Matias Iglicki, MD, PhD, on patient selection, technical pitfalls and why symmetry decides outcomes in flanged vs sutured fixation
QUICK TAKE
Consider Yamane when: healthy sclera, combined phacovitrectomy, conjunctiva needs preserving or patient is elderly, monocular or on anticoagulant therapy
Consider Gore-Tex when: fragile or abnormal sclera, extensive conjunctival scarring, young patient with connective tissue disorder or future surgeries likely
Key pearl: Mark entry points 2 mm from the limbus, exactly 180 degrees apart, before any needle pass—asymmetry is the top cause of tilt and decentration
Secondary IOL fixation has evolved considerably, with sutureless flanged techniques gaining traction as an alternative to traditional scleral-sutured approaches. Although both approaches can provide excellent visual outcomes and durable fixation when performed correctly, they differ in surgical efficiency, IOL centration, technique-specific considerations and the types of eyes in which each may be best suited.
In this Q&A conversation with Ophthalmology Times Europe (OTE), Matias Iglicki, MD, PhD, FEBO, FICO, discusses findings from a prospective comparative study of 300 eyes presented at the American Society of Retina Specialists (ASRS) 44th Annual Scientific Meeting.1 He shares practical considerations for choosing between Yamane flanged fixation and Gore-Tex suture-based fixation, including patient selection, the learning curve for sutureless fixation, technical pitfalls and the importance of collaboration between anterior and posterior segment surgeons.
Note: Transcript edited lightly for clarity and length.
Matias Iglicki, MD, PhD, FEBO, FICO: In our prospective comparative study of 300 eyes presented at ASRS 2026, both the Yamane sutureless flanged technique and ePTFE (Gore-Tex)-sutured scleral fixation delivered excellent and broadly comparable final visual outcomes. The meaningful differences lie elsewhere. Sutureless flanged fixation is faster, requires fewer conjunctival and scleral manipulations and avoids suture-related complications altogether—there is no knot to erode, no suture to degrade and no late breakage to worry about. Its Achilles’ heel is precision: haptic asymmetry can translate into IOL tilt and decentration, and flange-related issues such as exposure or haptic slippage are technique-dependent.
Gore-Tex fixation, by contrast, offers extraordinary long-term material stability—ePTFE essentially does not degrade—and four-point fixation of an appropriate IOL gives highly predictable centration and minimal tilt. The trade-offs are longer surgical times, larger conjunctival openings and the theoretical risks of any transscleral suture: erosion, exposure and endophthalmitis as a late portal of entry. In short: flanged fixation wins on efficiency and elegance; Gore-Tex wins on predictability of centration and material permanence. Both are durable when performed correctly, and the honest message from our data is that the surgeon’s mastery of the chosen technique matters more than the technique itself.
Iglicki: Absolutely. I favour Gore-Tex-sutured fixation in eyes with abnormal or fragile sclera where flange burial is unreliable—high myopia with thin sclera, previous scleral buckles and eyes with extensive conjunctival scarring where I want to control exactly where the fixation elements sit. I also lean towards Gore-Tex in young patients with connective tissue disorders such as Marfan syndrome, where I expect decades of pseudophakic life and want four-point fixation of a stable one-piece hydrophilic acrylic lens, and in eyes that will likely need future surgeries, since a sutured lens tolerates subsequent manipulation well.
I favour the Yamane flanged technique in routine aphakia with healthy sclera, in combined phacovitrectomy settings where efficiency matters, in eyes with limited conjunctiva that I want to preserve for possible future glaucoma surgery, and in patients where minimizing surgical time is a priority—patients who are elderly, patients with monocular vision and patients on anticoagulant therapy. Anatomical red flags for Yamane include very thin sclera, deeply set eyes that make needle passes ergonomically awkward and any situation where I cannot guarantee symmetric haptic tunnels 180 degrees apart. When the anatomy tells you the flange will not sit securely, listen to it.
Iglicki: My first advice is to respect the technique’s apparent simplicity—it is deceptive. The Yamane technique looks like a two-minute manoeuvre on video, but every step encodes a geometric decision that determines final IOL position. Start in wet lab or model eyes until the needle docking becomes reproducible, then select forgiving first cases: aphakic eyes with healthy sclera, good visualization and no hurry. Perform the first cases with a vitreoretinal setup and complete the anterior vitrectomy meticulously; vitreous entangled in a haptic is a silent disaster.
The most common pitfalls are asymmetry and haptic damage. Asymmetric scleral tunnels—different distances from the limbus, different tunnel lengths or entry points not truly 180 degrees apart—produce tilt and decentration that no flange can compensate. Grasping the haptic tip incorrectly or forcing it into the needle lumen kinks or breaks it, and a damaged haptic should be considered a compromised fixation. Needle selection matters more than most surgeons appreciate: we published comparative work on 30-gauge versus 27-gauge needle approaches for flanged fixation in Acta Diabetologica, and the interaction between needle lumen, haptic material and flange size is a real variable, not a detail.2 Finally, do not oversize the flange and do not leave it proud of the sclera—bury it, always, or you have created a conjunctival erosion waiting to happen.
Iglicki: This collaboration is, in my view, one of the most underrated determinants of outcome in secondary IOL surgery. The best results happen when the referral occurs early and with the eye in the best possible condition. When a cataract surgeon faces a complicated case—a dropped nucleus, a compromised capsule or inadequate support—the wisest move is often restraint: close the eye safely, avoid aggressive anterior segment manoeuvres to retrieve posterior fragments, document the anatomy and refer promptly. An eye that arrives quiet, with an intact iris and healthy cornea, gives the vitreoretinal surgeon every option; an eye that arrives after prolonged anterior vitrectomy attempts often has fewer.
Conversely, the vitreoretinal surgeon must communicate back: what fixation was performed, what IOL and power were implanted and what to watch for. Shared preoperative planning—biometry, IOL choice or whether to stage or combine procedures—measurably improves refractive outcomes. In my practice at the University of Buenos Aires, we have built exactly this kind of corridor with our anterior segment colleagues, and I can say without hesitation that the eyes managed collaboratively from day one do better than those that arrive as salvage cases. These patients belong to both of us; the sooner both surgeons think of it that way, the better the outcome.
Iglicki: Symmetry is everything. If I could transmit only one idea, it would be this: before you make any needle pass, mark your entry points with the eye in primary position—exactly 2 mm from the limbus, exactly 180 degrees apart—and make both scleral tunnels with identical angulation and identical length. Every late problem attributed to the Yamane technique—tilt, decentration, refractive surprise or even flange exposure—traces back, far more often than surgeons admit, to a few hundred microns of asymmetry at this step. The flange forgives many things; geometry forgives nothing. Measure, mark and only then pass the needle. The two minutes you invest in marking will save you from the revision surgery no one enjoys performing.
