This video was part of a roundtable discussion involving surgeons Christina Y. Weng, MD, MBA; Mrinali Gupta, MD, FASRS; Nimesh A. “Nemo” Patel, MD; and Frank Brodie, MD, MBA. An edited transcript of the case presentation and discussion follows below:

Christina Y. Weng, MD, MBA: So this is the counterpart to Nemo’s 4-point fixation. I, like Frank, love the modified Yamane technique. I think it is just so slick. I’ve gotten so used to it. I can do these cases in a matter of minutes, which is amazing, because thinking back maybe 6 or 7 years ago doing these secondary intraocular lenses (IOLs) was a little bit of a headache. They just seemed very complicated. And I just love how simple this technique is, so I'm a big fan. But of course with every one of these techniques, there are tradeoffs. One of the disadvantages of a 2-point fixation is that you have to be super careful—not just about centration, but about axial symmetry, because tilt is a very real thing, especially with certain types of IOLs like the CT Lucia 602 (Zeiss), which is the one I prefer to use.

So anyway, what I was saying was, with these roundtables, you always hear about all these different ways that people prefer to do these secondary IOLs. And I think that any time you see that there's like a thousand ways to skin a cat, it means that we haven’t landed on an ideal or perfect technique yet. So I’m going to take a second to brag on Frank. He’s the co-founder of Long Bridge Medical, and he's doing some really exciting stuff with his team. He's developing this prosthetic capsular bag for those of you who haven't seen it yet. And I think it may not only simplify these secondary IOLs that we do, but it really has a lot of amazing potential to open up this world of possibilities, because the IOLs that we could potentially use with the prosthetic capsular bag become endless and sort of in line with some of our anterior-segment surgeons and the premium IOLs that they’re able to offer. Those all become a possibility, which I think patients really value.

But Frank, while you're hurrying up with your team and bringing LensOne to us, I’m sticking with the modified Yamane technique for now. And this case that I’m going to show is actually an 84-year-old physician patient who had a fall and dislocated her original 3-piece IOL. So I explanted that. I did a modified Yamane for her with a CT Lucia 602. She did really well for about 3 or 4 years, but then came back just a few months ago with acutely changed vision. And indeed, her CT Lucia 602 was not dislocated, but it was twisted like a rotisserie 45°. And unfortunately that is something that’s been reported with all IOLs—I don't want to particularly pick on the CT Lucia 602, but that certainly has been an issue with that particular IOL. So I'm going to show you how I fixed it. This is what I’ve been doing recently, and it's worked out really nicely. I just want to show this technique.

You'll notice that the IOL is tilted 45°. It doesn't look that severe, but you'll see it better when I put in the iris hooks. So opening up the conjunctiva, drying up the surface, and I'm making 5 marks around the limbus, 3 mm apart. And here you can really appreciate it now. I also like to put in an infusion line just for stability, but this is really the bulk of the technique. I'm feeding a 9-0 Prolene into the bore of a 25-gauge needle, and I'm feeding first both ends of a double-arm suture superiorly. And I'm basically going to form a 5-point star.

Here, both of the ends are in now, and then you just keep on repeating the same technique, drawing a star like we all learned to do in elementary school, but you basically put the 25-gauge through, feed the 9-0 Prolene through, and then here we go again for the next pass.

You're forming a scaffold. All of these sutures are being passed behind the IOL, which is tilted. And if you make that scaffold planar, it corrects the tilt. So you can see here are both ends. I'm tying just a knot and rotating the knot in and that’s what the final outcome looks like.

So just a really quick video, but this has really worked nicely. I want to also give a shout out to Prithvi Ramtohul, MD, who’s been doing a lot of these as well with me and we've been exchanging notes. It’s very quick to do and it avoids having to explant the IOL and then put in a whole new one, which can be pretty traumatic for the eye. But I just wanted to show what I've been doing.

The 5-point star technique with Prolene is something I actually had developed originally for silicone oil retention in aphakic eyes. And of course, big shout out to Dean Eliott, MD, and Ron Gentile, MD, who developed the original suture technique—I just kind of changed the shape because I think it's a lot faster to do it with one continuous suture. But we don't do those that often. We found out that this worked really well for IOLs that were tilted, which we do see pretty often.

So I just wanted your thoughts on similar techniques, maybe not this, but if you see something like a tilted IOL, how do you handle that? Do you usually explant and put in a new one? Are you willing to do the same technique in a patient who’s had this sort of complication now with point fixation? I'll start with you, Frank, if you don't mind, just because you have a lot of experience with these and are very familiar with the space.

Frank Brodie, MD, MBA: I'll tell you, that was beautiful, Christina. I've actually done that exact technique for silicone oil retention and it works really well for that. I'd never thought about doing it for an IOL like this, so that's terrific.

One of the things that really pushed me to start partnering with cornea on these cases was I had a series of 2 CT Lucia 602s in a row in the same patient do the rotisserie on me. And then I did the Alcon lens MA60AC, and it was a traumatic two-and-a-half hours in the OR. And I kind of wonder, had I just known this technique on that first one, I would've done it and been out of there. So that’s spectacular—I’m really glad to know it now. Thank you.

Dr. Weng: Thanks so much, Frank. Hey, can you talk a little bit about when you do explant them, what is your general approach and any tips for doing that?

Dr. Brodie: Yeah, for explant, I do it pretty conservatively. I will snip my nubs. I’m nervous to pull things all the way through. I worry I’m going to lose a piece. I'm worried I'm traumatizing the sclera. Take my nub, take down conjunctiva, cut off, take it out—I’ll “pacman” the lens to take it out—and just kind of commit to taking the time. I don't have any great shortcuts or tricks. To my detriment, really, the Yamane technique is the one I have in my toolkit. I never really trained on a sutured IOL technique, so I will keep trying it. And as in the case I just mentioned, it doesn't always work out well. You're in the OR a long time until you find a lens that doesn’t rotate on you.

Dr. Weng: These secondary IOLs, I find that when they go smoothly, they’re so easy. They take a few minutes. When they don't go well, and you run into obstacles, they can really be very, very challenging cases. What's nice about the bulbed ends of the modified Yamane, in my opinion, is that you can release the fixated portions from externally. You can just basically push the bulb, advance it outward, and cut the bulb and then it really easily releases. I think one of the really tricky parts that Nimo showed really nicely in his case is that if you have Prolene and one side is fixated and the other isn't, to release the side that’s still fixated can be quite tricky. And a lot of times you have to do that from the inside while using curved retinal scissors or whatnot and really kind of finagling your way around an area that's quite vascular and making sure you don't hit one of those ciliary processes. So I love the points that you brought up.

Nemo, it sounds like you had a comment. 

Nimesh A. “Nemo” Patel, MD: That was pretty cool; I think that was a great idea. I had a lens tilt and I did do the laser that has been reported and it did surprisingly work pretty well. One tip for that is to use a 23-gauge laser. So I think we had set it up 25 and I had trouble tilting the laser around to laser upward towards the lens. So using a stiffer 23-gauge was a little bit better for that, and it worked really well. We had tried to cut and reposition it, and it really still wasn't sitting right, and it did appear that the haptic-optic junction was the major cause, and it fixed very nicely. I’ve actually started doing that on the primary cases. I don't know if that helps or not. We'll never know, but I figure while I'm in there, might as well.

And so that was going to be one of my questions to you: Have you thought about given we just looked at all of our data at Mass Eye and Ear, it's 11% tilt rate return to the OR, including cornea and retina. So given that, would you consider doing this? I know it’s probably a little bit extra time. Would you consider just doing this on every case? 

Dr. Weng: It's a great question and I'm glad you brought that up. It's funny that you came up with the number 11%, because I was digging through the literature a few months ago when this happened and that number is actually also cited by the anterior-segment literature in papers that have been published.^1,2 So it’s definitely not a rare thing.

I love the thought and I've seen really nice outcomes with sort of that haptic-optic junction curing with the laser. I haven’t done it myself to be honest, so I'd love to ask you a little bit more about it, but I don't know that we have enough data to suggest that doing it from a primary standpoint would help, but certainly I’ve seen a lot of people fix it that way and I do think that was the culprit in this case with that type of tilting.

Can you tell us, Nemo, just a little bit about the settings you’re using? And where are you directing the laser exactly?

Dr. Patel: So right at the area where the haptic-optic junction is fixed. The question is, how do you know what angle to stick it at? So what we did is, we put a light pipe in the back and essentially un-tilt the lens so that the haptic-optic junction is at the right angle that you think it's going to stay. And then I use the continuous laser and just put it on for a few seconds. You see it turn white and then you just wait and then you let the light pipe go and it's still there and you’re like, “Oh, that's magic.” But my question to you is actually, are you going to use this 5-point technique primarily? 

Dr. Weng: I don't know that I would necessarily. I'd have to give that a little bit more thought. I will say that Prithvi Ramtohul, MD, who’s been doing a lot of these, has actually used them for completely dislocated IOLs. I’ve done them for tilting, but he's done it for completely dislocated IOLs just to kind of form a scaffold, and he rescues the lenses and places them just anteriorly to the scaffold. So I think there’s a lot that we can be doing with this.

I don't know that it's worth on every patient if most of them still do okay, I guess is kind of my thought right now. But I do think it’s nice to have in your back pocket for rescue because that way you don’t have to take it out and do a whole complete new surgery, which can be pretty traumatic to the eye. 

Frank, you were going to comment?

Dr. Brodie: Yeah, I was just thinking, I guess I'd be a little bit nervous to do that with a 1-piece if it wasn't fixated as something because it does feel like you could get a lot of movement. I'd want some nice big haptics to be pushing and centering me and prevent slippage, so I'd be interested in that. If he’s got a technique to allow you to do that and get away with it, that'd be great.

Dr. Weng: I think he's working on putting together a series and I'm also curious to learn more about applying the technique in that way. Mrinali, comments?

Mrinali Gupta, MD, FASRS: I love this. I've done this technique for aniridic oil eyes and it’s super straightforward. It never would’ve occurred to me to do it in this.

Do you put it in the same location behind the limbus as you would for retention sutures? Because, obviously, if you go a little bit too far—even a millimeter further posteriorly—it's not pushing on the lens to do its job.

Dr. Weng: That's exactly right and you're so spot on: Marking is everything and the positioning of the 5-point star is so critical here because like you said, you want it right behind the IOL, because if you're too far back, you're going to be undercorrected because it’s that tension that's helping keep it planar.

So what I would recommend for this—not that I've done many at all—but I would look at how far you put back the IOL. So this IOL was placed about 2.75 mm back and I'd add maybe like 0.25 mm to that and that's why I put the markings at 3 mm back. So it’s immediately behind the IOL. You don't want it too anterior either, because then that can anteriorly vault the IOL, which can cause chafing, like Frank talked about earlier. These are already kind of anterior the way we put them in anyway, but I think you’re absolutely right.

And that can be customized to each patient depending on how far back you externalize the haptics. I'm sure that varies from person to person, but that's a really good point. I think marking and being very meticulous about placement of those sutures is everything here. RP

References

1. Cho BJ, Yu HG. Surgical outcomes according to vitreous management after scleral fixation of posterior chamber intraocular lenses. Retina. 2014;34(10):1977-1984. doi:10.1097/IAE.0000000000000168

2. Zeilinger J, Regitnig P, Kronschläger M, et al. Comparison of decentration, tilt, and dynamic stability between retropupillary iris claw and scleral fixated intraocular lenses with flanged haptics. J Cataract Refract Surg. Published online May 11, 2026. doi:10.1097/j.jcrs.0000000000001975