424
TECHNIQUE
Trailing-haptic-first modification
of double-needle intrascleral haptic
fixation technique
Dooho Brian Kim, MD
The Yamane double-needle intrascleral haptic fixation technique for
posterior chamber intraocular lens (IOL) fixation in the setting of ab-
sent or inadequate capsule support is a minimally invasive IOL fixa-
tion technique that requires scleral incisions using needles to
externalize the IOL haptics. Despite being a seemingly easy and
intuitive procedure, there are significant challenges when learning
this technique. The most difficult step is threading the trailing haptic
with the needle for fixation. If using an IOL with weak haptics, this
step can result in haptic kink or breakage, which renders the haptics
r. Shin Yamane first described his technique of
D
intraocular lens (IOL) fixation in the absence of
adequate capsule support in 2016 at the ASCRS
Symposium on Cataract, IOL and Refractive Surgery.A
As described, the leading haptic and optic are delivered
into the anterior chamber using an IOL injector through
a keratome incision. Ninety degrees from the keratome
incision, a 30-gauge needle is used to create a sclerotomy
incision posterior to the limbus and the needle is
tunneled through sclera and into the vitreous space. An
intraocular forceps is used to thread the leading haptic
of the IOL into the lumen of the needle. A second sclerot-
omy incision using another 30-gauge needle is created
180 degrees from the first sclerotomy, and the trailing
haptic is threaded into the lumen of the needle using an
intraocular forceps in similar fashion. Both needles are
externalized from the sclerotomies, and handheld cautery
is used to create a flange or bulb, which secures the IOL.
The haptics are pushed into the eye, the flanges are
pushed flush with the sclera, and the conjunctiva is
reapproximated.
The Yamane double-needle technique is an elegant
approach to IOL fixation because it bypasses the need
for significant conjunctival and scleral dissection,
scleral flaps, glue, or suture lassoing. 1 Yet the technique
Submitted: December 7, 2017 | Final revision submitted: January 14, 2018 | Accepted: January 31, 2018
From Professional Eye Associates, Dalton, Georgia, USA.
Corresponding author: D. Brian Kim, MD, Professional Eye Associates, 1111 Professional Boulevard, Dalton, Georgia 30720, USA. Email: kim@professionaleye.com.
Q 2018 ASCRS and ESCRS
Published by Elsevier Inc.
useless for this technique and necessitating explantation of the IOL.
Even when an IOL with strong and rigid haptics is used, the rigid
haptics make threading the trailing haptic the most difficult step.
The trailing-haptic-first technique is a distinct modification that en-
hances the ease and success of the double-needle technique.
J Cataract Refract Surg 2018; 44:424–428 Q 2018 ASCRS and ESCRS
Online Video
is not without challenges. The original technique de-
scribes threading the leading haptic into the lumen of
the first sclerotomy needle. However, securing the lead-
ing haptic into the needle makes fixation of the trailing
haptic even more difficult. Those experienced with this
technique would agree that threading the trailing haptic
into the needle is the single more difficult step to
perform.
In general, IOL haptics are made of poly(methyl meth-
acrylate) (PMMA), polyimide (Elastimide), polypro-
pylene (Prolene), or polyvinylidene fluoride (PVDF).
For the purposes of this paper, haptic material is stratified
into the following 2 groups: more deformable (PMMA,
polyimide, polypropylene) and less deformable (poly-
vinylidene) haptics. If an IOL with more deformable
haptics is used, threading the trailing haptic can result
in haptic kinking or breakage and ultimately failure of
the technique. The rigid haptic PVDF material should
be used to maximize success; however, the rigidity also
makes surgical manipulation of the trailing haptic more
difficult. Risks include loss of the IOL into the vitreous
space, iris trauma, or inadvertent contact with the cornea,
all of which can result in complications and prolonged
surgical time. The following is a description that
minimizes these challenges.
0886-3350/$ - see frontmatter
https://doi.org/10.1016/j.jcrs.2018.01.027
 TECHNIQUE: MODIFICATION OF DOUBLE-NEEDLE INTRASCLERAL HAPTIC FIXATION
Figure 1. Top: Drawing of the eye shows the 1.0 mm inferior limbal
incision and the 3.0 mm superior limbal incision. Bottom: A 23-
gauge microforceps is placed through an inferior limbal incision,
and the IOL injector is placed through a superior limbal incision.
The surgical technician advances the IOL twist-type plunger, and
the leading haptic is advanced. The 23-gauge microforceps are
used to grasp the tip of the haptic (Asp Z aspiration;
C.D.E. Z cumulative dissipated energy; IOP Z intraocular pressure;
Vac Z vacuum).
SURGICAL TECHNIQUE
The modification entails a trailing-haptic-first
approach. The 30-gauge one-half-inch thin-walled
needles (TSK Laboratory Japan) should be used to
enhance the ability to fixate the haptics. Two needles
are prepared, 1 for the left-side haptic and 1 for the right.
Each needle is bent with the bevel facing upward, the
right-side needle is bent approximately three fourths in
length (bent w9.0 mm from the tip), and the left needle
Figure 3. The leading haptic is externalized (Asp Z aspiration;
C.D.E. Z cumulative dissipated energy; IOP Z intraocular pressure;
Vac Z vacuum).
425
Figure 2. As the optic is delivered, the microforceps is used to exter-
nalize the leading haptic out of the limbal incision (Asp Z aspiration;
C.D.E. Z cumulative dissipated energy; IOP Z intraocular pressure;
Vac Z vacuum).
is bent at the hub. Both are bent at approximately 80
degrees.
An inferior 1.0 mm limbal incision and a superior
3.0 mm limbal incision are created (Figure 1, top). The
IOL (CT Lucia 602, Carl Zeiss Meditec AG, formerly
EC3PAL, Aaren Scientific, Inc.) is inserted through the
superior incision using an IOL injector. The surgical
technician advances the twist-type plunger while the
surgeon holds the shaft of the injector. As the
haptic emerges from the injector, the surgeon places a
23-gauge microforceps through the inferior incision to
grasp the tip of the leading haptic (Figure 1, top) and ex-
ternalizes it out of the limbal incision (Figures 2 and 3)
(Video 1, available at http://jcrsjournal.org). The
trailing haptic is placed in the anterior chamber with a
forceps.
The right-side needle is used to pierce conjunctiva and
sclera at mark D (Figures 4 and 5) to tunnel through the
sclera toward mark B and then to pierce into the vitreous
space. The needle is rotated clockwise and emerges from
under the iris and into view (Figure 6). Because the
Figure 4. Landmarks for needle incision placement. The surgeon
would be sitting superiorly, which would be at the bottom of the im-
age. Marks A and B are 180 degrees apart and set 2.0 mm posterior
to the limbus. Mark C is 2.0 mm above mark A, while mark D is
2.0 mm below mark B.
Volume 44 Issue 4 April 2018
426 TECHNIQUE: MODIFICATION OF DOUBLE-NEEDLE INTRASCLERAL HAPTIC FIXATION
Figure 5. A bent 30-gauge thin-walled needle pierces conjunctiva
and sclera at mark D (see Figure 4) and tunnels through sclera
toward mark B (see Figure 4) (Asp Z aspiration; C.D.E. Z
cumulative dissipated energy; IOP Z intraocular pressure;
Vac Z vacuum).
leading haptic is externalized, access to the trailing haptic
is significantly improved relative to the original tech-
nique. Through a 1.0 mm limbal incision, a 23-gauge mi-
croforceps is used to grasp the distal end of the trailing
haptic to thread it into the lumen of the right needle
(Figure 7). The bevel is used as a platform to dock the
haptic into the needle (Video 2, available at http://
jcrsjournal.org). At least one half of the haptic should
be threaded into the needle to maximize security. The
23-gauge microforceps is used to pull the leading haptic
into the eye (Figures 8 and 9) (Video 3, available at
http://jcrsjournal.org).
The left-side 30-gauge one-half-inch thin-walled
needle punctures the conjunctiva and sclera at mark C
(Figures 4 and 10) and tunnels through sclera toward
mark A before piercing through the vitreous space and
rotating into view (Figure 11). A microforceps is used
to grasp the haptic to thread it into the lumen of the nee-
dle. The bevel of the needle is used as a platform to facil-
itate docking the haptic into the needle (Figure 12)
(Video 3, available at http://jcrsjournal.org). Both
Figure 7. The trailing haptic is threaded into the needle. Note the
improved access to the trailing haptic because the leading haptic
is outside of the eye. (Asp Z aspiration; C.D.E. Z cumulative
dissipated energy; IOP Z intraocular pressure; Vac Z vacuum).
Volume 44 Issue 4 April 2018
Figure 6. The needle is rotated nearly perpendicular to sclera
and punctures the vitreous space. The needle emerges from
under the iris and into view (Asp Z aspiration; C.D.E. Z
cumulative dissipated energy; IOP Z intraocular pressure;
Vac Z vacuum).
needles are externalized, which exposes the haptics.
Handheld cautery is used to create a terminal bulb or
flange. The haptic bulbs are pushed flush to the sclera
and the conjunctiva reapproximated (Video 4, available
at http://jcrsjournal.org).
DISCUSSION
The IOL haptic material is critical to the success of this
technique. Any other material besides PVDF can break or
bend and render the haptic useless. The sturdy nature of
the PVDF material makes it ideally suited for this tech-
nique; however, the same rigid nature also makes threading
the haptic into the needle more difficult because the haptics
resist flexion and manipulation.
As described by the original technique, the leading
haptic and optic are delivered into the anterior cham-
ber. The leading haptic is fixated with the needle before
the trailing haptic. Although threading the leading
haptic into the left-side needle is easy to perform, this
actually makes threading the trailing haptic even more
difficult. This is because the leading-haptic-needle com-
plex tends to resist bending, which tends to push the
Figure 8. The leading haptic is grasped with a microforceps
(Asp Z aspiration; C.D.E. Z cumulative dissipated energy;
IOP Z intraocular pressure; Vac Z vacuum).
 TECHNIQUE: MODIFICATION OF DOUBLE-NEEDLE INTRASCLERAL HAPTIC FIXATION
Figure 9. The leading haptic is pulled into the eye with a microfor-
ceps (Asp Z aspiration; C.D.E. Z cumulative dissipated energy;
IOP Z intraocular pressure; Vac Z vacuum).
optic and trailing haptic out of view. Some surgical gym-
nastics are required to try and reach the distal end of the
trailing haptic. One option is to use the right needle to
push the edge of the optic so that the trailing haptic is
more accessible. Alternatively, a handshake technique
with a pair of microforceps can be used to grasp the
trailing haptic in sequential steps until the distal haptic
is reached; however, this approach would require a third
set of hands to hold the right-side needle in position
during this maneuver. In essence, threading the leading
haptic first makes it far more difficult to thread the
trailing haptic and regardless of which technique is
used, threading the trailing haptic is not easy. As a
result, surgeons learning the Yamane technique might
struggle and become increasingly frustrated. Moreover,
the fear of dislodging the leading haptic from the needle
through excessive force and manipulation might further
intimidate the surgeon. The trailing-haptic-first tech-
nique modification bypasses all these challenges by
threading the trailing haptic into the needle first. This
Figure 11. The needle is rotated near perpendicular to sclera and
punctures the vitreous space. The needle emerges from under the
iris and into view (Asp Z aspiration; C.D.E. Z cumulative dissipated
energy; IOP Z intraocular pressure; Vac Z vacuum).
427
Figure 10. A bent 30-gauge thin-walled needle pierces conjunctiva
and sclera at mark C (see Figure 4) and tunnels through sclera
toward mark A (see Figure 4) (Asp Z aspiration; C.D.E. Z
cumulative dissipated energy; IOP Z intraocular pressure; Vac Z
vacuum).
is best accomplished by externalizing the leading haptic
through a limbal incision. Externalizing the leading
haptic in this manner is advantageous because (1) it is
easy to do, (2) the IOL is secure and will not slip into
the vitreous space, and (3) the IOL sits in a more ante-
rior position, which enhances the ability to thread the
trailing haptic into the right-side needle.
As originally described, threading the trailing haptic
into the needle is the most difficult and intimidating
step for the learning surgeon. To my knowledge, this is
the first and only modification describing fixation of the
trailing haptic with the needle before the leading haptic.
The trailing-haptic-first approach is a significant depar-
ture from Yamane’s original technique. This simple
adjustment bypasses the problems described and provides
a simpler and easier approach, which reduces surgeon
anxiety and improves surgeon success. Although there is
a learning curve, I believe these modifications will make
it easier to adopt, which enhances efficiency, consistency,
and safety.
Figure 12. A microforceps is used to grasp the leading haptic to
thread it into the lumen of the needle (Asp Z aspiration;
C.D.E. Z cumulative dissipated energy; IOP Z intraocular pressure;
Vac Z vacuum).
Volume 44 Issue 4 April 2018
428 TECHNIQUE: MODIFICATION OF DOUBLE-NEEDLE INTRASCLERAL HAPTIC FIXATION

REFERENCES
WHAT WAS KNOWN 1. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral
intraocular lens fixation with double-needle technique. Ophthalmology 2017;
 The double-needle intrascleral haptic fixation technique is
124:1136–1142
a minimally invasive method for posterior chamber IOL
fixation in the setting of absent or inadequate capsule OTHER CITED MATERIAL
support. A. Yamane S, “Transconjunctival Intrascleral IOL Fixation With Double-Needle
Technique,” film presented at the ASCRS Symposium on Cataract, IOL
WHAT THIS PAPER ADDS and Refractive Surgery, New Orleans, Louisiana, USA, May 2016. Available
at: http://ascrs2016.conferencefilms.com/atables.wcs?entryidZ0082&bp
 The trailing-haptic-first modification is a completely different Z1. Accessed February 23, 2018
approach than the original Yamane technique because the
trailing haptic is threaded with the needle before the Disclosure: The author has no financial or proprietary interest in any
leading haptic. This is only possible because the leading material or method mentioned.
haptic is externalized through an inferior limbal incision,
which secures the IOL and improves access to the trailing
haptic. First author:
 Threading the trailing haptic with the needle before the Dooho Brian Kim, MD
leading haptic essentially eliminates the surgical chal-
Professional Eye Associates, Dalton,
lenges of the original technique. This modification should
Georgia, USA
improve ease of learning, efficiency, consistency, and
safety.

Volume 44 Issue 4 April 2018