needed. You can just… As soon as you create just a little bit of elevation, and then… Or expansion… And then you really want to be able to bury these within the superficial layers of the sclera. Because the biggest risk with this technique — and now you can see I’m using the Utratas to bury that in — the biggest risk is really that you may get erosion over time. I have seen it happen once. It was an earlier case where I made a large flange and did not bury it sufficiently. I was doing this jiggle test. It makes me feel good about how strongly it’s fixated. You can see this avoided disturbing this nicely functioning bleb. And allowed the patient to keep the lens they wanted. And that really I think was a benefit to them. And we’re getting a little bit further in our talk. So I’m gonna go more quickly here. Just wanted to show you another example. This again is a bilateral, double belt loop, I call it. See what a taper this was cut at. That really facilitates your ability to put it into the lumen of the needle. Trying to be close to the optic-haptic junction. So variations of this: You can take a longer needle, a 27-gauge needle, even 5-0 prolene, and place the needle all the way across through a paracentesis, and load that externally. It’s easier especially if you don’t have really good quality intraocular forceps. So loading it externally, definitely an option. You can even preload. And again, there’s that safety flange. Very large. You can preload the suture into the lumen of the needle and push it forward as well. So a couple different ways of doing it. I tend to load intraocularly. I’m gonna go past that, because there are a few things I want to point out. This is extreme phimosis. This patient had a CTR. Somebody asked: What about a CTR in the eye? Just leave it. That’s another loop it’s going around and helps to stabilize it. So this patient has CTRs, I think it was a retinitis pigmentosa, potentially, patient. Obviously very aggressive fibrosis and phimosis. See the CTR right there. You can see it in the periphery here. There’s the CTR. What I’m doing is I’m going through the closed loop haptic. And now I’m externalizing it, outside of a paracentesis and loading the suture externally. And that I think — especially I’ve done this on mission trips where I don’t have all my fancy equipment. And that definitely makes it a more straightforward procedure. So I’m not gonna show you the rest of this. Because I do want to move on. To tell you: If you want to take a picture of this, these are step-by-step instructions of what to do with the belt loop. You mark posteriorly, 2 millimeters from the limbus. 180 degrees apart. Use that 30-gauge TSK needle if you’re using 6-0 prolene, pass it through the conjunctiva and sclera behind the optic through the capsular bag and then through the sulcus. And then create these small flanges. It’s very important that you bury them. And if you look to the right here, you’ll see that there’s a video of an extruded — that’s the one I was telling you about. It’s a large flange. See? That’s way too big. And it did erode through conjunctiva. And what I did was go back to the OR, trimmed it, melted a small flange, buried it appropriately. Now you can see it’s a tiny little dot buried in the superficial sclera, and the patient did very well. But we want to avoid the risk of endophthalmitis. So where would you want to avoid an IOL exchange? Well, cases like I showed you. Maybe they had a premium lens, maybe it’s a difficult to remove lens. You have to make a large incision, it’s a PMMA lens. You want to avoid the conjunctiva. So maybe trabeculectomy or a tube. It’s working well. Maybe they had a lot of surgery. Vitrectomy or a buckle. And you don’t want to get into the conjunctiva or it’s very scarred. And to avoid an anterior vitrectomy of course as well. So here’s the potential complications. There definitely are case studies showing endophthalmitis after this procedure, and you don’t want to risk that with patients. And talk about eye rubbing. So last polling question. In the setting of a dislocated bag-lens complex, like what we’ve been talking about, in what settings would you most often consider suturing the current lens, rather than exchanging the lens? So would it be conjunctival scarring from prior surgery? Like we talked about? Prior trabeculectomy or tube shunt? Maybe they have a dislocated premium lens. Or it’s difficult to remove the lens? And I know you may not know, but just in your practice, what do you envision if you’re not doing this already? Would be the major reason — what would be the patient circumstances where you would consider this technique? And for me, it’s really all of those things. And just in general, I like avoiding an anterior vitrectomy. I think that it avoids some of the complications that can happen with removing the lens and with vitrectomy. But… You know, there are settings that we find most often. So difficult to remove lenses… Yeah. I think that that’s a big one. And it depends on what area you live in and what the primary lens that’s been implanted is. So if you primarily in your region have PMMA lenses or plate haptic lenses, this is another reason why I would look for any method for retaining that lens, instead of having to exchange it. So let’s see. So this is the conclusion. Preoperative planning pearls. Make sure you have lots of options. I always have three lens choices and three plans available. Plan A, Plan B, Plan C. And I tell the patient: My primary goal is going to be to do the least invasive way possible. If we can retain the lens you have, that’s what I want to do. But I’ll have backup plans as well. I really won’t know exactly what’s gonna happen until I’m in your eye. Practice techniques, if they’re new, prior to the day of surgery. There are lots of eye models out there or if you can get donated eyes or pig eyes — but practice as much as you can so you’re not challenged on the day of surgery. Review videos. There’s tons of videos online. I’ll have videos on the belt loop right after this slide. Have plenty of supplies on hand. Sometimes I’ll think: I’m gonna do this technique and we’ll have this suture or this particular disposable available. Make sure your staff know you need it and they’re not on backorder and they’ve ordered them already. And review your whole plan with your team so they know what you’re doing. I often have them look at a video with me as well if I’m trying something new. And tell them exactly what I’m trying to achieve. And video your own cases, if possible. Even with smartphones. We can video our cases and look at them and try to refine techniques. So to I’m gonna give you the slide, actually. Let me close this for a second. I’m gonna show you the slide that has the links. So here it is. Let me look and see if I can answer some of these questions. So what technique for IOL removal? We talked about that. Soemmering ring. We did talk about that as well. Is there an indication of strabismus surgery in patients with scleral fixated IOLs? No. But I would definitely talk… If you’re the surgeon, of course you know what the issues are. If you’re referring to somebody else, I would definitely tell them where the suture is. What to look for. Is it a flange? Is it Gore-Tex suture? Is it prolene suture? And I would let them know that they maybe want to avoid that area if possible. But generally speaking, we’re not suturing at 3 and 9 o’clock, and that’s generally where strabismus surgery is taking place. So not an issue, usually. Do I recommend Yamane technique for refixation of a PMMA 3-piece IOL? Again, it just matters what the haptics are made of. So haptics of PMMA lenses are typically not PMMA. I don’t really know the answer to this question. But whatever lens you’re trying to use for a 3-piece, and we have several in the US, many of them do make flanges. The flange looks different depending on the haptic material. So sometimes it looks more tapered. And I can show you a picture. It will be hard for me to get to right now. But sometimes it looks tapered. And be aware of that. Make a larger flange. And sometimes it looks more like a button. And that material is really the best for creating a flange for the Yamane technique. So practice. Look at what happens when you use cautery on the lens you intend to use. And let’s see. So what situation do you prefer McCannel? I really use the iris fixation as my backup. Sometimes it’s Plan B. So if I try a Yamane surgery, and for whatever reason, my lens is tilting, I’m having difficulty with centration, just… Maybe it was a long day and it’s just a tough case or whatever it is… That’s my backup. And so I will put an iris fixated lens. There’s a double needle technique for that, that was popularized by a surgeon, John Hart. If you look on YouTube for double needle iris fixation with John Hart, you will see this technique. And by placing one of the needles primarily, and then going back and placing a second needle, you can actually make a more — a smaller bite of the iris more peripherally. And you’ll avoid that cat eye appearance that happens when the suture is too close to the optic. So that is the subject of another talk. But the videos that are on YouTube are really helpful. And that works well. And of course, you want to use 9-0 prolene. You can use 10-0 prolene too, but you’re at risk of breakage. And the cases I see that have breakage are typically iris fixated lenses. Thank you. You’re welcome. Please give more details on haptic elongation technique. So this is not a technique that I’ve used. But what you do is you create a large flange. Take a flat ended forceps. Squish that into a round circle. Take a 30-gauge needle and make a perforation in the middle of that squished circle. And then put the haptic through that. And then make a flange. That will stop it from being pulled through that squished circle. So if you Google haptic elongation, you’ll find that. I haven’t used it, but I have some ideas of how it could be really helpful. Regarding belt loop. Have you encountered suture slipping around the haptic? I have. Not postoperatively, but intraoperatively. So if you pull one side too tight to begin with, it will stretch out. Especially a single piece acrylic lens. It will stretch that haptic straighter. And if there was not a lot of fibrosis around the optic or around the haptic, it can slip off. So early in my experience with the belt loop, I did do that once. And so be careful. What I do now is I don’t tighten one side or the other. Once I put one belt loop, it’s not tight at all. And then I slowly externalize more and more suture on either side, balancing the two sides. Watching the lens come more anterior to a normal position, behind the iris. The typical thing you’ll do is not bring out enough suture. Because it’s a different feel. It feels like it’s tight when it’s not. But if you go very slowly, you’ll get it up there where you need it. Without pulling one side too tight and decentering the lens and elongating the haptic. That’s when that will happen. Exposed suture eroding the conj in a scleral sutured IOL or Yamane. So what I would do is what I showed in that last slide. Just go back to the OR, externalize a little bit more of the suture, cut the end, make a smaller flange, and rebury it. If it’s a scleral sutured IOL with Gore-Tex, that’s happened as well. And sometimes… The technique I would typically use with Gore-Tex involves making a sclerotomy, and you can just bury it better into a sclerotomy. Or you can create a small pocket to push it up into the sclera. But that always involves taking down conjunctiva. With the Yamane fixated or flange, you don’t have to take down the conjunctiva. And let’s see. Which of these is easiest learning curve? I like the belt loop. I think it’s pretty accessible. I think it’s actually probably more accessible than anything else. Especially if you externalize the end of the needle through a paracentesis. That stabilizes the eye. You can use any forceps to introduce the prolene suture, and it’s pretty straightforward. That’s what I think. Nylon 9-0, in case you don’t have prolene — the problem with nylon is it breaks. It degrades much sooner than prolene. That’s why we use it. But if all you have is nylon, then that’s what you have to use, unfortunately. Masket basket? I love that. First of all, I love the name. And Sam Masket is a great guy, I love Nicole Framm. Really cool thing. I actually haven’t used it. Because generally I grab it with the intraocular forceps and bring it anteriorly. But it’s a great safety net. And I think it’s a nice technique to know about. There will be a case I’m sure some day in the future where this will be the right thing for me, but I haven’t used it. Scleral puncture for the belt loop. So I mark 2 millimeters posterior to the limbus. And the first pass, the one that goes posterior and through the capsular bag, I put just posterior to the 2 millimeter mark. And then the second pass, which is the one through the sulcus anterior to the IOL, I’ll place just anterior to the 2 millimeter mark. So they end up being about a half millimeter apart on either side of the 2 millimeter mark, posterior to the limbus. Do I prefer Yamane? I do. Just because I don’t have to take down conjunctiva. So I think the glued IOL technique is great. Some people… A lot of people have a lot of experience doing it. And it’s very slick. It can really be used with most haptics that are 3-piece IOLs. I have done a bunch of them. But once Yamane came along, I actually have mostly done Yamane technique or belt loop. You’re welcome. Thank you guys. I’m so glad everybody was here from so many different areas. I was thrilled to see the list. I will treasure it. I hope that we all meet in person some day in the future. I’ll answer a few more questions too, but I just want to tell you how much I have enjoyed knowing that I’m connecting globally with so many people. My experience for the retrofixated iris claw lens — we don’t have access to it in aphakic powers here. And it’s not really used as a phakic IOL much either. So I have no experience. I would like to have experience. But we don’t have access to it. I would learn from all of you. So excited to see where you all are from. Thanks for joining me today. I think we got through all the questions, hopefully. Thank you guys.