Kourtney Houser, MD; Joshua Duncan, DO; Mitchell P. Weikert, MD; and Zaina Al-Mohtaseb, MD
A novel, small-incision, sutureless, transconjunctival scleral fixation technique was first described by Yamane et al in 2017.1 This technique, using small-gauge sclerotomies and a small clear-corneal incision results in fast visual recovery and a low risk of postoperative hypotony.
Preparation
- Place a 19- or 20-gauge anterior chamber maintainer or a pars plana infusion trocar to maintain a firm intraocular pressure inferotemporally for right eyes or superotemporally for left eyes.
- Create 2 paracenteses at approximately 8 and 1 o’clock in a right eye or 2 and 7 o’clock in a left eye.
- Bend 25-gauge Grieshaber MaxGrip (Alcon Laboratories, Inc) forceps in a 60-degree curve using a sliding technique. Exercise caution so as not to damage the grasping mechanism. MicroSurgical Technology’s 23- and 25-gauge forceps are acceptable alternative and reusable forceps.
- Bend two 30-gauge, half-inch, large lumen, thin-walled needles (TSK Ultra Thin Wall Needle; Tochigi Seiko) and loosely attach each to a non-luer-locking tuberculin syringe filled with balanced salt solution (BSS). The BSS fill prevents bubbles from entering the eye following needle passage.
- Test insertion of intraocular lens (IOL) haptics to ensure they fit through the lumen of each needle.
IOL Fixation
- Using a temporal approach, mark the corneal limbus at 6 and 12 o’clock, exactly 180 degrees apart. If you are satisfied with the location of these marks, place 2 additional marks on the conjunctiva 2.5 mm peripheral to the limbus. This preparation helps to maintain centration and allows for correct placement of the needles for scleral insertion.
- Create a clear corneal incision (2.4 to 2.75 mm in width) just left of temporal, centered at approximately 10 o’clock (right eye) and 4 o’clock (left eye). This position facilitates alignment of the trailing haptic with its fixation needle.
- Insert the 3-piece IOL via injector into the anterior chamber, with the leading haptic resting on the nasal iris and the trailing haptic outside of the eye.
- Stabilize the globe with toothed forceps near the marked point of needle insertion, starting with the 12 o’clock position in the right eye or the 6 o’clock position in the left eye (for the leading haptic). Insert one of the pre-bent 30-gauge needles on the BSS-filled tuberculin syringe into the sclera in a nasal direction at a 20-degree angle relative to the limbus and directed 5 degrees downward relative to the iris plane (per the original Yamane video2). Insert the needle 1.5 bevel lengths into the sclera before directing it radially to enter the eye through the ciliary sulcus (Figure 49-1). Watch the iris root carefully to ensure the needle is entirely posterior to the iris.
Figure 49-1. Insert a pre-bent 30-gauge needle into the sclera 2.5 mm peripheral to the limbus at a 20-degree angle relative to the limbus, directed 5 degrees downward relative to the iris plane, and in a nasal direction.
Figure 49-2. Insert the 25-gauge MaxGrip forceps through the 2 o’clock paracentesis (for a left eye), grasp the leading haptic, and thread it into the needle.
Figure 49-3. Insert the second needle into the sclera in a temporal direction, equal in angle and opposite in direction as the first.
Figure 49-4. Grasp the trailing haptic with MaxGrip forceps through the 5 o’clock paracentesis (for the left eye) and thread the haptic into the needle.
Figure 49-5. Grasp the haptics once externalized with tying forceps to prevent retraction back into sclera.
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