- Email: [email protected]
Combined double-needle flanged-haptic intrascleral fixation of an intraocular lens and Descemet-stripping endothelial keratoplasty
593
TECHNIQUE
Combined double-needle flanged-haptic intrascleral fixation of an intraocular lens and Descemet-stripping endothelial keratoplasty Lorenzo J. Cervantes, MD
A slight modification to the Yamane transconjunctival doubleneedle flanged-haptic technique of intrascleral fixation of an intraocular lens (IOL) shows the technique’s usefulness when combined with Descemet-stripping endothelial keratoplasty (DSEK). The modification uses bipolar cautery to create flanges at the tip of the IOL haptics and delays tucking the haptics into the scleral tunnels until DSEK has been completed. Bipolar cautery enables the technique to be used in situations in which disposable low- or
D
ysfunctional intraocular lenses (IOL) or aphakia can be accompanied by significant corneal edema indicating endothelial keratoplasty. Secondary IOL implantation combined with Descemet-stripping endothelial keratoplasty (DSEK) is an option for patients and surgeons electing to address the problems simultaneously.1 Various IOL implantation techniques in this setting have been described. YamaneA described secondary IOL implantation using intrascleral fixation of a sulcusbased 3-piece IOL with haptics modified using hightemperature cautery to create bulbous flanged tips, which was an update to his previously described technique.2 This method is performed without scleral flaps or sutures, instead using tunnels created with a thin-walled 30-gauge or standard 27-gauge needle. The benefits of this derive from the relatively minimal invasiveness. A conjunctival peritomy is not necessary, and the technique can therefore be performed in eyes in which disturbing the conjunctiva could be detrimental. Because most 3-piece IOL models can be used in this technique, a standard clear corneal incision (CCI) can be used to accommodate a folding IOL, minimizing surgically induced astigmatism and corneal denervation. As originally described, disposable high-temperature cautery is used to melt the haptic tips to create a flange.
high-temperature cautery, as originally described, might not be possible. Delaying the haptic tuck until after the complete air fill of DSEK means the surgeon can be confident of the IOL position at all times. This combined technique can be a viable option for patients with aphakia and endothelial cell dysfunction. J Cataract Refract Surg 2017; 43:593–596 Q 2017 ASCRS and ESCRS Online Video
This article describes the use of bipolar cautery to create the flanged haptics and shows the stability of the fixated IOL in the context of a combined procedure with DSEK by delaying the haptic tuck until complete air fill of the anterior chamber. These modifications are applicable to all variations of the double-needle flanged-haptic and DSEK techniques. SURGICAL TECHNIQUE Prior to the procedure, it is recommended that the surgeon verify that (1) the IOL haptic can fit snugly into the lumen of a specially made thin-walled 30-gauge or a standard 27-gauge needle, and (2) if using bipolar cautery, the tip of the planned IOL haptic can be adequately melted to create the flange using a test IOL (Figure 1). The needles are bent in line with the bevel to a length that is approximately the distance from the sulcus to the pupil center. Ensuring IOL centration with haptic placement exactly 180 degrees apart is accomplished by marking the geographic center of the cornea and using an axis marker centered on this point to mark the needle entry points. Corneal markings for DSEK centration are placed as necessary. Two paracenteses are oriented 90 degrees from the anticipated main incision site as access for intraocular forceps. Another paracentesis is made for an
Submitted: November 12, 2016 | Final revision submitted: January 3, 2017 | Accepted: January 10, 2017 From OptiCare PC, Waterbury, Connecticut, USA. Corresponding author: Lorenzo J. Cervantes, MD, OptiCare PC, 87 Grandview Avenue, Waterbury, Connecticut 06708, USA. E-mail: [email protected]. Q 2017 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.04.025
594
TECHNIQUE: COMBINED DOUBLE-NEEDLE INTRASCLERAL IOL FIXATION AND DSEK
Figure 1. Prior to surgery, verify that (A) the haptic fits securely in the needle and (B) the cautery creates adequate heat to create the flange. The flange made in this case (C) is funnel-shaped and roughly the diameter of a 27-gauge needle.
anterior chamber maintainer (ACM). A CCI is made of adequate size to accommodate the IOL and the DSEK graft. At this time, if needed, an anterior or pars plana vitrectomy can be performed. The 3-piece IOL is inserted into the anterior chamber with the trailing haptic external to the incision. The first needle insertion site is 1.5 to 2.0 mm posterior to the limbus at the left corneal axis marking and passes through conjunctiva and sclera, creating a beveled intrascleral tunnel 1.5 to 2.0 mm posterior and parallel to the limbus tangent. When it enters the sulcus, the needle is directed toward the lead haptic, which is guided into the needle using an intraocular forceps. With the haptic secure, the needle can be left in the tunnel and a similar procedure can be performed on the trailing haptic. After the haptics are docked, both needles can be removed and the haptics externalized. Bipolar forceps cautery powered by a phacoemulsification system is set to its highest power. With the pedal completely depressed, the closed cautery tips are brought close to the haptic tip, without actual contact, to create a bulbous flange. Acetylcholine chloride (Miochol) is used to induce miosis, protecting against posterior migration of the DSEK graft or air. The haptic tips remain external to the conjunctiva as the DSEK graft is prepared, inserted, and unfolded using the surgeon’s preferred methods. After the main incision has been sutured securely, the ACM removed, and the graft in position, a complete air fill of the anterior chamber is slowly achieved to a high pressure while the position of the haptic flanges are watched. With a secure IOL, there would be no movement of the haptic tips despite significant anterior chamber pressure from the gas fill or from massaging any interface fluid (Figure 2). After the graft has remained adherent under air for an appropriate time and the eye has been brought back to physiologic pressure, the flanged haptics can be tucked into the scleral tunnels. No additional change in the DSEK postoperative course is necessary.
Volume 43 Issue 5 May 2017
Video 1 (available at http://jcrsjournal.org) shows the technique used and the modifications described. DISCUSSION Pseudophakic and aphakic bullous keratopathy are frequent causes of secondary endothelial cell dysfunction and indications for endothelial keratoplasty. Patients with these conditions often require an IOL exchange or secondary IOL implantation, performed in stages or simultaneously with DSEK. Combining the procedures does not appear to have a detrimental effect on the graft or visual outcomes,3 although in 1 study,4 the rates of cystoid macular edema were higher than when the procedures were performed alone. Without adequate anterior chamber depth or capsule support for appropriate IOLs, artificial support is necessary and has been accomplished in combination with endothelial keratoplasty in a variety of ways, including iris-sutured, iris-claw, scleral-sutured, and intrascleralfixated methods.5–10 The technique presented by YamaneA allows intrascleral haptic fixation without the need for conjunctival peritomy, scleral flaps, or an assistant. The technique described in this report shows that the flange tips can be made with bipolar cautery and that the IOL is stable despite high intraoperative anterior chamber pressure, allowing the procedure to be combined with DSEK. The minimalistic approach of the double-needle flanged-haptic technique enables scleral fixation of an IOL with tools that are readily and inexpensively available in many operating room settings. Most 3-piece IOLs can be used with slight variations in the shape of the resulting flange. The surgeon should test the haptic fit in the needle and the ability to create the flange on a test IOL prior to surgery. The original technique used a thin-walled 30gauge needle and disposable cautery. However, capture of the haptic can be accomplished with a 27-gauge needle and bipolar cautery can produce enough heat to melt the haptic tip. It should be noted that a thin-tipped jewelertype forceps cautery (product number K8-7010, Katena
TECHNIQUE: COMBINED DOUBLE-NEEDLE INTRASCLERAL IOL FIXATION AND DSEK
595
Figure 2. A 27-gauge needle is bent (A) and inserted tangentially (B) approximately 2.0 mm posterior and parallel to the limbus tangent. Using an intraocular forceps (C), the lead haptic (thin arrow) is engaged by the needle (thick arrow) and a similar procedure is performed with the trailing haptic. The haptics (asterisks) are externalized (D) where the haptic tips are melted to create the flanges (E and F). Despite significant anterior chamber pressurization (G) during the air fill and the interface fluid massage (H), the externalized IOL haptics remain visible and stable. After the allotted time has elapsed and physiologic pressure achieved, the flanges can be tucked into the sclera (I).
Products, Inc.) was unable to create the flange when it was tested. Thicker-tipped McPherson-type forceps cautery (product number K8-7020 or K8-7021, Katena Products, Inc.) easily melted the haptics. The actual temperature of different tips was not recorded, but it was presumed that the thinner caliber tipped forceps could not conduct enough current to produce adequate heat to melt the haptic. Intraoperatively, after the DSEK graft has been placed, the anterior chamber air fill should be done slowly,
carefully watching the position of the externalized haptics. Scleral tunnels of adequate length prevent rotation and posterior IOL displacement. In conclusion, the technique in this report shows that intrascleral fixation of an IOL using the flanged-haptic double-needle technique can be accomplished with bipolar cautery and that the IOL is stable despite high intraoperative anterior chamber pressures, allowing the procedure to be combined with DSEK.
Volume 43 Issue 5 May 2017
596
TECHNIQUE: COMBINED DOUBLE-NEEDLE INTRASCLERAL IOL FIXATION AND DSEK
WHAT WAS KNOWN Combined IOL fixation and DSEK is an option for patients with poor capsule support and endothelial dysfunction. The double-needle flanged-haptic technique of intrascleral fixation of an IOL described by Yamane can be performed without conjunctival peritomy, scleral flaps, or an assistant.
WHAT THIS PAPER ADDS The double-needle flanged-haptic technique is an option that can be combined with DSEK. Haptic flanges can be made using bipolar cautery. The IOL position can be verified during the anterior chamber air fill by delaying scleral tuck of the haptics until the graft has been secured.
REFERENCES 1. Wylęgała E, Tarnawska D. Management of pseudophakic bullous keratopathy by combined Descemet-stripping endothelial keratoplasty and intraocular lens exchange. J Cataract Refract Surg 2008; 34:1708–1714 2. Yamane S, Inoue M, Arakawa A, Kadonosono K. Sutureless 27-gauge needle–guided intrascleral intraocular lens implantation with lamellar scleral dissection. Ophthalmology 2014; 121:61–66. Available at: http://www. aaojournal.org/article/S0161-6420(13)00803-8/pdf. Accessed March 10, 2017 3. Shah AK, Terry MA, Shamie N, Chen ES, Phillips PM, Hoar KL, Friend DJ, Davis-Boozer D. Complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty with intraocular lens exchange. Am J Ophthalmol 2010; 149:390–397 4. Yazu H, Yamaguchi T, Dogru M, Ishii N, Satake Y, Shimazaki J. Descemetstripping automated endothelial keratoplasty in eyes with transscleralsutured intraocular lenses. J Cataract Refract Surg 2016; 42:846–854 5. Cagini C, Fiore T, Leontiadis A, Biondi L, Leaci R, Delfini E, Macaluso C. Simultaneous Descemet stripping automated endothelial keratoplasty and aphakic iris-fixated intraocular lens implantation: a case series. Cornea 2011; 30:1167–1169
Volume 43 Issue 5 May 2017
lez FM, Mannis MJ, Izquierdo L Jr, Sa nchez JG, Vela squez LF, Rojas S. 6. Ve Simultaneous surgery for corneal edema and aphakia: DSEK and placement of a retropupillary iris claw lens. Cornea 2014; 33:197–200 7. Narang P, Agarwal A, Dua HS, Kumar DA, Jacob S, Agarwal A. Glued intrascleral fixation of intraocular lens with pupilloplasty and pre-Descemet endothelial keratoplasty: a triple procedure. Cornea 2015; 34:1627–1631 8. Sinha R, Shekhar H, Sharma N, Tandon R, Titiyal JS, Vajpayee RB. Intrascleral fibrin glue intraocular lens fixation combined with Descemetstripping automated endothelial keratoplasty or penetrating keratoplasty. J Cataract Refract Surg 2012; 38:1240–1245 9. Prakash G, Agarwal A, Jacob S, Kumar DA, Chaudhary P, Agarwal A. Femtosecond-assisted Descemet stripping automated endothelial keratoplasty with fibrin glue-assisted sutureless posterior chamber lens implantation. Cornea 2010; 29:1315–1319 10. Karimian F, Sadoughi M-M. Air-assisted Descemet stripping automated endothelial keratoplasty with posterior chamber fixation of an aphakic irisclaw lens. J Ophthalmic Vis Res 2010; 5:205–210. Available at: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3379922/pdf/jovr-5-3-218-7791-pb.pdf. Accessed March 10, 2017 OTHER CITED MATERIAL A. Yamane S, “Transconjunctival Intrascleral IOL Fixation With Double-Needle Technique,” film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016, and the 29th annual meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons, Bali, Indonesia, July 2016. Available at: http://ascrs2016. conferencefilms.com/atables.wcs?entryidZ0082&bpZ1. Accessed March 10, 2017
Disclosure: The author has no financial or proprietary interest in any material or method mentioned.
First author: Lorenzo J. Cervantes, MD OptiCare PC, Waterbury, Connecticut, USA
TECHNIQUE
Combined double-needle flanged-haptic intrascleral fixation of an intraocular lens and Descemet-stripping endothelial keratoplasty Lorenzo J. Cervantes, MD
A slight modification to the Yamane transconjunctival doubleneedle flanged-haptic technique of intrascleral fixation of an intraocular lens (IOL) shows the technique’s usefulness when combined with Descemet-stripping endothelial keratoplasty (DSEK). The modification uses bipolar cautery to create flanges at the tip of the IOL haptics and delays tucking the haptics into the scleral tunnels until DSEK has been completed. Bipolar cautery enables the technique to be used in situations in which disposable low- or
D
ysfunctional intraocular lenses (IOL) or aphakia can be accompanied by significant corneal edema indicating endothelial keratoplasty. Secondary IOL implantation combined with Descemet-stripping endothelial keratoplasty (DSEK) is an option for patients and surgeons electing to address the problems simultaneously.1 Various IOL implantation techniques in this setting have been described. YamaneA described secondary IOL implantation using intrascleral fixation of a sulcusbased 3-piece IOL with haptics modified using hightemperature cautery to create bulbous flanged tips, which was an update to his previously described technique.2 This method is performed without scleral flaps or sutures, instead using tunnels created with a thin-walled 30-gauge or standard 27-gauge needle. The benefits of this derive from the relatively minimal invasiveness. A conjunctival peritomy is not necessary, and the technique can therefore be performed in eyes in which disturbing the conjunctiva could be detrimental. Because most 3-piece IOL models can be used in this technique, a standard clear corneal incision (CCI) can be used to accommodate a folding IOL, minimizing surgically induced astigmatism and corneal denervation. As originally described, disposable high-temperature cautery is used to melt the haptic tips to create a flange.
high-temperature cautery, as originally described, might not be possible. Delaying the haptic tuck until after the complete air fill of DSEK means the surgeon can be confident of the IOL position at all times. This combined technique can be a viable option for patients with aphakia and endothelial cell dysfunction. J Cataract Refract Surg 2017; 43:593–596 Q 2017 ASCRS and ESCRS Online Video
This article describes the use of bipolar cautery to create the flanged haptics and shows the stability of the fixated IOL in the context of a combined procedure with DSEK by delaying the haptic tuck until complete air fill of the anterior chamber. These modifications are applicable to all variations of the double-needle flanged-haptic and DSEK techniques. SURGICAL TECHNIQUE Prior to the procedure, it is recommended that the surgeon verify that (1) the IOL haptic can fit snugly into the lumen of a specially made thin-walled 30-gauge or a standard 27-gauge needle, and (2) if using bipolar cautery, the tip of the planned IOL haptic can be adequately melted to create the flange using a test IOL (Figure 1). The needles are bent in line with the bevel to a length that is approximately the distance from the sulcus to the pupil center. Ensuring IOL centration with haptic placement exactly 180 degrees apart is accomplished by marking the geographic center of the cornea and using an axis marker centered on this point to mark the needle entry points. Corneal markings for DSEK centration are placed as necessary. Two paracenteses are oriented 90 degrees from the anticipated main incision site as access for intraocular forceps. Another paracentesis is made for an
Submitted: November 12, 2016 | Final revision submitted: January 3, 2017 | Accepted: January 10, 2017 From OptiCare PC, Waterbury, Connecticut, USA. Corresponding author: Lorenzo J. Cervantes, MD, OptiCare PC, 87 Grandview Avenue, Waterbury, Connecticut 06708, USA. E-mail: [email protected]. Q 2017 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.04.025
594
TECHNIQUE: COMBINED DOUBLE-NEEDLE INTRASCLERAL IOL FIXATION AND DSEK
Figure 1. Prior to surgery, verify that (A) the haptic fits securely in the needle and (B) the cautery creates adequate heat to create the flange. The flange made in this case (C) is funnel-shaped and roughly the diameter of a 27-gauge needle.
anterior chamber maintainer (ACM). A CCI is made of adequate size to accommodate the IOL and the DSEK graft. At this time, if needed, an anterior or pars plana vitrectomy can be performed. The 3-piece IOL is inserted into the anterior chamber with the trailing haptic external to the incision. The first needle insertion site is 1.5 to 2.0 mm posterior to the limbus at the left corneal axis marking and passes through conjunctiva and sclera, creating a beveled intrascleral tunnel 1.5 to 2.0 mm posterior and parallel to the limbus tangent. When it enters the sulcus, the needle is directed toward the lead haptic, which is guided into the needle using an intraocular forceps. With the haptic secure, the needle can be left in the tunnel and a similar procedure can be performed on the trailing haptic. After the haptics are docked, both needles can be removed and the haptics externalized. Bipolar forceps cautery powered by a phacoemulsification system is set to its highest power. With the pedal completely depressed, the closed cautery tips are brought close to the haptic tip, without actual contact, to create a bulbous flange. Acetylcholine chloride (Miochol) is used to induce miosis, protecting against posterior migration of the DSEK graft or air. The haptic tips remain external to the conjunctiva as the DSEK graft is prepared, inserted, and unfolded using the surgeon’s preferred methods. After the main incision has been sutured securely, the ACM removed, and the graft in position, a complete air fill of the anterior chamber is slowly achieved to a high pressure while the position of the haptic flanges are watched. With a secure IOL, there would be no movement of the haptic tips despite significant anterior chamber pressure from the gas fill or from massaging any interface fluid (Figure 2). After the graft has remained adherent under air for an appropriate time and the eye has been brought back to physiologic pressure, the flanged haptics can be tucked into the scleral tunnels. No additional change in the DSEK postoperative course is necessary.
Volume 43 Issue 5 May 2017
Video 1 (available at http://jcrsjournal.org) shows the technique used and the modifications described. DISCUSSION Pseudophakic and aphakic bullous keratopathy are frequent causes of secondary endothelial cell dysfunction and indications for endothelial keratoplasty. Patients with these conditions often require an IOL exchange or secondary IOL implantation, performed in stages or simultaneously with DSEK. Combining the procedures does not appear to have a detrimental effect on the graft or visual outcomes,3 although in 1 study,4 the rates of cystoid macular edema were higher than when the procedures were performed alone. Without adequate anterior chamber depth or capsule support for appropriate IOLs, artificial support is necessary and has been accomplished in combination with endothelial keratoplasty in a variety of ways, including iris-sutured, iris-claw, scleral-sutured, and intrascleralfixated methods.5–10 The technique presented by YamaneA allows intrascleral haptic fixation without the need for conjunctival peritomy, scleral flaps, or an assistant. The technique described in this report shows that the flange tips can be made with bipolar cautery and that the IOL is stable despite high intraoperative anterior chamber pressure, allowing the procedure to be combined with DSEK. The minimalistic approach of the double-needle flanged-haptic technique enables scleral fixation of an IOL with tools that are readily and inexpensively available in many operating room settings. Most 3-piece IOLs can be used with slight variations in the shape of the resulting flange. The surgeon should test the haptic fit in the needle and the ability to create the flange on a test IOL prior to surgery. The original technique used a thin-walled 30gauge needle and disposable cautery. However, capture of the haptic can be accomplished with a 27-gauge needle and bipolar cautery can produce enough heat to melt the haptic tip. It should be noted that a thin-tipped jewelertype forceps cautery (product number K8-7010, Katena
TECHNIQUE: COMBINED DOUBLE-NEEDLE INTRASCLERAL IOL FIXATION AND DSEK
595
Figure 2. A 27-gauge needle is bent (A) and inserted tangentially (B) approximately 2.0 mm posterior and parallel to the limbus tangent. Using an intraocular forceps (C), the lead haptic (thin arrow) is engaged by the needle (thick arrow) and a similar procedure is performed with the trailing haptic. The haptics (asterisks) are externalized (D) where the haptic tips are melted to create the flanges (E and F). Despite significant anterior chamber pressurization (G) during the air fill and the interface fluid massage (H), the externalized IOL haptics remain visible and stable. After the allotted time has elapsed and physiologic pressure achieved, the flanges can be tucked into the sclera (I).
Products, Inc.) was unable to create the flange when it was tested. Thicker-tipped McPherson-type forceps cautery (product number K8-7020 or K8-7021, Katena Products, Inc.) easily melted the haptics. The actual temperature of different tips was not recorded, but it was presumed that the thinner caliber tipped forceps could not conduct enough current to produce adequate heat to melt the haptic. Intraoperatively, after the DSEK graft has been placed, the anterior chamber air fill should be done slowly,
carefully watching the position of the externalized haptics. Scleral tunnels of adequate length prevent rotation and posterior IOL displacement. In conclusion, the technique in this report shows that intrascleral fixation of an IOL using the flanged-haptic double-needle technique can be accomplished with bipolar cautery and that the IOL is stable despite high intraoperative anterior chamber pressures, allowing the procedure to be combined with DSEK.
Volume 43 Issue 5 May 2017
596
TECHNIQUE: COMBINED DOUBLE-NEEDLE INTRASCLERAL IOL FIXATION AND DSEK
WHAT WAS KNOWN Combined IOL fixation and DSEK is an option for patients with poor capsule support and endothelial dysfunction. The double-needle flanged-haptic technique of intrascleral fixation of an IOL described by Yamane can be performed without conjunctival peritomy, scleral flaps, or an assistant.
WHAT THIS PAPER ADDS The double-needle flanged-haptic technique is an option that can be combined with DSEK. Haptic flanges can be made using bipolar cautery. The IOL position can be verified during the anterior chamber air fill by delaying scleral tuck of the haptics until the graft has been secured.
REFERENCES 1. Wylęgała E, Tarnawska D. Management of pseudophakic bullous keratopathy by combined Descemet-stripping endothelial keratoplasty and intraocular lens exchange. J Cataract Refract Surg 2008; 34:1708–1714 2. Yamane S, Inoue M, Arakawa A, Kadonosono K. Sutureless 27-gauge needle–guided intrascleral intraocular lens implantation with lamellar scleral dissection. Ophthalmology 2014; 121:61–66. Available at: http://www. aaojournal.org/article/S0161-6420(13)00803-8/pdf. Accessed March 10, 2017 3. Shah AK, Terry MA, Shamie N, Chen ES, Phillips PM, Hoar KL, Friend DJ, Davis-Boozer D. Complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty with intraocular lens exchange. Am J Ophthalmol 2010; 149:390–397 4. Yazu H, Yamaguchi T, Dogru M, Ishii N, Satake Y, Shimazaki J. Descemetstripping automated endothelial keratoplasty in eyes with transscleralsutured intraocular lenses. J Cataract Refract Surg 2016; 42:846–854 5. Cagini C, Fiore T, Leontiadis A, Biondi L, Leaci R, Delfini E, Macaluso C. Simultaneous Descemet stripping automated endothelial keratoplasty and aphakic iris-fixated intraocular lens implantation: a case series. Cornea 2011; 30:1167–1169
Volume 43 Issue 5 May 2017
lez FM, Mannis MJ, Izquierdo L Jr, Sa nchez JG, Vela squez LF, Rojas S. 6. Ve Simultaneous surgery for corneal edema and aphakia: DSEK and placement of a retropupillary iris claw lens. Cornea 2014; 33:197–200 7. Narang P, Agarwal A, Dua HS, Kumar DA, Jacob S, Agarwal A. Glued intrascleral fixation of intraocular lens with pupilloplasty and pre-Descemet endothelial keratoplasty: a triple procedure. Cornea 2015; 34:1627–1631 8. Sinha R, Shekhar H, Sharma N, Tandon R, Titiyal JS, Vajpayee RB. Intrascleral fibrin glue intraocular lens fixation combined with Descemetstripping automated endothelial keratoplasty or penetrating keratoplasty. J Cataract Refract Surg 2012; 38:1240–1245 9. Prakash G, Agarwal A, Jacob S, Kumar DA, Chaudhary P, Agarwal A. Femtosecond-assisted Descemet stripping automated endothelial keratoplasty with fibrin glue-assisted sutureless posterior chamber lens implantation. Cornea 2010; 29:1315–1319 10. Karimian F, Sadoughi M-M. Air-assisted Descemet stripping automated endothelial keratoplasty with posterior chamber fixation of an aphakic irisclaw lens. J Ophthalmic Vis Res 2010; 5:205–210. Available at: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3379922/pdf/jovr-5-3-218-7791-pb.pdf. Accessed March 10, 2017 OTHER CITED MATERIAL A. Yamane S, “Transconjunctival Intrascleral IOL Fixation With Double-Needle Technique,” film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, New Orleans, Louisiana, USA, May 2016, and the 29th annual meeting of the Asia-Pacific Association of Cataract & Refractive Surgeons, Bali, Indonesia, July 2016. Available at: http://ascrs2016. conferencefilms.com/atables.wcs?entryidZ0082&bpZ1. Accessed March 10, 2017
Disclosure: The author has no financial or proprietary interest in any material or method mentioned.
First author: Lorenzo J. Cervantes, MD OptiCare PC, Waterbury, Connecticut, USA