Background: Sutureless intrascleral intraocular lens (IOL) fixation using the Yamane technique is an option for visual rehabilitation in eyes without capsular support. The aim of this study is to report long-term visual outcomes and clinical predictors in consecutive real-world cohorts, a topic addressed by very few previous studies. Methods: This was a single-center, single-surgeon consecutive case series including 87 eyes of 85 patients who underwent Yamane SFIOL for aphakia or lens/posterior chamber IOL ectopia, with at least 12 months of follow-up. BCVA was measured using a Snellen chart and recorded in decimal notation. To identify predictors of postoperative BCVA, univariable screening was first performed, followed by a clinically driven multivariable linear mixed-effect regression. Results: Mean age was 68.2 ± 11.4 years, and 70.6% were male. Median follow-up was 26.5 months. Median BCVA improved from 0.2 ± 0.2 (range 0.001-1.0) preoperatively to 0.9 ± 0.2 (range 0.2-1.0) postoperatively (p < 0.001). Surgical indication and preoperative comorbidity burden were not linked to postoperative BCVA. In the multivariable analysis, older age (B = -0.005, p = 0.027), macular edema (B = -0.242, p = 0.035), and prior silicone oil removal (B = -0.237, p = 0.046) independently predicted lower postoperative BCVA. Conclusions: Yamane SFIOL provides significant long-term visual improvement, with outcomes mainly determined by patient age and retinal status. This study offers new data on functional outcomes and clinically relevant predictors in a consecutive real-world cohort, supporting the reliability and long-term efficacy of sutureless scleral IOL fixation.

To describe a haptic-bending adjustment technique for correcting persistent posterior intraocular lens (IOL) tilt after flanged intrascleral fixation and to evaluate its anatomical and optical outcomes. This retrospective case series included four eyes with symptomatic postoperative IOL tilt following flanged intrascleral fixation. The haptics were first shortened and re-flanged, and an additional bend was created approximately 1 mm proximal to the haptic tip on the side corresponding to the posterior tilt. IOL tilt was quantified using Scheimpflug imaging, and refractive outcomes were analyzed using power-vector analysis of manifest refraction. Patient age ranged from 32 to 63 years, with a mean operative time of 25.5 ± 8.23 minutes. IOL tilt decreased from 6-8° to 2-4° and remained stable during follow-up. All eyes showed improved visual acuity and reduced refractive astigmatism without change in corneal astigmatism. No intraoperative complications, recurrent tilt, or reoperations occurred. Haptic bending combined with haptic shortening may provide a feasible option for correcting posterior IOL tilt after flanged intrascleral fixation without creating new scleral tunnels or exchanging the IOL.

To evaluate the refractive prediction accuracy of intraocular lens (IOL) power calculation formulas after flanged intrascleral IOL fixation(SF-IOL; Yamane technique) in long axial length (AL) eyes. The University of Osaka Hospital, Osaka, Japan. Retrospective observational cohort study. Eyes undergoing SF-IOL between January 2023 and April 2024 were classified into normal (N, <26.0 mm) and long (L, ≥26.0 mm) AL groups. Barrett Universal II, Hoffer Q, Holladay 1, and SRK/T were evaluated. Prediction error (PE) was defined as 3-month postoperative spherical equivalent minus predicted value. Prediction accuracy was assessed using root mean square absolute error (RMSAE) and the Formula Performance Index (FPI). Fifty-three eyes from 50 patients were analyzed (N=35; L=18). Mean AL was 24.6±0.8 mm (N) and 27.1±1.0 mm (L). Mean PE (N and L) was -0.55±0.72 D and -0.64±0.62 D with Barrett Universal II (P=0.52), -0.68±0.77 D and -0.45±0.62 D with Hoffer Q (P=0.32), -0.78±0.74 D and -0.31±0.72 D with Holladay 1 (P=0.043), and -0.74±0.72 D and -0.62±0.72 D with SRK/T (P=0.60). In L group, Holladay 1 showed PE nearest zero; however, demonstrated steep AL-PE regression slope and low FPI. Barrett Universal II yielded the lowest RMSAE and the highest FPI. Barrett Universal II demonstrated the highest overall predictive accuracy in long AL eyes undergoing SF-IOL. Although Holladay 1 produced a smaller PE in long AL, this reflected systematic offset rather than superior accuracy, as indicated by its lower FPI.

Long-term Clinical Outcomes of a Modified Yamane Technique for Intrascleral Sutureless Posterior Chamber Intraocular Lens Fixation.

To evaluate whether two simplified mo-difications of flanged intrascleral fixation techniques (Yamane and Canabrava) provide comparable refractive outcomes and complication rates while reducing surgical complexity in tro-car-assisted vitrectomy. This retrospective observational study included 88 patients who underwent flanged fixation surgery with vitrectomy. In the modified Yamane technique, a single-path sclerotomy with bilateral symmetry was performed instead of an angled sclerotomy. In the modified Canabrava technique, the intraocular lens was inserted first, followed by the creation of a circular polypropylene loop with 2-mm flange spacing. Postoperative refractive parameters, including intraocular lens astigmatism, and complications such as intraocular lens iris capture were analyzed. Of the 88 patients, 70 underwent the modified Yamane technique, and 18 underwent the modified Canabrava technique. No significant differences were observed between the two techniques regarding refractive outcomes or postoperative complications, except for surgical duration, which was significantly shorter (p<0.001) in one technique. Mean intraocular lens astigmatism was -0.675 D for Yamane and -0.666 D for Canabrava. Optimizing needle engagement for symmetry in the Yamane technique and narrowing flange spacing while ensuring a circular polypropylene configuration in the Canabrava technique may reduce surgical complexity and improve postoperative outcomes.

To demonstrate the novel use of a 31-gauge needle for flanged intrascleral intraocular lens (IOL) fixation using the double-needle technique. Flanged intrascleral IOL fixation was performed using the ZELOSTAT 31G (ASTI, Shizuoka, Japan) needle in a 73-year-old male with right IOL subluxation. The IOL was successfully fixated with smooth intraoperative handling, excellent postoperative outcomes, no complications, and minimal refractive error. The 31-gauge needle has a larger inner diameter compared to the conventional 30-gauge thin-wall needle, which may facilitate intrascleral IOL fixation procedures.

Correspondence

PurposeThe purpose of this study was to evaluate a novel method using stretchable strain sensors for analyzing hand movements during simulated intrascleral intraocular lens (IOL) fixation, allowing differentiation between expert and novice surgeons.MethodsSix participants (3 experts and 3 novices) performed intrascleral IOL fixation on a simulated eye model while wearing stretchable strain sensors on all fingers to capture real-time finger movements. Two critical procedural phases were defined: leading and trailing haptic insertions (critical process [CP]1 and CP2, respectively). Time-series data extracted from the sensors were processed using “tsfresh” to compute multidimensional features, and they were classified using a light-gradient boosting machine (LightGBM). Performance was assessed using three-fold cross-validation, and the feature space was further explored using principal component analysis (PCA).ResultsIn total, 107 procedures were analyzed. Experts completed CP1 and CP2 more quickly than novices. Feature extraction yielded 899 and 472 features for CP1 and CP2, respectively. The LightGBM classifier achieved high accuracy in distinguishing experts from novices, with average accuracies of approximately 87% to 88% for CP1 and 86% to 87% for CP2. PCA showed that thumb and index finger movements of the dominant hand substantially contributed to the discrimination of skill levels.ConclusionsOur findings showed the feasibility of using wearable strain sensors to quantify microsurgical finger movements, facilitating objective evaluation of surgical skills. This approach represents a promising step toward more refined and data-driven surgical training and evaluation methods.Translational RelevanceThis novel sensor-based method could help refine surgical training and evaluation, potentially enhancing patient safety and outcomes through data-driven skill assessment.

The objective of this study was to apply secondary intraocular lens (IOL) intrascleral fixation with lens capsule preservation in a patient with IOL dislocation following mature cataract surgery with incomplete continuous curvilinear capsulorhexis (CCC). A 56-year-old Japanese woman experienced distorted vision 4 days after phacoemulsification and intracapsular IOL implantation for a mature cataract. Slit-lamp examination revealed inferior-nasal dislocation of the intracapsular IOL through an anterior capsule defect (3-6 o'clock) caused by peripheral extension of the CCC during the primary surgery. IOL extraction followed by intrascleral fixation with lens capsule preservation was performed 1 week after the initial surgery. The secondary surgery involved inserting a 30 G needle between the lens capsule and iris, with IOL fixation to the sclera using a double-needle technique. The IOL optics were successfully captured through the incomplete anterior CCC of the preserved lens capsule. No intraoperative vitreous prolapse occurred, eliminating the need for a vitrectomy. The IOL remained well-fixed without IOL pupillary capture. Additionally, no significant complications such as retinal detachment or vitreous hemorrhage were observed. Preserving the capsule during secondary intrascleral fixation for IOL dislocation in patients with incomplete CCC offers several advantages, including reduced intraoperative vitreous prolapse, minimized surgical invasiveness, suppression of postoperative iris flutter, and prevention of IOL capture within the pupil. However, the long-term outcomes, including the potential risk of lens capsule drop, warrant further investigation with more cases.

To compare the surgical outcomes of two techniques for managing dislocated lenses with zonular insufficiency. This study included 64 eyes of 64 patients with complete or near-complete zonular loss undergoing lens removal surgery. Patients were divided into two groups: Group 1 (n = 34) underwent phacoemulsification with temporary capsular tension ring assistance, followed by anterior vitrectomy or pars plana vitrectomy; Group 2 (n = 30) underwent ultrasonic fragmatome-assisted lens removal with perfluorocarbon liquid support and subsequent pars plana vitrectomy. Intrascleral intraocular lens fixation and peripheral iridectomy were performed in all cases. The mean age of patients was 64.1 ± 9.7 years in Group 1 and 65.7 ± 8.6 years in Group 2 ( P = 0.51). Postoperative best-corrected visual acuity significantly improved in both groups ( P < 0.001). No clinically significant intrascleral intraocular lens decentration or tilt was observed in either group. Cystoid macular edema and transient intraocular pressure elevation were noted in 5.9% of Group 1, compared with 23.3% and 20% in Group 2, respectively ( P = 0.04 and P = 0.08, respectively). Retinal detachment occurred in 3 cases (10%) in Group 2, whereas no such complications were observed in Group 1 ( P = 0.05). Cortical remnants were detected in the posterior segment in three eyes (10%) in Group 2, whereas no such complications were observed in Group 1 ( P = 0.05). Phacoemulsification with temporary capsular tension ring assistance, followed by scleral Intrascleral intraocular lens fixation and pars plana vitrectomy/anterior vitrectomy, provided a safer surgical approach with fewer complications in patients with dislocated lenses compared with fragmatome-assisted techniques.

To evaluate the efficiency and safety of iris retractor-assisted cataract surgery with modified scleral fixation for treating subluxated lenses. We developed a modified technique combining iris retractors with intrascleral intraocular lens (IOL) fixation for the treatment of moderate or severe lens subluxation due to non-progressive or progressive zonular defects. A retrospective case series study was conducted, including patients diagnosed with severe zonular dialysis who underwent this technique. Clinical data were collected and analyzed, including comprehensive ophthalmic examinations, anterior segment optical coherence tomography, surgical procedures, and outcome measures such as visual acuity and IOL positioning. Fourteen eyes from fourteen patients (four females and ten males), with a mean age of 56.36 ± 17.74years and severe zonular loss, were enrolled in the study. All patients were followed up for a mean of 22.5 ± 15.4months (range 4-49months). The mean visual acuity improved significantly after surgery (p < 0.001), and the IOLs were well-centered. Postoperative transient intraocular hypertension was observed in one patient. This modified technique simplifies the surgical procedures for treating severe lens subluxation and reduces postoperative complications.

Postoperative complications of intrascleral intraocular lens fixation: A systematic review and meta-analysis.

BackgroundPupillary capture can cause complications after intrascleral intraocular lens (IOL) fixation; however, no method has been established to definitively prevent pupillary capture. Therefore, we aimed to examine the differences in the incidence of pupillary capture in patients who underwent intrascleral IOL fixation and had intraoperative lens capsule preservation or lens capsule loss.MethodsThis single-center, retrospective study, conducted at a University Hospital, included 83 eyes from 83 patients. The eyes were allocated to the capsule and no-capsule groups based on the presence or absence of capsule, respectively. Patient demographics, causative diseases, incidence of pupillary capture at 1 year postoperatively, anterior chamber depths (ACDs), IOL tilts, and decentrations of the two groups were analyzed and compared.ResultsThe capsule and no-capsule groups comprised 26 and 57 eyes, respectively. The indications for intrascleral IOL fixation were: IOL dislocation in 6 (23.1%) and 41 (71.9%), artificial aphakia in 4 (15.4%) and 2 (3.5%), conversion during cataract surgery due to complications (zonular dialysis or posterior capsule rupture) in 14 (53.9%) and 3 (5.3%), lens dislocation in 0 and 11 (19.3%), and IOL opacification in 2 (7.7%) and 0 eyes in the capsule and no-capsule groups, respectively (P < 0.05). The postoperative outcomes including ACD, magnitude of tilt, or decentration of the fixed IOL did not differ between the two groups (P > 0.05). Pupillary capture was observed in eight eyes, all in the no-capsule group (P < 0.05).ConclusionsWhen performing intrascleral fixation in cases where the lens capsule remains, preserving the capsule and fixing the IOL under the capsule may prevent postoperative pupillary capture.

Response to letter to editor regarding LONG-TERM OUTCOMES OF SUTURELESS INTRASCLERAL INTRAOCULAR LENS FIXATION IN CHILDREN AND ADULTS: Single-Surgeon Case Series With and Without Haptic Flanging With Up to 11 Years of Follow-Up.

ObjectivesThis study aimed to identify the etiology and the direction of dislocation of the natural crystalline lens or intraocular lens (IOL) in IOL intrascleral fixation surgery and to determine the change in intraocular pressure (IOP) after surgery.MethodsWe retrospectively investigated the diagnosis, direction of lens and IOL dislocation, and IOP before and after surgery (preoperatively and one day, one week, and one month postoperatively) in 236 eyes from 228 patients who underwent IOL intrascleral fixation at Chiba University Hospital between February 2015 and September 2020.ResultsIOL intrascleral fixation was performed in 48 (20.3%) patients with long eye axis, 44 (18.6%) with pseudoexfoliation (PEX), 42 (17.8%) with intraoperative problems such as ciliary zonule rupture or posterior capsule rupture, 40 (16.9%) with a history of trauma, 34 (14.4%) with a history of vitrectomy, 21 (8.9%) with atopic dermatitis, six (2.5%) with genetic diseases such as Marfan syndrome, four (1.7%) with retinitis pigmentosa, and 58 (24.6%) with unknown causes. Downward IOL dislocation was the most common (52 cases), while IOL falling into the vitreous cavity was seen in 46 cases, aphakic eye in 31 cases, and anterior lens dislocation in 16 cases. In general, IOP was significantly lower at one month postoperatively than preoperatively. Specifically, in the trauma, PEX, and unknown causes groups, as well as the groups with anterior lens deviation, IOL fell into the vitreous cavity, and with IOL downward deviation, IOP was significantly lower.ConclusionIOP was significantly lower one month postoperatively than preoperatively after IOL intrascleral fixation. Patients who underwent IOL intrascleral fixation surgery were most commonly found to have long eye axis, PEX, and intraoperative problems. Downward deviation of the IOL or IOL falling into the vitreous cavity was most common. IOP was significantly lower one month postoperatively than preoperatively after IOL intrascleral fixation.

To evaluate the refractive prediction error of common intraocular lens (IOL) power calculation formulas in patients who underwent intrascleral IOL fixation using the four-flanged technique. This prospective, longitudinal, single-site, single-surgeon study's setting was the Department for Ophthalmology and Optometry, Medical University of Vienna, Austria. Patients who received IOL implantation via the four-flanged technique were followed up to 3 months after the operation. Refraction was measured using the Early Treatment of Diabetic Retinopathy Study visual acuity test at 4 m. Lens decentration, tilt, and aqueous anterior chamber depth were evaluated using anterior segment optical coherence tomography. The SRKT, Holladay 1, and Hoffer-Q formulas were used to assess prediction error (PE) and absolute error (AE). Correlations between axial length, keratometry, and white-to-white distance were subsequently evaluated. A total of 28 eyes of 28 patients were examined in this study. The application of all formulas resulted in a hyperopic PE (SRKT: 0.35 ± 0.86 diopters [D], Holladay 1: 0.36 ± 0.78 D and Hoffer-Q: 0.37 ± 0.73 D). There was no variation between the PE of different formulas discovered (P > .05). The AE was within 0.50 D in 54% to 61% and within 1.00 D in 79% of eyes, depending on the formula used. Furthermore, Cochrane's Q test detected no significant distinctions between formulas (P > .05). The PE of each formula demonstrated a significant correlation to the axial length of the eyes (P < .05). The correlation estimates ranged from -0.25 D/mm to -0.39 D/mm, subject to the applied formula. This study demonstrates that the four-flanged technique for scleral IOL fixation yields reliable outcomes. PE was closest to zero using the Hoffer-Q formula, although there was no statistically significant difference compared to the other formulas. Axial length emerged as the most pertinent factor for PE. Short eyes resulted in a more hyperopic outcome, whereas longer eyes resulted in a more myopic outcome than intended. This myopic and hyperopic shift was due to the standardized surgical technique with an externalization of the haptics 2.5 mm behind the limbus resulting in a consistent aqueous anterior chamber depth across all eye lengths, coupled with a reduction or increase in the distance from the IOL to the macula, which is dependent on the length of the eye. [J Refract Surg. 2024;40(12):e985-e993.].

Peripheral Iridectomy in Intrascleral Intraocular Lens Fixation: Preventing Reverse Pupillary Block

BackgroundImplantation of intraocular lens in the capsular bag has become the standard of care in aphakic state. However, in the absence of capsular support, several techniques and intraocular lenses are available. Our study aims to report the safety, efficacy, and clinical outcomes of transconjunctival intrascleral intraocular lens fixation with Yamane’s double-needle technique and flanged haptics.MethodsProspective, observational study with some retrospective data collection. The study enrolled 13 patients (16 eyes) who underwent transconjunctival intrascleral fixation of an intraocular lens with Yamane’s technique between June 2017 and April 2019 at Dhahran Eye Specialist Hospital and King Fahd University Hospital. All patients underwent preoperative and postoperative comprehensive evaluation, including uncorrected and best-corrected vision, intraocular pressure, slit-lamp examination, dilated fundus examination, and ultrasound biomicroscopy. We excluded patients with visually significant coexistent pathology such as retinal diseases, glaucoma, follow-up less than three months, and combined surgery such as keratoplasty.ResultsThe mean preoperative uncorrected visual acuity was 1.50 logMAR, and it improved to 0.60 logMAR. The mean preoperative best-corrected visual acuity was 0.70 logMAR, and it improved to 0.40 logMAR. The median safety index was 2.0, and the median efficacy index was 1.58. The postoperative complications included iris capture by the intraocular lens in one eye (7.7%), haptic extrusion in one eye (7.7%), and transient cornea edema in one eye (7.7%). There were no detected reports during the follow-up period of postoperative retinal detachment, choroidal detachment, elevation of the intraocular pressure (> 25 mmHg), hypotony, hyphema, vitreous hemorrhage, or endophthalmitis.ConclusionsThe transconjunctival intrascleral fixation of an intraocular lens is safe and effective with a short learning curve and was not associated with significant intraoperative or postoperative complications.

To investigate the surgical outcomes of intrascleral intraocular lens (IOL) fixation using a modified extraocular forceps-guided technique. Retrospective case series. Overall, 81 eyes of 78 patients who underwent intrascleral IOL fixation using the modified extraocular forceps-guided technique were included. The procedure entailed creating 2 scleral half-layer T-shaped incisions perpendicular to the main incision and forming a scleral tunnel. A 25-gauge trocar was inserted at the lower end of the T-shaped incision to perform vitrectomy. A 27-gauge needle was inserted from the left-hand port, and the leading haptic was inserted into the needle lumen. After removal of the right-hand trocar, a 90°-curved intrascleral fixation forceps was inserted into the eye, exposing the tip at the main incision, thus allowing the tip of the extraocular trailing haptic to be gripped and both haptics to be pulled out. The left-hand trocar was removed, and the haptics were buried in the scleral tunnel. The surgical outcomes of this technique were retrospectively evaluated on the basis of the medical records. The induction of haptics was successful in all cases. The preoperative best-corrected visual acuity improved from 0.35±0.68 to 0.12±0.36 logMAR postoperatively (P<0.01). The refractive error was -0.27±0.87 D; IOL decentration, 0.39±0.18 mm; IOL tilt, 5.97±2.65°; IOL astigmatism, 0.35±0.36 D; and corneal endothelial cell loss, 10.3±12.7%. There were no serious complications related to the surgical technique. The modified extraocular forceps-guided technique allows for safe and straightforward induction of the trailing haptics and enables the performance of intrascleral IOL fixation with minimal scleral incisions.

Objective: To evaluate the efficacy of sutureless intrascleral intraocular lens (IOL) fixation with the modified Yamane technique. Methods: It was a retrospective case series study. Patients undergoing sutureless intrascleral IOL fixation with the modified Yamane technique were included at Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University from January 2022 to September 2023. Uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA), recorded as the logarithm of the minimum angle of resolution (logMAR), were measured before surgery and at 1 day, 3 days, 1 week, 1 month, and 3 months postoperatively. Refractive error and intraocular pressure were also checked. Anterior segment examination with a slit lamp microscope, fundus examination, anterior segment and posterior segment optical coherence tomography were performed. Intraoperative and postoperative ocular complications were documented. Results: A total of 53 patients (53 eyes) were included in this study, comprising 40 males and 13 females, with a median age of 60 (49, 68) years. Among them, the proportion of a history of trauma was 22.6% (12/53). There was 1 eye with intraoperative vitreous hemorrhage (1.9%). All eyes had no obvious hypotony, no obvious inflammation in the anterior chamber, and no pupillary abnormalities at 1 week after surgery. The mean follow-up time was (8.0±3.3) months (range, 3 to 16 months). There was no iris capture, re-dislocation, or haptic exposure of the IOL during the follow-up. The corneal endothelial cell density was (2 236±704) cells/mm2 preoperatively and (1 964±628) cells/mm2 at 1 month, with significant difference (P<0.001). The UCVA (logMAR) was 1.53±0.75 preoperatively, 0.18±0.17 at 1 month, 0.15±0.14 at 3 months, and 0.14±0.13 at the final visit (P<0.001). The UCVA (logMAR) at 1 month was significantly different from that at 3 months and the final visit (both P<0.05). At 1 month, 50.9% (27/53) of the eyes had an UCVA (logMAR)≤0.1, and the rate was 56.6% (30/53) at 3 months. The BCVA (logMAR) was 0.25±0.21, 0.03±0.06, 0.02±0.06, and 0.02±0.06 before surgery, at postoperative1 month, 3 months, and the final visit, respectively (P<0.001). The BCVA (logMAR) at 1 month was not significantly different from that at 3 months and the final visit (both P>0.05). The rate of the eyes with a BCVA (logMAR)≤0 was 81.1% (43/53) at 1 month and 83.0% (44/53) at 3 months. The IOL tilt was (5.18±2.60)° at postoperative 1 month and (5.08±2.48)° at postoperative 3 months, without statistically significant difference (P>0.05). The IOL decentration was (0.35±0.24) mm at postoperative 1 month and (0.32±0.24) mm at postoperative 3 months, without statistically significant difference (P>0.05). Conclusion: Sutureless intrascleral IOL fixation with the modified Yamane technique is simpler and more minimally invasive to achieve a stable and centered IOL implantation with fewer complications and good visual prognosis.