I wish I hadn’t done that: Lessons learned from Yamane gone wrong
This column is the latest article in the ongoing series “I wish I hadn’t done that.” Past submissions can be read here.
Suddenly, and for reasons that I cannot explain, my practice is awash in dislocated IOLs. Most of these are not my fault — he said defensively — but now they are definitely my problem.
Source: Jack S. Parker, MD, PhD
Lately, my preferred procedure for repair is Yamane intrascleral haptic fixation. This operation has acquired a reputation for technical difficulty, so naturally it is a point of great pride to perform this surgery successfully. Of course, nothing deflates feelings of superiority and self-importance like seeing these lenses in the postoperative period decentered, dangling or tilted and requiring reoperation or referral out.
In the past, I became so discouraged by my own failures in these regards that I abandoned the Yamane method and retreated back to glued IOL fixation for most of my cases. The glued IOL technique described originally by Dr. Amar Agarwal is an older strategy but remains an effective, simple and safe way to scleral fixate a wide variety of IOLs without sutures.
For the past year, however, I have returned to Yamane, mostly because of the potential time savings vs. the glued technique, but also because of a lingering sense of guilt and inadequacy in being unable to perform this operation skillfully. Gradually, I have picked up a few tricks that have made things a bit easier for me. Most notably, I have come to prefer the MA50BM lens (Alcon) instead of the Zeiss CT Lucia because the former has a larger optic and therefore seems to be more forgiving of decentration. It also provides a bigger backboard for unfolding maneuvers in the event that I am combining the operation with DMEK. Beyond this, I have started paying more careful attention to the length of my needle passes through the sclera (which, I think, is the primary factor influencing centration), and finally, I have begun copying Richard MacKool’s strategy of externalizing the trailing haptic and docking it into the needle, outside the eye, which renders the most technically challenging element of this operation immensely easier. These little improvements have significantly reduced my rates of lens decentration and tilt. That is why, recently, I had to figure out a brand-new way to screw up this surgery, which is the subject of this month’s column.
The patient was a sweet lady with a dislocated three-piece IOL placed elsewhere many years ago. For some reason, I decided to explant this lens and replace it with a MA50BM with Yamane fixation. The old lens came out, and the new lens went in without any problems. I externalized the first haptic, cauterized the tip, and then timidly fed the length of it a little bit back into the sclera (Figure 1a). For the trailing haptic, I externalized the needle via the main wound and docked the trailing haptic outside the eye (Figure 1b). The haptic of an MA50BM fits snugly into the lumen of a 30-gauge TSK, so there is little risk of it slipping out. Nevertheless, this possibility so concerned me that I inserted almost 50% of the length of the haptic into the needle before withdrawing it from the sclera. Just before I could cauterize the tip of this second haptic, I looked down and saw the problem. The first haptic was torn almost completely away from the optic (Figure 2). Apparently, when externalizing the second haptic, I had put too much tension on the lens. This probably occurred because I had not fed enough of the leading haptic back into the eye after I cauterized the tip. I compounded this mistake by inserting too much of the second haptic into the needle and therefore pulled too much out of the eye. As a consequence, the lens was stretched significantly from both directions, and this resulted in one of the haptics ripping almost totally off the optic.
I wish I could conclude the lesson here with the nice little learning point: “tuck the first haptic back into the eye more, and do not externalize so much of the second.” Alas, the story gets worse.
In case anyone is wondering whether you can just leave the lens like this, with one suspiciously loose haptic, let me tell you, no, you cannot. I know this from experience because that is exactly what I did. I thought, “Maybe this will be OK.” It was not OK. At the 1-week postoperative visit, the superior haptic and the optic were completely disconnected. Back to surgery.
The superficial lesson here has to do with maneuvers to avoid stressing the haptic-optic junction during Yamane fixation using MA50BM lenses. But the real lesson has to do with denial. What I should have done was cut the damaged lens out of the eye and start over. That would have been an embarrassing admission of defeat but better to start over than to try to get away with something and have to go back and do it later, which is exactly what happened. There may be some element of truth in the well-worn saying that “great is the enemy of good,” but too often, this aphorism may be an excuse to let substandard work slide. “Good enough,” in practice, usually means bad.
- For more information:
- Jack S. Parker, MD, PhD, of Parker Cornea in Vestavia Hills, Alabama, can be reached at jack.parker@gmail.com.
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