Talley Rostov is a partner at Northwest Eye Surgeons in Seattle, Washington, and serves as a board member and medical liaison for SightLife. She is a consultant for Glaukos.

Audrey Talley Rostov, MD

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There are several ways of treating patients with a dislocated

 or with no capsular bag at all, but in my experience, the most straightforward and least invasive for these situations is the Yamane technique. 

I consider it safer than scleral-sutured IOLs because it requires smaller incisions (3 mm vs 7 mm for suture techniques), and the haptic fixations used in this approach allow for consistency and longevity in comparison with the scleral sutures. 

The technique is even simpler than the glue-assisted intrascleral fixation because it does not require creating scleral flaps. 

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But despite its elegant conception, the Yamane technique can be tricky, particularly if you do not have the right tools at hand.


First, you need a suitable IOL. My current preferred one is a 3-piece SofPort lens (LI61AO; Bausch + Lomb).

The lens is fairly straightforward to use in the scleral IOL fixation technique; you just need to remember not to grab the haptics too aggressively because they could break. Another IOL option is the CT Lucia 602 (Carl Zeiss Meditec) with resilient polyvinylidene fluoride haptics.

Of course, you need more tools than the IOL. The Yamane technique requires accurate measurement and marking, the creation of intrascleral tunnels, and careful externalization of the IOL haptic to facilitate IOL centration. 

Haptic flanging reduces IOL dislocations after cataract surgery


Typically, you would need to order the individual items from various vendors, but since adopting the Scleral IOL Fixation Solutions Pack (SFP-1001; MicroSurgical Technology [MST]) into our practice, we have been able to perform the Yamane technique more consistently.


The pack is so easy to use that it can take the stress out of performing the procedure. This is particularly so for surgeons who do not have much experience performing the Yamane technique, which was my case.

Before learning this technique, I used to perform the glue-assisted intrascleral fixation technique, which could sometimes cause challenges with the alignment (which needs to be exactly 180º if you want to avoid tilting the IOL). 

Accurate alignment is even more important with the Yamane technique, and this is where you see that these instruments are really designed with the surgeon in mind.

This company is quite good at finding a specific need and creating the ideal solution. A great example is the marking guide for making the scleral marks by which the needles will be introduced. 

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These markings need to be exactly 180º apart or you risk tilting the IOL. But with the centration marking guide included in the pack, the marking is accurate and effortless.

Other tools in the pack that I like are the needle holders. These make inserting and manipulating the new low-profile 30-gauge thin wall needles much easier, while allowing an ideal visibility to perform the delicate maneuvers needed during the Yamane technique. (There are 3 of these needles, so you have 1 extra for backup, just in case). 

The needles come with silicone stoppers, which is a very smart way of assuring the surgeon that they will not lose the needles while inserting the haptic or the second needle.

Small-aperture single-piece IOL could fill unmet need in patients


One of my recent cases requiring IOL fixation involved a 95-year-old woman in excellent health with IOL dislocation. 

Her daughter had noticed that her mother was having some difficulty navigating around and that she was less sure of herself because she had lost her binocular view. 

The retina surgeon did a vitrectomy, after which she had no capsule left. At that point, as a surgeon, you are faced with the challenge of how you are going to fixate this IOL without a capsule, and I thought she was a perfect candidate for the Yamane technique.

I really wanted to help this woman because at that age there is an increased risk of falling, which could greatly impact her quality of life. (See "Scleral IOL fixation technique".)

Analyzing the visual, non-visual benefits of VLF IOLs

One day postoperative the patient’s vision was already around 20/50 uncorrected. Within a couple of weeks, she was doing well and was back to a full life. 

At 95, that may seem like an exaggeration, but this woman appeared much younger than her actual age.


Now that I have the essential tools for the Yamane technique at hand, I have been able to use the sutureless transscleral IOL fixation technique for the benefit of my patients more consistently. 

With a little practice, and the right tools, any surgeon should be able to master this elegant and safe technique. 



Talley Rostov is in private practice at Northwest Eye Surgeons in Seattle, Washington. She is on the medical advisory board at SightLife, also in Seattle, and is a consultant to Alcon, Bausch + Lomb, and Lensar.

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Ophthalmology lost a higher share of patient volume than any other specialty during the initial months of the 

) pandemic (March and April 2020). 

It is estimated that ophthalmic practice volume fell by 81% during that time frame, led by declines in 

(97%) and patients seeking care for glaucoma (88%).

COVID-19: Practices falling short of pre-pandemic levels



That was certainly true for our practice, Northwest Eye Surgeons. During the 2 months we were closed for everything except urgent and emergent cases, we lost 95% of our normal volume. 

The partners worked without pay, and most of our employees, including physicians, were furloughed. The good news is that we have bounced back to nearly 100% of our previous volume. Corneal refractive surgery volume is higher now than at this time last year.



The most important step in our recovery was a thoughtful, cautious approach to welcoming back patients safely. We ramped up in phases to ensure our protocols were working (and workable).

For example, we added a check-in kiosk, with a masked staff member nearby to help. The staff member takes temperatures, asks screening questions, and escorts the patient to an assigned seat. 



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These waiting areas have been spread out and numbered, so the staff knows that Mrs Smith is in Seating Area 1. We require patients wear masks, and we even tape them on to ensure they stay properly over the mouth and nose.

Each physician carries a clear shield for the slit lamp and cleans it between patients. I also have implemented a “no talking” rule at the slit lamp. I explain in advance that this measure keeps us both safer. If the patient forgets this rule, I step a few feet away and gently remind them.

All patients undergoing laser or surgical procedures (small incision lenticule extraction [SMILE], laser in situ keratomileusis [LASIK], corneal cross-linking, cataract surgery, or a corneal transplant) are required to get a COVID-19 test within 72 hours before surgery. 

We are fortunate in Washington state to get test results within 12 to 24 hours. A negative test result and universal mask wearing were essential to us in offering cross-linking, which is performed in the clinic rather than the ambulatory surgical center (ASC), and is one of the longer procedures we perform.



Slit-lamp breath shields: Larger is better for protection from coronavirus during exam

The pandemic has provided good motivation to sanitize our exam rooms in the clinic even better than we already were; few changes were needed to the sterile environment in our ASC. The biggest change in the ASC has been limiting the number of people in the lunchroom and staff lounge.


Many patients have asked me, “Should I just wait to have surgery until all this has settled down?” What they are really asking is for us to be clear about the trade-off between risks and rewards. 

I tell patients that I do not recommend waiting, for 2 reasons. The first is that the risk of getting COVID-19 during surgery is low. We are experienced in safety protocols and have taken many extra steps to protect patients and ourselves. 

We explained all these steps in 

. 

I tell patients that the ASC is the safest place I go every week.



Surgery during the COVID-19 pandemic: Staying sharp

The second reason not to wait is that there are significant benefits to having surgery. The reality is that “all this” is not going away anytime soon. 

Even though many talented people are working diligently on better treatments and vaccines, we will never reach 100% immunity. We will still need to take precautions to protect ourselves and our patients from 

could result in a denser lens and increase the risk of complications. Restoring functional vision is critical for fall prevention and mobility in older adults.

 

Postponing cross-linking for progressive keratoconus could be even more damaging if the condition continues and the patient loses vision permanently.

Teleretinal screening fails to do double duty for detecting glaucoma, cataracts


In addition to government programs that helped many practices, like the Paycheck Protection Program loans, the ophthalmic industry has also found creative ways to help practices relaunch successfully. 

BVI, for example, just released a line of patient packs to help US ophthalmologists bring back patients to the office and the operating room with confidence. The packs include a face mask, cap, shoe covers and a gown. 

Johnson & Johnson Vision is offering a 

 to help ophthalmologists educate patients and navigate a safe reopening. 

Glaukos is giving 

patients vouchers to reduce out-of-pocket costs 

related to the FDA-approved iLink cross-linking procedure. Through the Living with Keratoconus Patient Support Program, patients with commercial insurance are eligible to get up to $100 toward their nonreimbursable copay expenses for cross-linking procedures completed from mid-June through the end of 2020. 





The company also offers a patient assistance program to support financially eligible, uninsured patients with drug costs at no charge.


Interestingly, we have seen significant growth in our practice in corneal refractive surgery, which arguably, could be postponed. 

Among patients whose disposable income has not been as affected by the pandemic, many are finding that they have the time to research 

 surgery, the desire to prioritize quality-of-life improvements, and the motivation to get rid of glasses that fog up when they wear a mask. 



Dispelling myths about refractive lens exchange



Many practices nationwide promote LASIK and SMILE specifically to deal with face mask fog.

Wearing a mask more frequently has spurred some patients to take the plunge—especially if laser surgery was a priority. 



1. Strata Decision Technology. National patient and procedure volume tracker. Version 5.11.20. Published May 11, 2020. Accessed Month, XX, 2020. https://www.stratadecision.com/national-patient-and-procedure-volume-tracker/

2. Brannan S, Dewar C, Sen J, Clarke D, Marshall T, Murray PI. A prospective study of the rate of falls before and after cataract surgery. 

 2003;87(5):560-562. doi:10.1136/bjo.87.5.560

Safety protocols, creative solutions help physicians restore patient traffic to normal during the pandemic. 


Audrey Talley Rostov, MD

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