Yamane Tekniği ile Skleral Fiksasyon ve Yeni Modifikasyonlar
Özet
Yamane tekniği, kapsül desteği zayıf veya yetersiz olan gözlerde afakinin düzeltilmesi amacıyla geliştirilen, haptik uçlarında flanşlar (yaka) oluşturularak üç parçalı göz içi lensinin (GİL) sütürsüz ve basit bir şekilde skleraya sabitlendiği yenilikçi bir cerrahi yöntemdir. 2017 yılında Yamane ve arkadaşları tarafından literatüre kazandırılan bu minimal invaziv teknik; skleral flep, sütür ve fibrin yapıştırıcı kullanımını ortadan kaldırarak cerrahi süreyi önemli ölçüde kısaltmakta ve transskleral sütürlü fiksasyon yöntemlerine kıyasla daha stabil bir GİL yerleşimi sağlamaktadır. Operasyon temelde, limbusun gerisinden açılan skleral tünellerden iğne yardımıyla haptiklerin dışarı çıkarılması, uçlarının koterle yakalaştırılması ve tünele geri itilerek sabitlenmesi esasına dayanır. Kısa cerrahi süresi sayesinde kornea endotel hücre kayıplarını azaltan bu yöntem; vitrektomi, keratoplasti, DMEK veya DSEK gibi kompleks ve uzun süreli korneal cerrahilerle de başarıyla kombine edilebilmektedir. Prosedürün en zorlayıcı basamağı ikinci haptiğin iğne içine yerleştirilmesidir; bu güçlüğü aşmak ve refraktif sonuçları mükemmelleştirmek adına haptik boylarının kısaltılması, iğne sabitleyicilerin kullanımı ve 27-G trokarlar ile forsepslerin entegre edilmesi gibi çeşitli cerrahi modifikasyonlar geliştirilmiştir. Öğrenme eğrisi barındırmasına ve optik tuzaklanma ile vitreus hemorajisi gibi potansiyel komplikasyon risklerine rağmen, yüksek fiksasyon gücü ve düşük invazivliği sayesinde afaki yönetiminde yaygın bir popülarite kazanmıştır.
The Yamane technique is an innovative, sutureless, and minimally invasive surgical method developed for managing aphakia in eyes with deficient capsular support, utilizing a double-needle approach to create flanges at the haptic tips of a three-piece intraocular lens (IOL) to securely fixate it within the sclera. Introduced in 2017, this revolutionizing procedure eliminates the need for scleral flaps, sutures, or fibrin glues, thereby significantly reducing operation time—often to less than half of sutured techniques—and minimizing corneal endothelial cell loss while ensuring superior axial stability and less IOL tilt. The procedure fundamentally involves creating parallel scleral tunnels with a 30-G or 27-G needle, externalizing the haptics, forming a collar-like bulb using cautery to increase fixation force fourfold, and re-inserting the tips back into the tunnels. Its efficiency allows for seamless combination with complex vitreoretinal and corneal surgeries like vitrectomy, keratoplasty, DMEK, or DSEK. Although the technique possesses a steep learning curve and carries minor non-specific risks such as optic capture or vitreous hemorrhage, various advanced modifications—including the trailing-haptic-first approach, needle stabilizers, haptic length adjustments for refractive precision, and the utilization of 27-G trocars with forceps—have been successfully developed to overcome its main challenge of secondary haptic docking
Referanslar
Wagoner MD, Cox TA, Ariyasu RG, et al. Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology. Ophthalmology. 2003 Apr;110(4):840-59. doi: 10.1016/s0161-6420(02)02000-6.
Malbran ES, Malbran E Jr, Negri I. Lens guide suture for transport and fixation in secondary IOL implantation after intracapsular extraction. Int Ophthalmol. 1986 May;9(2-3):151-60. doi: 10.1007/BF00159844.
Yamane S, Sato S, Maruyama-Inoue M, et al. Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique. Ophthalmology. 2017 Aug;124(8):1136-1142. doi: 10.1016/j.ophtha.2017.03.036. Epub 2017 Apr 27.
Yamane S, Ito A. Flanged fixation: Yamane technique and its application. Curr Opin Ophthalmol. 2021 Jan;32(1):19-24. doi: 10.1097/ICU.0000000000000720.
Mizuno Y, Sugimoto Y. A comparative study of transscleral suture-fixated and scleral-fixated intraocular lens implantation. Int Ophthalmol. 2019 Apr;39(4):839-845. doi: 10.1007/s10792-018-0883-5. Epub 2018 Mar 3.
Rocke JR, McGuinness MB, Atkins WK, et al. Refractive Outcomes of the Yamane Flanged Intrascleral Haptic Fixation Technique. Ophthalmology. 2020 Oct;127(10):1429-1431. doi: 10.1016/j.ophtha.2020.03.032. Epub 2020 Apr 3.
Do JR, Park SJ, Mukai R, et al. A 1-Year Prospective Comparative Study of Sutureless Flanged Intraocular Lens Fixation and Conventional Sutured Scleral Fixation in Intraocular Lens Dislocation. Ophthalmologica. 2021;244(1):68-75. doi: 10.1159/000507713. Epub 2020 Apr 6.
Rocke JR, McGuinness MB, Atkins WK, et al. Refractive Outcomes of the Yamane Flanged Intrascleral Haptic Fixation Technique. Ophthalmology. 2020 Oct;127(10):1429-1431. doi: 10.1016/j.ophtha.2020.03.032. Epub 2020 Apr 3.
Scharioth GB, Prasad S, Georgalas I, et al. Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2010; 36:254–259.
Agarwal A, Kumar DA, Jacob S, et al. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008; 34:1433–1438.
Stem MS, Wa CA, Todorich B, et al. 27-Gauge sutureless intrascleral fixation of intraocular lenses with haptic flanging: short-term clinical outcomes and a disinsertion force study. Retina. 2019; 39:2149–2154.
Iglicki M, Zur D, Negri HP, et al. Results in comparison between 30 gauge ultrathin wall and 27 gauge needle in sutureless intraocular lens flanged technique in diabetic patients: 24-month follow-up study. Acta Diabetol 2020; 57:1151–1157.
Cervantes LJ. Combined double-needle flanged-haptic intrascleral fixation of an intraocular lens and Descemet-stripping endothelial keratoplasty. J Cataract Refract Surg. 2017; 43:593–596.
Rocha KM, Gouvea L, Milliken CM. Combined flanged intrascleral intraocular lens fixation with corneal transplant. Am J Ophthalmol Case Rep. 2018; 13:1–5.
Kim DB. Trailing-haptic-first modification of double-needle intrascleral haptic fixation technique. J Cataract Refract Surg. 2018; 44:424–428.
Bonnell A, Polo R, Shah S, et al. One-year outcomes of a novel surgical technique for sutureless intrascleral fixation of a three-piece intraocular lens using a 30-gauge needle. Retina. 2020; 40:1148–1152
Ishikawa H, Fukuyama H, Komuku Y, et al. Flanged intraocular lens fixation via 27-gauge trocars using a double-needle technique decreases surgical wounds without losing its therapeutic effect. Acta Ophthalmol. 2020; 98:499–503.
Ucar F, Cetinkaya S. Flattened flanged intrascleral intraocular lens fixation technique. Int Ophthalmol. 2020; 40:1455–1460.
Yamane S. Flanged IOL fixation with intraoperative adjustment of refractive error. Washington, DC: American Society of Cataract and Refractive Surgery. 2018.
Yamane S, Maruyama-Inoue M, Kadonosono K. Needle stabilizer for flanged intraocular lens fixation. Retin.a 2019; 39:801.
Kurimori HY, Inoue M, Hirakata A. Adjustments of haptics length for tilted intraocular lens after intrascleral fixation. Am J Ophthalmol Case Rep 2018; 10:180–184.
