October 2019

CATARACT

Webinar Spotlight
What the audience valued most from the Yamane technique webinar


by Liz Hillman EyeWorld Senior Staff Writer


Dr. Weikert described where to place incisions, make markings, and the necessity of 20-degree needle angulation to allow proper haptic orientation.
Source: ASCRS webinar screenshot

 

The ASCRS Cataract Clinical Committee hosted a webinar covering the increasingly popular flanged, double-needle intrascleral IOL fixation technique pioneered by Shin Yamane, MD, PhD. This technique was first showcased at the 2016 ASCRS Film Festival where it won the grand prize.
After the webinar, attendees shared the most valuable tips they learned. EyeWorld compiled some of that feedback and augmented it with additional insights from the webinar’s expert panelists Mitchell Weikert, MD, Brandon Ayres, MD, and Steve Safran, MD, who were led by moderator Nicole Fram, MD.

“Type of IOL, the type of needle, and the choice of anterior or posterior infusion.” “Materials needed for the case.” “Needle gauges and loops materials.”
Dr. Weikert said he uses the TSK aesthetic 30-gauge needle with 13 mm bore (PRC-3000131), but you could use a larger needle, such as a 27-gauge. MicroSurgical Technology (MST) is developing a needle set for the Yamane technique, Dr. Weikert said. Both Drs. Weikert and Safran noted the importance of inspecting/testing the needle before starting the case to make sure the lumen is adequate to receive the haptic.
The needles should be angled about 5 degrees from the surface of the eye, but “you want to come in pretty flat along the iris plane” so you enter in the sulcus, Dr. Weikert said, explaining that approaching too steeply can result in suboptimal externalized haptics.
Dr. Weikert said it’s important to have balanced salt solution in the syringe loose on the needle. This solution should be pushed through the tip of the needle to prevent air bubbles when you are inserting it. The syringe is removed after needle insertion. Dr. Weikert uses 25-gauge MAXGRIP forceps (Alcon) through the paracentesis. An AC maintainer or a trocar can be helpful in these cases as well, Dr. Weikert said.
Three-piece IOLs should be used. Dr. Weikert said they have used different kinds, but the CT LUCIA 602 (Carl Zeiss Meditec) is his favorite due to its stronger, shape-maintaining PVDF haptics.

“Meticulous measurement and practice in wet labs.” “Needle and paracentesis placement …”
Dr. Weikert noted the 20-degree needle angulation needed for proper haptic orientation. One way to ensure this is to make three marks on each side. Mark the eye 180 degrees across the limbus, then 2 mm away from the limbus on that same plane. See Figure A and B to view these marks and where the third mark should be made in relation.
Dr. Ayres said despite being experienced with Yamane, he takes a long time to measure. “It’s all about measuring five times for good centration,” he said.
Dr. Weikert advocated practicing this technique in the lab, specifically mentioning SimulEYE (InsEYEt). Dr. Fram said using the SimulEYE gives you the confidence to practice incision placement, marking, and techniques to grab the distal haptic.

“Symmetry is key to IOL centration.” “Critical for symmetrical tunnels to ensure centering.” “Avoiding decentration.”
Once the lens is in the eye and the haptics externalized, you might notice the lens pivoting when you start to embed the haptics. Decentration is related to asymmetrical scleral tunnels, Dr. Weikert noted. “In general, if you’ve got one side that positions a little better than the other, you can always trim the haptics or melt one a little more than the other,” he said.
Dr. Safran said he doesn’t like shortening one of the haptics to achieve centration and would rather make a new scleral tunnel to achieve centration. Making one haptic shorter than the other could cause tilt, he cautioned.

“Redocking the haptic if the IOL is decentered.”
If the lens is decentered while performing the Yamane technique, so much so that haptic trimming won’t correct it, Dr. Safran said he redocks the haptics to achieve perfect centration. If the sclerotomy positions, for example, are causing the decentration, Dr. Safran said one should create a new sclerotomy in the correct position, grab the haptic pulling it back into the eye, and redock the haptic into your new needle pass.

“Doing pars plana anterior vitrectomy before bringing through the IOL/bag complex into the AC.”
“Even in patients who have already had a vitrectomy, be ready for more vitrectomy,” Dr. Ayres said.
To comfortably manage a subluxated IOL or IOL exchange, Dr. Ayres said it’s essential to perform pars plana incisions. “I don’t think these cases are well managed if you can only use the anterior segment,” he said. “You’ve got to be able to lift these lenses, and I think doing a vitrectomy before you put that lens into the anterior chamber is important just to make sure there is no vitreous traction.”
Dr. Fram pointed out that ASCRS provides wet lab trainings for anterior and pars plana vitrectomy. If you are a novice with this, however, she said starting these cases with a fully vitrectomized eye or performing the case with a retina specialist is helpful.
Dr. Safran also advocated for pars plana vitrectomy because he said the manipulations of the Yamane technique are behind the iris.

“Peripheral iridotomy.” “PI at the end of the case.”
Dr. Safran said it’s a “critical step” to make a peripheral iridotomy (PI) with a vitrector in order to avoid reverse pupillary block; it’s something he does on every Yamane case. He makes the PI on the temporal side because it causes less monocular diplopia. Dr. Safran said it’s important to engage the iris with the cutter on (vs. aspiration) so as to not make too large of a PI. Some high myopes, he noted, may need more than one PI.

About the doctors

Brandon Ayres, MD
Instructor
Sidney Kimmel Medical College, Thomas Jefferson University
Philadelphia

Nicole Fram, MD
Clinical instructor of ophthalmology
Stein Eye Institute, University of California, Los Angeles

Steve Safran, MD
Solo practice
Lawrenceville, New Jersey

Mitchell Weikert, MD
Associate professor
Cullen Eye Institute, Baylor College of Medicine
Houston

Relevant financial interests

Ayres
: MicroSurgical Technology
Fram: None
Safran: None
Weikert: None

Watch the webinar

The full webinar— “Management of Dislocated IOLs and Secondary IOL Placement: Yamane Technique”
—can be found in the ASCRS Center for Learning, www.ascrs.org/center-for-learning.

Tips from Dr. Ayres

•Being prepared in the operating room, both mentally and with the correct instrumentation, is essential for a good outcome.
•Know the details of the IOL being removed and the IOL being placed.
•Consider future surgical procedures and the impact this has on IOL selection and IOL fixation technique.
•Have a backup plan in place in case “things happen.”

Contact information

Ayres: brandonayres@me.com
Fram: nicfram@yahoo.com
Safran: safran12@comcast.net
Weikert: mweikert@bcm.edu

What the audience valued most from the Yamane technique webinar What the audience valued most from the Yamane technique webinar
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