Minimalistic modified Yamane technique: intraocular lens haptic docking with injector and 27-gauge needle, without infusion line

Minimalistic modified Yamane technique: intraocular lens haptic docking with injector and 27-gauge needle, without infusion line | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Minimalistic modified Yamane technique: intraocular lens haptic docking with injector and 27-gauge needle, without infusion line Mohd-Asyraaf ABDUL-KADIR, Yong Zheng WAI, Lik Thai LIM This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6117485/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To report a modified minimalist Yamane technique for scleral fixated intraocular lens (IOL) that is safer, faster and more economical, without infusion line support. Methods: The modified Yamane technique was adapted; the first haptics was docked into the sclerotomy needle directly from the lens injector and second haptic was docked into the sclerotomy needle whilst the IOL is in anterior chamber, by using a suture-tying forceps and without infusion line support. Results: The unaided visual acuity of 6/7.5 was achieved postoperatively on Day 1 and 1,3 and 6 months. No postoperative complications were identified and the IOL was well-centred. Conclusion: We introduced a modified Yamane method that is minimalistic, which is safer, faster and more economical, with less risk of possible trauma especially to the iris compared to the standard Yamane method and no need for expensive instruments such as the vitreo-retina micro-forceps. Yamane technique secondary IOL subluxated IOL intrascleral IOL fixation Figures Figure 1 Figure 2 Introduction Sutureless secondary intraocular lens (IOL) implantation has improved refractive outcomes in cases of absence of capsular support which traditionally may not yield the targeted results. Intrascleral IOL fixation was shown to have additional benefits over conventional transscleral suturing of IOL [ 1 – 3 ]. Other methods include iris-fixed IOL and anterior chamber IOL (ACIOL) [ 4 – 6 ]. Yamane introduced a method to fix secondary IOL that eliminates the need for extensive suturing, scleral and conjunctival dissection, or the use of glue. Pars plana vitrectomy was performed; subluxated crystalline lens were extracted or dislocated IOL was explanted. A 3-piece IOL was injected into the anterior chamber and the trailing haptic was left outside. The transconjunctival approach incorporated two angled sclerotomies at 180 degrees opposite each other using 30-gauge needles. The trailing haptic was captured within the needle lumen and externalized and the haptics’ ends then cauterized and flanged with a diameter of 0.3mm. The flanged haptics were pushed back and secured into the scleral tunnels and peripheral iridotomies were made to prevent iris capture of the IOL [ 7 ]. Yamane technique has been modified according to the regional resources and to improve its execution. We introduced a minimalist modified Yamane technique with secondary IOL implantation; without infusion line support, performed by one surgeon (LTL) at ESC where the surgeon was a visiting consultant surgeon, as described below. Technique Case 1 A minimalistic modified Yamane technique was performed on an aphakic patient who previously had a penetrating eye injury. The procedure was performed under local anesthesia without an infusion line. Two 27-gauge needles are bent at 70 degrees about three-fourths in length and a marker was used to mark the sclerotomy ports of entry, at 2mm from the limbus as per Fig. 1 . Sclerotomies were made at marked sites using the 27-gauge needle. Anterior vitrectomy was performed with the aid of vitreous visualization by Triamcinolone. Balanced salt solution (BSS) was used to maintain globe turgidity, and viscoelastic was injected into the anterior chamber (AC) to protect the corneal endothelium as well as contributing the globe turgidity. As a 3-piece IOL was injected into the anterior chamber, the leading haptic was partially released. The right hand held the lens injector, and the left hand guided the sclerotomy needle to allow the haptic docking into the needle as per Fig. 2 . Then, as both hands were now on the lens injector, the IOL was advanced further and stopped and the action above was repeated to ensure the haptic was adequately secured into the needle before the entire IOL was inserted into the AC. The trailing haptic was kept outside the keratome incision and a tying forceps was used to internalize the trailing haptic into the AC and to dock it into the second sclerotomy needle before externalizing it. Both ends of the haptics were externalized, cauterised, flanged, and buried into the sclera. Case 2 A minimalistic modified Yamane technique was performed on a patient with a subluxated one-piece IOL who had the primary cataract extraction done 5 years prior. The minimalist Yamane approach was done without any infusion line support and the globe turgidity was maintained by balance salt solution (BSS) and viscoelastic. A standard self-sealing 2.75mm corneal (keratome) incision was made at 90 degrees to the sclerotomy sites. Viscoelastic was injected into the AC to protect the corneal endothelium and the dislocated IOL-capsule complex was removed. Anterior vitrectomy was performed with the vitreous visualization aided by intravitreal triamcinolone. The surgical wounds were hydrated, and further BSS was slowly injected through the paracentesis, followed by viscoelastic into the anterior chamber to improve the turgidity of the globe. Similar steps of 3-piece IOL haptic docking into sclerotomy needles as in Case 1 were repeated and completed. An infusion line was not used in the case. Results Preoperative best corrected VA (BCVA) in Case 1 was 6/60 with + 10 diopter lens and in Case 2 was 6/36. Both eyes achieved 6/ 7.5 unaided VA at postoperative day 1, and 1,3 and 6 months. No postoperative complications were identified. Both IOLs were well-centred with no tilting. This illustrated that the above minimalistic modified Yamane technique of sutureless scleral fixated-IOL can be applied to cases of aphakia and/or lack of capsular support safely and efficiently. Discussion Refractive correction in aphakia, subluxated and dislocated IOLs without capsular support is made possible by the implantation of secondary IOLs. Scleral-fixated is preferred as it reduces iris contact with IOL and iritis, risks of pupillary block and cornea and iridocorneal angle damage, secondary glaucoma versus iris-fixated and ACIOL although it is more difficult to perform [ 8 , 9 ]. Previously, the use of fibrin glue with intrascleral IOL fixation instead of suturing was reported. However, it was associated with wide sclerotomies and risk of hypotony [ 10 ]. Meanwhile, suture exposure and late endophthalmitis are recognized as late-stage complications of trans-scleral IOL suture fixation [ 11 ]. In the series of 100 cases with the original Yamane technique, the mean IOL tilt was 3.4° ± 2.5 °. There was no significant loss of endothelium, 8% had iris capture, 5% with vitreous hemorrhage, and 1% with cystoid macular edema with no incidence of postoperative retinal detachment, endophthalmitis or IOL dislocation [ 7 ]. Similarly, another study that modified the original Yamane technique and used a 27-gauge needle also found no significant changes in endothelial density and macular thickness at 6 months with only two eyes having slight IOL decentration [ 12 ]. This has led to its more widely adaptation with various three-piece IOLs as a 27-gauge needle is more readily available globally than a 30-gauge needle. Yamane technique provides advantages that minimize complications secondary to suturing and eliminate the necessity to use a specific IOL for its execution. A steep learning curve may impose a challenge for surgeons to use this method. Threading the trailing haptic into the needle can be challenging, especially with rigid haptics. Nevertheless, using an IOL with a weak haptic may increase the risk of it getting kinked or broken and render the IOL useless for the Yamane technique [ 13 ]. Postoperative IOL tilt and decentration may incur an undesirable refractive outcome which is potentially due to malformation of the haptics, misaligned position of scleral tunnels, and inappropriate angles of the needles [ 13 , 14 ]. A needle stabilizer for flanged IOL fixation was introduced later and significantly reduced the IOL tilt compared to the control group [ 14 ]. Modified Yamane techniques have been introduced to address these issues [ 15 , 16 ]. Kim introduced the trailing-haptic-first method to overcome the frustration faced by surgeons since the leading-haptic-needle complex tends to resist bending during threading the trailing haptic. However, this requires the assistance of the surgical technician to advance the twist-type IOL plunger and 23-gauge microforceps to thread the haptic into the needle [ 13 ]. A handshake technique with a pair of microforceps would require a third set of hands to hold the right-side needle in position during this method. On the other hand, Yamane inserted the IOL into the anterior chamber first before maneuvering the haptics into the needle and the trailing haptic was kept outside initially to prevent it from falling into the vitreous cavity which could increase the risk of injury to the anterior chamber structures [ 7 ]. In our minimalist modified Yamane method, a single surgeon (LTL) performed the trans-scleral IOL fixation and the equipment used is readily available; using the tying forceps and the 27-gauge needle without the need for a vitreoretinal micro-forceps or infusion line. The globe turgidity was maintained by adequate BSS and viscoelastic. With the method described above to fixate the 3-piece IOL, the time taken was relatively short, with standard 2.75mm keratome incision, hence minimal loss of fluid and/or viscoelastic, thus maintaining the well-formed AC during the procedure, as illustrated in Fig. 2 . We also minimized the risk of iris trauma as the IOL was not pre-placed in the anterior chamber, and instead by utilizing the hand-shake technique, directly docking the leading haptic with the 27-G needle. We introduced a refined, minimalist Yamane method that simplifies the procedure by eliminating the need for additional assistance or specialized (costly) equipment while reducing the risk of iris trauma compared to the standard approach. Conclusion This minimalistic modified Yamane technique has the potential to enhance the safety, efficiency, and accessibility of sutureless transscleral fixation of 3-piece IOLs for managing aphakia without capsular support. By streamlining the procedure, it may reduce surgical complexity and improve patient outcomes, with good consistency. Declarations Ethics approval and consent to participate This study adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients. The Eye Specialist Centre (ESC) currently has a Research Ethics Committee, known as the Eye Specialist Centre Research Ethics Committee (ESCREC). The ESCREC had given ethical approval for this manuscript on 22 April 2025, with reference ESCREC2504-LTL(1). Consent for publication Written consents were obtained from all patients. Availability of data and material Data is available upon request. Competing interests The authors declare that they have no competing interests. Funding The author(s) received no specific funding for this work. Authors' contributions MA, YZW and LTL contributed to the writing of the manuscript, prepared the figures, and revised the manuscript. Surgery planned, performed and recorded by LTL. All authors reviewed the manuscript. Acknowledgments This patient’s surgery was planned, prepared and done at the Eye Specialist Centre (ESC) Kuching where the surgeon (LTL) was a visiting consultant surgeon. References Yamane S, Inoue M, Arakawa A, Kadonosono K. Sutureless 27-gauge needle-guided intrascleral intraocular lens implantation with lamellar scleral dissection. Ophthalmology. 2014;121(1):61–6. Sinha R, Bansal M, Sharma N, Dada T, Tandon R, Titiyal JS. Transscleral Suture-Fixated Versus Intrascleral Haptic-Fixated Intraocular Lens: A Comparative Study. Eye Contact Lens. 2017;43(6):389–93. Scharioth GB, Prasad S, Georgalas I, Tataru C, Pavlidis M. Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2010;36(2):254–9. Yazdani-Abyaneh A, Djalilian AR, Fard MA. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg. 2016;42(12):1707–12. Zeh WG, Price FW, Jr. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg. 2000;26(7):1028–34. Por YM, Lavin MJ. Techniques of intraocular lens suspension in the absence of capsular/zonular support. Surv Ophthalmol. 2005;50(5):429–62. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique. Ophthalmology. 2017;124(8):1136–42. Baykara M, Ozcetin H, Yilmaz S, Timucin OB. Posterior iris fixation of the iris-claw intraocular lens implantation through a scleral tunnel incision. Am J Ophthalmol. 2007;144(4):586–91. Evereklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg. 2003;29(2):301–8. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34(9):1433–8. Anand R, Bowman RW. Simplified technique for suturing dislocated posterior chamber intraocular lens to the ciliary sulcus. Arch Ophthalmol. 1990;108(9):1205–6. Kelkar AS, Fogla R, Kelkar J, Kothari AA, Mehta H, Amoaku W. Sutureless 27-gauge needle-assisted transconjunctival intrascleral intraocular lens fixation: Initial experience. Indian J Ophthalmol. 2017;65(12):1450–3. Kim DB. Trailing-haptic-first modification of double-needle intrascleral haptic fixation technique. J Cataract Refract Surg. 2018;44(4):424–8. Yamane S, Maruyama-Inoue M, Kadonosono K. Needle Stabilizer for Flanged Intraocular Lens Fixation. Retina. 2019;39(4):801. Ucar F, Cetinkaya S. Flattened flanged intrascleral intraocular lens fixation technique. Int Ophthalmol. 2020;40(6):1455–60. Najafi M, Yamane S, Johnston RH. Modified Flanged Intrascleral Fixation of Intraocular Lens for Vitreoretinal Surgeons. Ophthalmic Surg Lasers Imaging Retina. 2020;51(2):125–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6117485","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":451691706,"identity":"4b98c6d1-cd7f-45d2-9e66-be3dd079a586","order_by":0,"name":"Mohd-Asyraaf ABDUL-KADIR","email":"","orcid":"","institution":"Universiti Malaysia Sarawak (UNIMAS)","correspondingAuthor":false,"prefix":"","firstName":"Mohd-Asyraaf","middleName":"","lastName":"ABDUL-KADIR","suffix":""},{"id":451691707,"identity":"7692f4eb-f8c9-4390-899c-acf215f769c2","order_by":1,"name":"Yong Zheng WAI","email":"","orcid":"","institution":"Hospital Duchess of Kent","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"Zheng","lastName":"WAI","suffix":""},{"id":451691708,"identity":"de1ec415-b76f-4596-af0a-8ce04d108102","order_by":2,"name":"Lik Thai LIM","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAn0lEQVRIiWNgGAWjYBACPgbmhgMMFQwMbERrYWNjBGo5Q6oWBsY2UhzGJt/YeOjmvMN5fGKHH39gzDlMnC2Hc7cdLmaTTjOTYNxGgpbENukEMwYStMwBaUn//IEELQ0gLTkGxDosseFwzrF0kJYyicRt6YS18DMfPvw5p8Y6cf7s9M0fPm6zJqwFFSQwNJOqhYGhjnQto2AUjIJRMOwBAPBLOSkrCHKxAAAAAElFTkSuQmCC","orcid":"","institution":"Universiti Malaysia Sarawak (UNIMAS)","correspondingAuthor":true,"prefix":"","firstName":"Lik","middleName":"Thai","lastName":"LIM","suffix":""}],"badges":[],"createdAt":"2025-02-27 04:53:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6117485/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6117485/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82153408,"identity":"ea461e1c-8941-4d9f-8c0c-57fd5346b343","added_by":"auto","created_at":"2025-05-07 07:25:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56261,"visible":true,"origin":"","legend":"\u003cp\u003eLandmarks site for sclerotomy sites. A and C are 2 mm above B and 2mm below D. B and D are 180 degrees apart and 2mm posterior to the limbus.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6117485/v1/b07e15606c921d7f8d7bb6e2.png"},{"id":82154730,"identity":"475024d8-5583-49f0-b154-669d2519a8e1","added_by":"auto","created_at":"2025-05-07 07:33:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2019795,"visible":true,"origin":"","legend":"\u003cp\u003e(A) The leading haptic of the IOL was docked into the 27-gauge needle from the injector directly. (B) As the leading haptic secured within the needle, the trailing haptic was externalised. (C) The trailing haptic was then internalised by using a tying forceps and docked into the second needle. (D) As the IOL is centred, both ends of haptics were externalised, cauterised, flanged and buried within the sclera.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6117485/v1/47460f0b2dc51d09ce0aa104.png"},{"id":87412327,"identity":"cdfaf340-b2b0-46f7-9c22-833898c36db1","added_by":"auto","created_at":"2025-07-23 14:02:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2275308,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6117485/v1/a7468184-231c-4163-8a3f-8e723f3a159f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimalistic modified Yamane technique: intraocular lens haptic docking with injector and 27-gauge needle, without infusion line","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSutureless secondary intraocular lens (IOL) implantation has improved refractive outcomes in cases of absence of capsular support which traditionally may not yield the targeted results. Intrascleral IOL fixation was shown to have additional benefits over conventional transscleral suturing of IOL [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Other methods include iris-fixed IOL and anterior chamber IOL (ACIOL) [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eYamane introduced a method to fix secondary IOL that eliminates the need for extensive suturing, scleral and conjunctival dissection, or the use of glue. Pars plana vitrectomy was performed; subluxated crystalline lens were extracted or dislocated IOL was explanted. A 3-piece IOL was injected into the anterior chamber and the trailing haptic was left outside. The transconjunctival approach incorporated two angled sclerotomies at 180 degrees opposite each other using 30-gauge needles. The trailing haptic was captured within the needle lumen and externalized and the haptics\u0026rsquo; ends then cauterized and flanged with a diameter of 0.3mm. The flanged haptics were pushed back and secured into the scleral tunnels and peripheral iridotomies were made to prevent iris capture of the IOL [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eYamane technique has been modified according to the regional resources and to improve its execution. We introduced a minimalist modified Yamane technique with secondary IOL implantation; without infusion line support, performed by one surgeon (LTL) at ESC where the surgeon was a visiting consultant surgeon, as described below.\u003c/p\u003e "},{"header":"Technique","content":"\u003cp\u003eCase 1\u003c/p\u003e\n\u003cp\u003eA minimalistic modified Yamane technique was performed on an aphakic patient who previously had a penetrating eye injury. The procedure was performed under local anesthesia without an infusion line. Two 27-gauge needles are bent at 70 degrees about three-fourths in length and a marker was used to mark the sclerotomy ports of entry, at 2mm from the limbus as per Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Sclerotomies were made at marked sites using the 27-gauge needle. Anterior vitrectomy was performed with the aid of vitreous visualization by Triamcinolone. Balanced salt solution (BSS) was used to maintain globe turgidity, and viscoelastic was injected into the anterior chamber (AC) to protect the corneal endothelium as well as contributing the globe turgidity. As a 3-piece IOL was injected into the anterior chamber, the leading haptic was partially released. The right hand held the lens injector, and the left hand guided the sclerotomy needle to allow the haptic docking into the needle as per Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Then, as both hands were now on the lens injector, the IOL was advanced further and stopped and the action above was repeated to ensure the haptic was adequately secured into the needle before the entire IOL was inserted into the AC. The trailing haptic was kept outside the keratome incision and a tying forceps was used to internalize the trailing haptic into the AC and to dock it into the second sclerotomy needle before externalizing it. Both ends of the haptics were externalized, cauterised, flanged, and buried into the sclera.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCase 2\u003c/h2\u003e \u003cp\u003eA minimalistic modified Yamane technique was performed on a patient with a subluxated one-piece IOL who had the primary cataract extraction done 5 years prior. The minimalist Yamane approach was done without any infusion line support and the globe turgidity was maintained by balance salt solution (BSS) and viscoelastic. A standard self-sealing 2.75mm corneal (keratome) incision was made at 90 degrees to the sclerotomy sites. Viscoelastic was injected into the AC to protect the corneal endothelium and the dislocated IOL-capsule complex was removed. Anterior vitrectomy was performed with the vitreous visualization aided by intravitreal triamcinolone. The surgical wounds were hydrated, and further BSS was slowly injected through the paracentesis, followed by viscoelastic into the anterior chamber to improve the turgidity of the globe. Similar steps of 3-piece IOL haptic docking into sclerotomy needles as in Case 1 were repeated and completed. An infusion line was not used in the case.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePreoperative best corrected VA (BCVA) in Case 1 was 6/60 with +\u0026thinsp;10 diopter lens and in Case 2 was 6/36. Both eyes achieved 6/ 7.5 unaided VA at postoperative day 1, and 1,3 and 6 months. No postoperative complications were identified. Both IOLs were well-centred with no tilting. This illustrated that the above minimalistic modified Yamane technique of sutureless scleral fixated-IOL can be applied to cases of aphakia and/or lack of capsular support safely and efficiently.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRefractive correction in aphakia, subluxated and dislocated IOLs without capsular support is made possible by the implantation of secondary IOLs. Scleral-fixated is preferred as it reduces iris contact with IOL and iritis, risks of pupillary block and cornea and iridocorneal angle damage, secondary glaucoma versus iris-fixated and ACIOL although it is more difficult to perform [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Previously, the use of fibrin glue with intrascleral IOL fixation instead of suturing was reported. However, it was associated with wide sclerotomies and risk of hypotony [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Meanwhile, suture exposure and late endophthalmitis are recognized as late-stage complications of trans-scleral IOL suture fixation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the series of 100 cases with the original Yamane technique, the mean IOL tilt was 3.4\u0026deg;\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.5 \u0026deg;. There was no significant loss of endothelium, 8% had iris capture, 5% with vitreous hemorrhage, and 1% with cystoid macular edema with no incidence of postoperative retinal detachment, endophthalmitis or IOL dislocation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, another study that modified the original Yamane technique and used a 27-gauge needle also found no significant changes in endothelial density and macular thickness at 6 months with only two eyes having slight IOL decentration [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This has led to its more widely adaptation with various three-piece IOLs as a 27-gauge needle is more readily available globally than a 30-gauge needle.\u003c/p\u003e \u003cp\u003eYamane technique provides advantages that minimize complications secondary to suturing and eliminate the necessity to use a specific IOL for its execution. A steep learning curve may impose a challenge for surgeons to use this method. Threading the trailing haptic into the needle can be challenging, especially with rigid haptics. Nevertheless, using an IOL with a weak haptic may increase the risk of it getting kinked or broken and render the IOL useless for the Yamane technique [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Postoperative IOL tilt and decentration may incur an undesirable refractive outcome which is potentially due to malformation of the haptics, misaligned position of scleral tunnels, and inappropriate angles of the needles [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A needle stabilizer for flanged IOL fixation was introduced later and significantly reduced the IOL tilt compared to the control group [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Modified Yamane techniques have been introduced to address these issues [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKim introduced the trailing-haptic-first method to overcome the frustration faced by surgeons since the leading-haptic-needle complex tends to resist bending during threading the trailing haptic. However, this requires the assistance of the surgical technician to advance the twist-type IOL plunger and 23-gauge microforceps to thread the haptic into the needle [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A handshake technique with a pair of microforceps would require a third set of hands to hold the right-side needle in position during this method. On the other hand, Yamane inserted the IOL into the anterior chamber first before maneuvering the haptics into the needle and the trailing haptic was kept outside initially to prevent it from falling into the vitreous cavity which could increase the risk of injury to the anterior chamber structures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our minimalist modified Yamane method, a single surgeon (LTL) performed the trans-scleral IOL fixation and the equipment used is readily available; using the tying forceps and the 27-gauge needle without the need for a vitreoretinal micro-forceps or infusion line. The globe turgidity was maintained by adequate BSS and viscoelastic. With the method described above to fixate the 3-piece IOL, the time taken was relatively short, with standard 2.75mm keratome incision, hence minimal loss of fluid and/or viscoelastic, thus maintaining the well-formed AC during the procedure, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. We also minimized the risk of iris trauma as the IOL was not pre-placed in the anterior chamber, and instead by utilizing the hand-shake technique, directly docking the leading haptic with the 27-G needle.\u003c/p\u003e \u003cp\u003eWe introduced a refined, minimalist Yamane method that simplifies the procedure by eliminating the need for additional assistance or specialized (costly) equipment while reducing the risk of iris trauma compared to the standard approach.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis minimalistic modified Yamane technique has the potential to enhance the safety, efficiency, and accessibility of sutureless transscleral fixation of 3-piece IOLs for managing aphakia without capsular support. By streamlining the procedure, it may reduce surgical complexity and improve patient outcomes, with good consistency.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients. The Eye Specialist Centre (ESC) currently has a Research Ethics Committee, known as the Eye Specialist Centre Research Ethics Committee (ESCREC). The ESCREC had given ethical approval for this manuscript on 22 April 2025, with reference ESCREC2504-LTL(1).\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWritten consents were obtained from all patients.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and material\u003c/h2\u003e\n\u003cp\u003eData is available upon request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe author(s) received no specific funding for this work.\u003c/p\u003e\n\u003ch2\u003eAuthors' contributions\u003c/h2\u003e\n\u003cp\u003eMA, YZW and LTL contributed to the writing of the manuscript, prepared the figures, and revised the manuscript. Surgery planned, performed and recorded by LTL.\u0026nbsp;All authors reviewed the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThis patient’s surgery was planned, prepared and done at the Eye Specialist Centre (ESC) Kuching where the surgeon (LTL) was a visiting consultant surgeon.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYamane S, Inoue M, Arakawa A, Kadonosono K. Sutureless 27-gauge needle-guided intrascleral intraocular lens implantation with lamellar scleral dissection. Ophthalmology. 2014;121(1):61\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinha R, Bansal M, Sharma N, Dada T, Tandon R, Titiyal JS. Transscleral Suture-Fixated Versus Intrascleral Haptic-Fixated Intraocular Lens: A Comparative Study. Eye Contact Lens. 2017;43(6):389\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScharioth GB, Prasad S, Georgalas I, Tataru C, Pavlidis M. Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2010;36(2):254\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYazdani-Abyaneh A, Djalilian AR, Fard MA. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg. 2016;42(12):1707\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeh WG, Price FW, Jr. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg. 2000;26(7):1028\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePor YM, Lavin MJ. Techniques of intraocular lens suspension in the absence of capsular/zonular support. Surv Ophthalmol. 2005;50(5):429\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique. Ophthalmology. 2017;124(8):1136\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaykara M, Ozcetin H, Yilmaz S, Timucin OB. Posterior iris fixation of the iris-claw intraocular lens implantation through a scleral tunnel incision. Am J Ophthalmol. 2007;144(4):586\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvereklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg. 2003;29(2):301\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34(9):1433\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnand R, Bowman RW. Simplified technique for suturing dislocated posterior chamber intraocular lens to the ciliary sulcus. Arch Ophthalmol. 1990;108(9):1205\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelkar AS, Fogla R, Kelkar J, Kothari AA, Mehta H, Amoaku W. Sutureless 27-gauge needle-assisted transconjunctival intrascleral intraocular lens fixation: Initial experience. Indian J Ophthalmol. 2017;65(12):1450\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim DB. Trailing-haptic-first modification of double-needle intrascleral haptic fixation technique. J Cataract Refract Surg. 2018;44(4):424\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamane S, Maruyama-Inoue M, Kadonosono K. Needle Stabilizer for Flanged Intraocular Lens Fixation. Retina. 2019;39(4):801.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUcar F, Cetinkaya S. Flattened flanged intrascleral intraocular lens fixation technique. Int Ophthalmol. 2020;40(6):1455\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNajafi M, Yamane S, Johnston RH. Modified Flanged Intrascleral Fixation of Intraocular Lens for Vitreoretinal Surgeons. Ophthalmic Surg Lasers Imaging Retina. 2020;51(2):125\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Yamane technique, secondary IOL, subluxated IOL, intrascleral IOL fixation","lastPublishedDoi":"10.21203/rs.3.rs-6117485/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6117485/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eTo report a modified minimalist Yamane technique for scleral fixated intraocular lens (IOL) that is safer, faster and more economical, without infusion line support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The modified Yamane technique was adapted; the first haptics was docked into the sclerotomy needle directly from the lens injector and second haptic was docked into the sclerotomy needle whilst the IOL is in anterior chamber, by using a suture-tying forceps and without infusion line support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe unaided visual acuity of 6/7.5 was achieved postoperatively on Day 1 and 1,3 and 6 months. No postoperative complications were identified and the IOL was well-centred.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eWe introduced a modified Yamane method that is minimalistic, which is safer, faster and more economical, with less risk of possible trauma especially to the iris compared to the standard Yamane method and no need for expensive instruments such as the vitreo-retina micro-forceps.\u003c/p\u003e","manuscriptTitle":"Minimalistic modified Yamane technique: intraocular lens haptic docking with injector and 27-gauge needle, without infusion line","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 07:25:21","doi":"10.21203/rs.3.rs-6117485/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d375fb47-44d9-4ebf-9e10-4426040a92d0","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-23T13:54:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 07:25:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6117485","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6117485","identity":"rs-6117485","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}