AAO 2026: Murtaza K. Adam, MD, on sutureless scleral-fixated IOLs

Flanged intrascleral intraocular lens (IOL) fixation with the double-needle technique, first described by Yamane et al in 2017,¹ has become a widely used option for secondary IOL placement in eyes without adequate capsular support. At the 2026 American Academy of Ophthalmology (AAO) Annual Meeting, held October 9–12 in New Orleans, Louisiana, Ophthalmology Times spoke with Murtaza K. Adam, MD, a partner at Colorado Retina Associates who trained at Wills Eye Hospital in Philadelphia, Pennsylvania, about how he approaches the technique in practice.

In the following Q&A, Adam discusses the step where surgeons most often struggle, how he chooses among flanged, Gore-Tex, and iris fixation, and the complications he works to prevent. Among them is IOL tilt, which reports have linked to haptic rotation in some lens models.² Adam also shares how surgeons new to the procedure can prepare through mentorship, wound construction, and preoperative planning.

This Q&A has beed edited for length and clarity.

Ophthalmology Times: Which step of the Yamane technique gives surgeons the most trouble?

Murtaza K. Adam, MD: I would say the main thing is getting that second haptic to be docked when you're fixating the trailing haptic of the IOL. The first leading haptic, after putting it in the eye, is pretty easy to get in terms of an angle into the first needle, because it's kind of a right-to-left angle. It's in the anterior chamber; you're working through a paracentesis. But the second one is challenging, because if you don't make your corneal incision a little bit to the left side of that cornea, sitting superiorly, you're going to have a really difficult, challenging angle to get your trailing haptic to dock in that right-sided needle.

The way to avoid it really is to make your incision a little bit left, a little bit wider, perhaps, and then make sure that you use both hands at the same time. Don't hold your needle and then try to get the haptic to go to it. Work with both hands together to get them to meet and shake so that you can dock it and then externalize it.

OT: How do clinical scenarios guide the choice among secondary IOL fixation techniques?

Adam: For most of my patients, the flange fixation with the double-needle-assist technique works for around 95% of patients. But there are certain cases in which Gore-Tex fixation may be better, or iris fixation might be a good option.

As an example, I had a patient who had a history of distant cataract surgery 20 years ago. He had a one-piece PMMA (polymethyl methacrylate) IOL that's rigid and you can't cut in half, and the width of an incision to take it out is about 6 millimeters. On top of it, he had some glaucoma history, and he had a history of corneal transplant. That's a patient where you don't want to make a large incision, if you can avoid it, to remove the IOL. You want to minimize endothelial damage and graft failure risk. So that's a patient in which, actually, I rescued his one-piece lens. I pulled up the optic above the iris plane but kept the haptics below it, and then I used Prolene sutures on each side of the eye in the iris stroma to secure it to the iris. Iris fixation can work in cases like that.

There are other cases where you have a CZ70 IOL, one that has little eyelets on the sides. That's also PMMA and hard to explant through a small incision. You need to make at least a 6-millimeter incision to remove it. Those are cases where I'll do a lasso technique using a Gore-Tex suture and then suture that to the sclera.

But for most patients, the technique is so versatile, and it minimizes the traumatic impact on the conjunctiva. So in a patient with a tube shunt, or a patient with a history of scleral buckle, you can usually find two little spots where the conjunctiva is pristine or untouched, and you can then fixate the lens there. I found that to be the most useful technique in my hands.

OT: What complications are most common after sutureless scleral-fixated IOL surgery?

Adam: Early on in my career of fixing these IOL cases, certainly tilt and decentration were a big issue. Because you only have two points of fixation, you really have to make sure that the haptics are centered on the visual axis. And then you also have to make sure that the tunnels you're creating in the sclera using the needles are even on each side. That's something that just takes time to progress and get consistency with, decentration and tilt are number 1.

Number 2, sometimes the tilt happens because of the IOL model. We saw, back in 2020 and 2021, a real uptick in the number of rotisserie tilts from the CT LUCIA (Carl Zeiss Meditec). That is being worked on from a manufacturing standpoint. It may have been resolved. We're waiting to get some data from Zeiss and Bausch + Lomb on that.

OT: What other complications warrant attention, and how can their risk be reduced?

Adam: If you have an eye with a history of uveitis or a history of glaucoma with a drainage device, hypotony is really common in these eyes. In patients with uveitis, the inflammation leads to reduced aqueous production. So I make sure I suture everything in these patients, I leave the pressure a little high, and I try to make sure that I use aggressive steroids postoperatively to minimize risk.

And then exposure of the haptic. It's interesting: when surgeons fixate their haptics at a superior or inferior orientation, so 12 and 6 o'clock, the eyelids rub against those haptics and the conjunctiva much more commonly than if you were to have them at 3 and 9. The rate of revision or exposure is unknown, but we know that 90% of erosions occur when they're superiorly placed. So I place all of mine horizontally. That really reduces the risk as well.

OT: What should surgeons new to the Yamane technique focus on first?

Adam: You want to set yourself up for success. If you happen to have another surgeon in the practice who has experience with the technique, learn from them. I've had my younger partners and associates come to the OR with me and I dictate out loud what I am doing and how I am doing it. Over the years, you learn tiny little nuances that make a case go from really challenging to quite easy and straightforward. So if you have a mentor and you can get that mentorship in person, that's great.

You can also review videos, that's how I learned the technique. I watched other surgeons who are excellent and proficient, and I studied their videos. Then over time, I found my own little internal pearls that make my cases a bit easier.

I think you want to give yourself enough time in the operating room. Don't schedule an IOL case you're doing for the first time for 45 minutes or an hour. Give yourself an hour and 15 minutes. You might finish early; you probably will. But you don't want to be stressed on a time crunch when you're learning a new technique.

OT: Which surgical fundamental matters most for a smooth case?

Adam: I think one of the most important things to set yourself up for success is good wound construction. If you make a corneal incision that is well beveled, that is not leaking, you're going to have a much easier, fluid and successful case. But if you have iris coming out of the eye, your chamber's shallow and you're getting hypotony throughout the case, that makes the case really, really hard.

"So work on the fundamentals of those corneal incisions, and your cases will go a lot faster."

OT: What role does preoperative planning play in scleral-fixated IOL outcomes?

Adam: I think when we think about surgery, we focus so much on the hands, so much on what we do mechanically. But a good surgical outcome also depends on thorough surgical planning. If you have a patient with a complex history, such as glaucoma or a history of buckle, take a look at the conjunctiva. Make sure you understand where you can fixate the lens.

Plan on preoperative biometry. I can't tell you how many retina surgeons just pick plano because they think that's the right lens for the patient, the right refractive target or outcome for the patient. And they don't really ask: Do you want near? What was your native vision? Do you have a history of LASIK? These things, if you plan ahead, can avoid unnecessary second surgeries.

For more from the meeting, visit Ophthalmology Times’ AAO 2026 coverage.

References
1. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique. Ophthalmology. 2017;124(8):1136-1142. doi:10.1016/j.ophtha.2017.03.036
2. Liu JC, Sheybani A. Haptic curing with endolaser after lens tilt in the Yamane technique. Am J Ophthalmol Case Rep. 2024;34:102049. Published 2024 Apr 16. doi:10.1016/j.ajoc.2024.102049