A Novel Modification of the Yamane Intrascleral Haptic Fixation Technique with Scleral Groove-Flap Coverage: A Case Series Study

Abstract

Purpose

To describe a modification of the Yamane double-needle technique using partial-thickness scleral groove-flap coverage of the terminal haptic flanges for secondary IOL implantation in eyes without adequate capsular support.

Methods

This surgical technique report describes a modified approach to flanged intrascleral haptic fixation (ISHF). At two fixation sites 180° apart, partial-thickness scleral grooves are created. After haptic externalization and cauterization, the terminal flanges are guided into the grooves and buried beneath scleral tissue rather than positioned directly beneath the conjunctiva.

Results

The technique was successfully performed in three eyes requiring secondary IOL implantation without adequate capsular support. At 12 months postoperatively, all patients demonstrated stable IOL centration with complete conjunctival epithelialization over the haptic sites. No cases of haptic exposure, endophthalmitis, or flange-related irritation were observed.

Conclusion

The scleral groove-flap modification preserves the essential workflow of the Yamane technique while providing additional scleral tissue coverage over the terminal haptic flanges. In this small case series without a comparison group, the technique was associated with stable IOL centration, complete conjunctival epithelialization, and no observed haptic exposure during 12 months of follow-up.

Introduction

Secondary intraocular lens implantation remains one of the most demanding steps in the management of aphakia, subluxated lenses, and eyes with inadequate capsular or zonular support. Available strategies include anterior chamber IOL implantation, iris fixation, transscleral suturing, glued IOL techniques, and sutureless intrascleral haptic fixation. Each method has advantages and limitations, and the final choice is influenced by ocular anatomy, comorbidities, conjunctival status, surgeon experience, and the need to avoid long-term suture-related complications.^1–4

The double-needle flanged intrascleral fixation technique popularized by Yamane et al has gained broad acceptance because it allows posterior chamber IOL fixation without sutures or glue, uses small-gauge transscleral tunnels, and provides stable haptic fixation through cautery-created terminal flanges.⁴ Reported outcomes have generally been favorable, and recent data continue to support the functional utility of the Yamane approach in eyes with aphakia, IOL subluxation, or IOL dislocation.⁵

Despite these benefits, haptic-related complications remain clinically relevant. The terminal flange must be large enough to prevent slippage yet small and well-positioned enough to avoid chronic conjunctival irritation.⁶ Conjunctival erosion and haptic exposure after sutureless scleral-fixated IOL implantation have been described and may require further surgery because exposed haptic material can cause discomfort, inflammation, and infection risk.^7,8

Several techniques have been described to improve long-term haptic coverage, including scleral tunnels, scleral flaps, conjunctival autografts, and haptic refixation strategies.^2,3,8,9 The present groove-flap modification differs in that the terminal haptic flange is intentionally positioned beneath a partial-thickness scleral layer at the time of secondary IOL implantation, thereby moving the flange away from direct subconjunctival contact. Unlike haptic refixation, which is generally performed after haptic exposure has already occurred, this approach is intended to provide additional tissue coverage during the initial implantation. It also differs from broader scleral flap and glued IOL techniques by using a limited superficial scleral groove while preserving the essential double-needle Yamane workflow without fibrin glue or permanent sutures. The concept is straightforward: before haptic externalization, a small partial-thickness scleral groove-flap is created at each fixation site; after flange formation, the terminal flange is gently tucked beneath the scleral tissue. This report describes the surgical steps and clinical outcomes of three eyes treated using this modified approach.

Materials and Methods

Study Design and Patients

This retrospective surgical technique report included three eyes of three patients who underwent secondary IOL implantation using the modified Yamane technique with scleral groove-flap coverage. Eligible eyes had aphakia, a subluxated/dislocated IOL, or inadequate capsular support in which in-the-bag or sulcus IOL placement was not appropriate. Eyes with uncontrolled ocular inflammation, active ocular infection, uncontrolled glaucoma, or retinal pathology requiring urgent separate management were not considered suitable for this approach.

Preoperative assessment included best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, intraocular pressure (IOP) measurement, dilated fundus examination, when possible, ocular biometry, and posterior segment imaging as clinically indicated. Follow-up examinations were performed on postoperative day 1, during the first postoperative week, and at approximately 1, 3, 6 and 12 months. The main clinical outcomes were successful IOL fixation, IOL centration, conjunctival epithelialization over the fixation sites, haptic or flange exposure, visual recovery, and adverse events. Given the descriptive nature and small sample size of this case series, outcomes were summarized descriptively, and no formal statistical analysis was performed.

Surgical Technique

All cases were performed under local anesthesia with sterile ophthalmic preparation and draping. A three-piece AvanseePreset intraocular lens (Kowa; model PN6AS), with a hydrophobic acrylic optic and polyvinylidene fluoride (PVDF) modified C-loop haptics, was selected for flanged intrascleral fixation. When vitreous was present in the anterior chamber or around the lens plane, anterior vitrectomy was performed as clinically required before IOL fixation. Two fixation meridians were marked 180 degrees apart, with each scleral entry point placed approximately 2.5 mm posterior to the limbus. At each fixation point, a horizontal partial-thickness scleral groove measuring approximately 1.5 mm x 1.5 mm was created with a supersharp blade in a limbus-parallel orientation (Figure 1A and B). The dissection was maintained within the superficial lamellar scleral plane, aiming for approximately one-third of the scleral thickness while preserving an intact scleral roof. A standard 25-gauge needle was then carefully advanced within the same lamellar plane to develop a small groove-flap pocket sufficient to accommodate the terminal haptic flange (Figure 1C). Care was taken to avoid deep dissection or full-thickness scleral penetration. Standard double-needle Yamane fixation was then performed. Two 30-gauge thin-walled needles were introduced at approximately a 20° angle to the limbus through the prepared scleral fixation sites, creating symmetric limbus-parallel scleral tunnels toward the ciliary sulcus. The leading and trailing haptics were docked into the needle lumens and externalized through the scleral tunnels. After externalization, each haptic tip was cauterized with low-temperature ophthalmic cautery to create a small terminal flange approximately 0.3–0.4 mm in diameter. Particular attention was given to equal tunnel length, symmetric haptic tension, and avoidance of haptic kinking. Focal scleral bleeding, when encountered, was controlled with gentle bipolar cautery before haptic burial, avoiding excessive cautery near the externalized haptic. The flange was then gently guided into the preformed scleral groove using a Sinskey hook and positioned beneath the partial-thickness scleral roof. Minimal traction was applied to the haptic during this maneuver to avoid haptic distortion or displacement of the IOL. IOL centration and stability were reassessed after positioning each flange. The flange was considered adequately positioned when it was completely covered by scleral tissue, with no visible haptic or flange prominence at the conjunctival surface (Figure 1D). The IOL position was checked for centration and stability. The conjunctiva was reapproximated with 8–0 Vicryl sutures or gentle bipolar cautery according to tissue status. At postoperative follow-up, the IOL was centered, the conjunctiva remained smooth over both fixation sites, and no haptic exposure, flange visibility, or IOL instability was observed (Figure 1E and F). Postoperative treatment consisted of topical moxifloxacin 0.5% four times daily for 7 days and prednisolone acetate 1% every 4 hours initially, followed by a gradual taper over 4 weeks according to the postoperative inflammatory response.

Figure 1.

Stepwise illustration of the modified Yamane technique with scleral groove-flap coverage. (A) A limited conjunctival peritomy is created anterior to the pre-marked scleral fixation site. (B) A horizontal partial-thickness scleral groove is created in a limbus-parallel orientation; the arrow indicates the prepared scleral groove. (C) A standard 25-gauge needle is used within the superficial lamellar scleral plane to develop the groove-flap pocket; the arrow indicates the needle entry site. (D) Final intraoperative appearance following haptic externalization, flange formation, and burial within the preformed scleral grooves. The arrows indicate the two flange burial sites beneath the scleral tissue. (E and F) Slit-lamp photographs at 2 weeks postoperatively show a smooth conjunctival surface with complete coverage of the haptic fixation sites and no visible haptic or flange.

Case Presentations

Case 1

A 62-year-old man presented with right-eye surgical aphakia after complicated cataract surgery with posterior capsule rupture. The cornea was clear, the conjunctiva was mobile, and no adequate capsular support remained for sulcus IOL placement. Preoperative BCVA was approximately 20/200. Secondary IOL implantation was performed using the modified Yamane technique described above. At 1 month, the IOL was centered and both haptic sites were covered. At 12 months, BCVA improved to 20/30, the conjunctiva remained smooth over both fixation sites, and no haptic exposure, flange visibility, or IOL instability was observed.

Case 2

A 48-year-old man had left-eye aphakia following traumatic crystalline lens subluxation and prior lens removal with anterior vitrectomy. The eye had localized conjunctival thinning from previous trauma but no active inflammation. Preoperative BCVA was approximately 20/400. The modified scleral groove-flap Yamane technique was selected to provide additional coverage over the flange sites. Early postoperative inflammation was mild and responded to topical corticosteroid therapy. At 12 months, BCVA improved to 20/40, with visual recovery limited by prior trauma and residual irregular astigmatism. The IOL was stable and centered, and both flange sites remained completely covered without conjunctival erosion.

Case 3

A 72-year-old woman presented with progressive visual decline due to late in-the-bag IOL-capsular complex dislocation associated with pseudoexfoliation. Preoperative BCVA was approximately 20/150. The unstable IOL-capsular complex was removed, anterior vitrectomy was performed, and a secondary three-piece IOL was implanted using the modified Yamane technique. At 6 and 12 months, the IOL remained clinically centered. BCVA improved to 20/25.

Results

All three procedures were completed without conversion to sutured fixation or IOL exchange. In each case, both haptic flanges were successfully buried beneath the partial-thickness scleral groove-flap. No intraoperative haptic breakage, uncontrolled bleeding, or wound leak was noted. At the 12-month review, all eyes had stable posterior chamber IOL fixation with complete conjunctival epithelialization over the fixation sites. Visual acuity improved in all three eyes. Final BCVA ranged from 20/40 to 20/25, with the lowest final acuity observed in the eye with a history of trauma and residual irregular astigmatism. No eye developed haptic exposure, conjunctival erosion, persistent flange-related foreign body sensation, clinically significant IOL decentration, retinal detachment, endophthalmitis, or persistent inflammation. IOP remained within the normal range throughout follow-up, with no sustained elevation requiring treatment. No new or progressive postoperative conjunctival thinning or suture-related irritation was observed. The case-level findings are summarized in Table 1.

Table 1.

Summary of the Three Cases Treated with Scleral Groove-Flap Modified Yamane Fixation

Case	Patient/Eye	Indication	Preop BCVA	12-Month BCVA	Final Anatomical Status
1	62-year-old male/right eye	Surgical aphakia after complicated cataract surgery	20/200	20/30	IOL centered and stable; flanges covered; no haptic exposure
2	48-year-old male/left eye	Traumatic aphakia after lens removal and anterior vitrectomy	20/400	20/40	IOL centered and stable; flanges covered; no haptic exposure
3	72-year-old female/right eye	Late IOL-capsular complex dislocation with pseudoexfoliation.	20/150	20/25	IOL centered and stable; flanges covered; no haptic exposure

Abbreviations: BCVA, best-corrected visual acuity; IOL, intraocular lens.

Discussion

The Yamane technique has become an important option for posterior chamber IOL fixation in eyes without adequate capsular support. Its appeal lies in the combination of small-gauge access, avoidance of suture degradation, and stable intrascleral haptic fixation through terminal flanges.^4,5 However, the success of the technique depends not only on correct IOL centration but also on reliable long-term coverage of the external haptic ends.

Haptic exposure is uncommon but important. Pakravan et al reported a multicenter series of eyes with conjunctival haptic erosion after sutureless intrascleral fixation, emphasizing that conjunctival assessment and management of exposed haptics are clinically relevant considerations.⁷ Gelman and Garg also described flange-based refixation for haptic exposure after glued intrascleral fixation, highlighting the broader need for durable haptic coverage in eyes undergoing secondary IOL surgery.⁸

The present modification is designed to address this problem at the time of secondary IOL implantation. The concept differs from simply pushing the flange back under conjunctiva. By making a shallow scleral groove before externalizing the haptic, the surgeon creates a controlled receiving space for the terminal flange. Once buried, the flange is separated from the conjunctiva by scleral tissue. The proposed mechanism is that positioning the terminal flange beneath scleral tissue may reduce direct mechanical contact and haptic prominence, potentially decreasing the risk of conjunctival irritation or erosion; however, this potential benefit was not directly evaluated in the present series.

The modification incorporates a principle used in earlier scleral flap and glued IOL techniques: interposition of scleral tissue over the externalized haptic.^2,3,9,10 In glued IOL fixation, haptics are externalized and secured beneath scleral flaps, whereas intrascleral tunnel approaches rely on adequate tunnel length and tissue apposition for stability.¹¹ The groove-flap modification applies this principle to the Yamane procedure without requiring fibrin glue, a broad scleral flap, or permanent sutures.¹²

The present modification differs from previously described approaches to haptic coverage in both its timing and mechanism. Conventional Yamane fixation relies on the terminal flange being retained within the scleral tunnel and positioned beneath the conjunctiva. Scleral flap and tunnel techniques may provide additional tissue coverage but generally involve a larger area of scleral dissection, whereas glued IOL techniques require fibrin glue and a different fixation workflow. Haptic refixation procedures, in contrast, are typically performed after an exposed or displaced haptic has already become clinically evident. In the present technique, the scleral groove-flap is created before haptic externalization, allowing the terminal flange to be deliberately positioned beneath partial-thickness scleral tissue during the initial implantation. This preserves the fundamental double-needle Yamane workflow while adding a limited superficial scleral coverage step.

From a practical perspective, the modification requires limited additional scleral dissection and uses instruments commonly available in anterior segment surgery. It may be particularly relevant in eyes with thin conjunctiva or prior conjunctival manipulation, where additional scleral coverage of the terminal flange may be desirable.

The modification has limitations. The series is small, non-comparative, and limited to 12 months of follow-up. It cannot prove superiority over the standard Yamane technique. In addition, the maneuver adds a lamellar scleral dissection step, which carries potential risks if performed too deeply or too aggressively. A deep groove may create full-thickness scleral entry, bleeding, or inadequate scleral support. A groove that is too tight may bend the haptic or induce IOL decentration. Therefore, the technique should be performed with controlled depth, gentle manipulation, and careful assessment of IOL centration before closure.

IOL centration and stability were assessed clinically, without objective quantitative measurement of IOL tilt or decentration. Future evaluation should include a larger prospective cohort with standardized anterior segment photography, ultrasound biomicroscopy or anterior segment OCT when available, objective IOL tilt/decentration analysis, and longer follow-up. A comparative study with standard Yamane fixation would be particularly useful to determine whether scleral groove-flap coverage meaningfully reduces late haptic exposure.

Conclusions

This scleral groove-flap modification of the Yamane technique adds a simple lamellar scleral coverage step over the terminal haptic flange. In three cases, the method achieved stable IOL fixation, smooth conjunctival healing, and no haptic exposure at 12 months. Whether this modification reduces late haptic exposure or conjunctival erosion requires further investigation in larger studies with longer follow-up.

Funding Statement

No external funding was received for this work.

Abbreviations

BCVA, best-corrected visual acuity; IOL, intraocular lens; IOP, intraocular pressure; ISHF, intrascleral haptic fixation; OCT, optical coherence tomography; PVDF, polyvinylidene fluoride.

Data Sharing Statement

The de-identified clinical data supporting this technical report are available from the corresponding author upon reasonable request, subject to applicable institutional, ethical, and patient privacy restrictions.

Ethics Approval and Informed Consent

This retrospective technical case series used de-identified clinical information. Institutional Review Board (IRB) approval was not required for this study, and no additional institutional approval was required for publication of the de-identified case details. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for Publication

Written informed consent for the surgical procedure and for publication of de-identified clinical details and images was obtained from all patients before submission.

Author Contributions

Ali Hendi Alghamdi made a significant contribution to the work reported, including the conception, study design, execution, acquisition of data, analysis and interpretation; drafting, revising, and critically reviewing the article; gave final approval of the version to be published; agreed on the journal to which the article has been submitted; and agrees to be accountable for all aspects of the work.

Disclosure

The author declares no conflicts of interest in relation to this work.