Yamane – Theory to Practice

Watch Abha Amin's first complex case with the Yamane technique

As Chief of Complex Anterior Segment Surgery at a tertiary referral hospital, I am very accustomed to challenging cases. Surgical complications such as IOL dislocations or retained lens material are most commonly the reasons for referral to our practice. Coexisting glaucoma, corneal edema, and iris damage are also frequently present, which makes case management more difficult. As a result, I often find myself performing secondary IOL implantation. My preferred method for this is iris fixation, which – in my experience – is minimally invasive. But when the iris is damaged, as is often the case, this is no longer a viable option. I have tried Gor-Tex sutures (Gore Medical) as an alternative fixation method, yet this presented other challenges, such as a difficulty in avoiding IOL tilt or rupture of the haptic eyelets.

Although cases can be difficult, improvements in techniques and technologies are constantly leading to improved surgical outcomes. The Yamane technique interested me as a solution for cases where iris fixation was not an option. Here, I describe my experience using the technique for the first time.

Preparation is key

Though the Yamane technique has great potential, making it efficient demands a great deal of work and preparation. For me, that meant reading articles, watching surgical videos, and most importantly, doing extensive training in two separate wet labs. Training sessions included the disassembly of an eye model to gain an inside out view – crucial to understanding the technique as it allowed me to see haptic fixation points inside the eye, and where I had entered when penetrating the globe. Interestingly, the haptic fixation points do not have the classic C shape that you would imagine; on the contrary, they are stretched out and very straight. This highlighted and underscored how important IOL model selection is in surgical success; the ability to open the model eye after completing the wet lab confirms your internal fixation and IOL placement, and shows whether your entry is through the sulcus or ciliary body.

Off the bench and into the operating room

Feeling as prepared as I could be, it was time to put what I had learned into practice. The opportunity to use the technique arose from a patient who had a complication during cataract surgery. The surgeon called from the operating room to inform me that part of the cataract had fallen posteriorly and there was a vitreous prolapse – I told him to not implant the IOL and to send the patient to me the next day. The patient was diabetic and on dialysis, and had lost his other eye a few months ago due to an infection  while in the hospital. He was aphakic and had insufficient capsular or iris support as the iris was traumatized and stuck to the wound. After examination by the retina service, it was decided to proceed with scleral fixation of the IOL using the Yamane technique. I proceeded immediately after an accompanying retinal surgeon removed the nuclear fragments through a pars plana vitrectomy and lensectomy. I used the CT Lucia IOL (Zeiss) with PVDF haptics, which, in my opinion, are the only haptics that would resist breaking, and the Scleral IOL Solutions Pack (MicroSurgical Technology) that provides the essential materials for the technique, including specialty needles with holders that provided optimum precision during the case.

The procedure was stressful, but my thorough preparation resulted in successful surgery.

Yamane case takeaways

i) Letting the needle go

For this first case, I was so fixated with capturing the haptic, that I did not “let the needle go”.  When I secured the haptic, I externalized it and quickly created the flange with low temp cautery. This made my next few steps more challenging. It is best to release the needle at the hub with the captured haptic deep into the anterior vitreous – then take a deep breath before continuing and trust that the 30 gauge thin walled needle will hold on to that haptic!

In my case, I was able to capture the trailing haptic, but it was more difficult than it needed to be. The needle holders in the Scleral IOL Solutions Pack allow for easy release and recapture of the needles so use them to your advantage.

ii) Opening the conjunctiva for enhanced visualization

The online surgical videos demonstrate needle penetration directly through the conjunctiva. Nevertheless, I personally wanted to see exactly where and how deep I was entering as I was creating the scleral tunnel before making the sharp turn and deep dive at the 2 mm point. I have no hesitation opening the conjunctiva to see what I am doing and then closing it, as it only takes a few more minutes.

The ultimate measure of success

The main indicator of a successful procedure is, of course, the patient’s outcome. The patient is doing very well post operation with a refractive error of -0.5 D and corrected visual acuity of 20/40 with no IOL tilt. His vision is still affected by mild macular edema from his diabetic retinopathy, so I will continue to monitor him to see how he progresses. All things considered, he looks very good and is functioning much better than before. I learned a lot from this first case, but it also reinforced how important it is to have the right equipment and preparation – especially the wet lab training.