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  double-  needle  flanged-haptic  technique  of  intrascleral  fixation  of  an 
intraoc-  ular  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  tun-  nels  until  DSEK  has  been  completed.  Bipolar  cautery  enables  the  technique  to  be  used  in  situations  in  which 
disposable low- or 
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 
pa- tients with aphakia and endothelial cell dysfunction. 
J Cataract Refract Surg 2017; 43:593–596 Q 2017 ASCRS and ESCRS 
Online Video 

D 
ysfunctional can indicating be accompanied endothelial intraocular by significant keratoplasty. lenses (IOL) corneal 
or Secondary aphakia edema 
IOL  implantation  combined  with  Descemet-stripping  endothelial  keratoplasty  (DSEK)  is  an  option for patients and 
surgeons  electing  to  address  the  problems  simulta-  neously.1  Various  IOL  implantation  techniques  in  this  setting 
have  been  described.  YamaneA  described  secondary  IOL  implantation  using  intrascleral fixation of a sulcus- based 
3-piece  IOL  with  haptics  modified  using  high-  temperature  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. 
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 sur- geon 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 place- ment 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 de- grees from the anticipated main incision site as access for intraocular forceps. Another paracentesis 
is made for an 
593 
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: lorenzo.cervantes.md@gmail.com. 
Q 2017 ASCRS and ESCRS Published by Elsevier Inc. 
0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.04.025 
 
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 vit- rectomy 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  intra-  scleral  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.  Af-  ter  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  re-  mained  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. 
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. 
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 
dysfunc- tion and indications for endothelial keratoplasty. Pa- tients 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 neces- sary and has been 
accomplished in combination with endothelial keratoplasty in a variety of ways, including iris-sutured, iris-claw, 
scleral-sutured, and intrascleral- fixated methods.5–10 The technique presented by Yama- neA 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 com- bined 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 30- gauge 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  jeweler-  type  forceps 
cautery (product number K8-7010, Katena 
 
595 TECHNIQUE: COMBINED DOUBLE-NEEDLE INTRASCLERAL IOL FIXATION AND DSEK 
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 
carefully watching the position of the externalized 
haptics. tested. Thicker-tipped McPherson-type forceps cautery 
Scleral tunnels of adequate length prevent rotation 
and (product number K8-7020 or K8-7021, Katena Products, 
posterior IOL displacement. Inc.) easily melted the 
haptics. The actual temperature 
In conclusion, the technique in this report shows 
that in- of different tips was not recorded, but it was presumed 
trascleral fixation of an IOL using the flanged-haptic 
dou- that the thinner caliber tipped forceps could not conduct 
ble-needle technique can be accomplished with 
bipolar enough current to produce adequate heat to melt the 
cautery and that the IOL is stable despite high 
intraopera- haptic. Intraoperatively, after the DSEK graft has been 
tive anterior chamber pressures, allowing the 
procedure placed, the anterior chamber air fill should be done slowly, 
to be combined with DSEK. 
Volume 43 Issue 5 May 2017 
 
596 
TECHNIQUE: COMBINED DOUBLE-NEEDLE INTRASCLERAL IOL FIXATION AND DSEK 
Volume 43 Issue 5 May 2017 
6. V ́elez FM, Mannis MJ, Izquierdo L Jr, S ́anchez JG, 
Vel ́asquez LF, Rojas S. WHAT WAS KNOWN Combined IOL fixation and DSEK is an option for patients 
Simultaneous surgery for corneal edema and aphakia: DSEK and place- ment 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 intra- with poor capsule support and 
endothelial dysfunction. 
scleral fixation of intraocular lens with pupilloplasty and 
pre-Descemet The double-needle flanged-haptic technique of intrascleral 
endothelial keratoplasty: a triple procedure. Cornea 2015; 
34:1627–1631 fixation of an IOL described by Yamane can be performed without conjunctival peritomy, scleral flaps, or an 
assistant. 
8. Sinha R, Shekhar H, Sharma N, Tandon R, Titiyal JS, Vajpayee RB. Intra- scleral fibrin glue intraocular lens fixation 
combined with Descemet- stripping automated endothelial keratoplasty or penetrating keratoplasty. WHAT THIS PAPER ADDS 
J Cataract Refract Surg 2012; 38:1240–1245 9. Prakash G, Agarwal A, Jacob S, Kumar DA, Chaudhary P, Agarwal A. The 
double-needle flanged-haptic technique is an option 
Femtosecond-assisted Descemet stripping automated 
endothelial kerato- that can be combined with DSEK. 
plasty with fibrin glue-assisted sutureless posterior 
chamber lens implanta- 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. 
tion. 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 iris- claw lens. J Ophthalmic Vis Res 2010; 5:205–210. Available at: 
https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3379922/pdf/jovr-5-3-218-779- 1-pb.pdf. Accessed March 10, 2017 
OTHER CITED MATERIAL A. Yamane S, “Transconjunctival Intrascleral IOL Fixation With Double-Needle REFERENCES 
1. Wylęgała E, Tarnawska D. Management of pseudophakic bullous ker- atopathy 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 nee- 
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  &  Refrac-  tive  Surgeons,  Bali,  Indonesia, 
July 2016. Available at: http://ascrs2016. conferencefilms.com/atables.wcs?entryidZ0082&bpZ1. Accessed March 10, 2017 
dle–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 
Disclosure: 
The author has no financial or proprietary interest in any material or method mentioned. 3. Shah AK, Terry MA, 
Shamie N, Chen ES, Phillips PM, Hoar KL, Friend DJ, Davis-Boozer D. Complications and clinical outcomes of Descemet strip- 
ping 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. Descemet- stripping automated endothelial keratoplasty in eyes with 
transscleral- sutured 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 
First author: Lorenzo J. Cervantes, MD 
OptiCare PC, Waterbury, Connecticut, USA