Visual outcomes and complications following posterior iris-claw aphakic intraocular lens implantation combined with penetrating keratoplasty

[Secondary implantation of retropupillary fixated iris-claw intraocular lenses]

BACKGROUND

There is no standard for the treatment of functional aphakia in cases with a compromised capsular system. Retropupillary fixation of an Artisan iris-claw IOL ("Intraokularlinse") is one of the established procedures.

OBJECTIVE

Aim of this study was the evaluation of indications, visual and refractive long-term results and complication rates after retropupillary implantation of an iris-claw lens.

MATERIAL AND METHODS

This retrospective study comprised 366 eyes that received a retropupillary Artisan intraocular lens (IOL) in a single center between January 2009 and December 2019. The mean follow-up period was 249 days (8 months) ±516 days.

RESULTS

IOL dislocation (68%) was the most common reason for a retropupillary iris-claw implantation. Previous vitrectomy was a significant preoperative risk factor for IOL dislocation (p = 0.0001). Best corrected visual acuity improved from 0.65 ± 0.64 (logMAR) preoperatively to 0.57 ± 0.51 (logMAR) 4-6 weeks after the surgery. The mean deviation from the planned refraction was +0.40 ± 1.37 dpt and 73% of the patients had a deviation within ±1 dpt of the planned refraction. Relevant postoperative complications during the first 4 weeks were pupillary distortion (42%), ocular hypotony (15%) and transient hyphema (14%). Late complications (≥4 weeks after the surgery) included persistent pupillary distortion (20%), cystoid macular edema (13%) and iris-claw disenclavation (6%).

CONCLUSION

The retropupillary Artisan implantation is an efficient method for treating aphakia without capsular support and provides good visual and refractive results with an acceptable surgical risk profile.

Implantation of retropupillary iris-claw lenses: A review on surgical management and outcomes

Iris-claw lenses have gained increasing popularity over the last years and are by many surgeons regarded as viable options in eyes with insufficient capsular or zonular support. The iris-claw lens has two haptics with fine fissures for folding (enclavating) the mid-peripheral part of the iris stroma and can either be placed in front of or posterior to the iris. In particular, the retropupillary implantation has been increasingly chosen probably due to having an anatomical position similar to that of the crystalline lens. The present review is based on a literature review and also on the authors' clinical experience with this lens, and it focuses on surgical techniques and outcomes especially related to the characteristics of this lens, having haptics with claws that fixate the lens to the posterior iris. Implanting retropupillary iris-claw lenses has a relatively short learning curve, and there are only few complications reported during surgery. Retropupillary iris-claw lenses have demonstrated generally favourable efficiency and safety. However, the outcomes are probably more influenced by the reason for surgery and eye comorbidity than the lens itself. Albeit seldom reported, the postoperative complications have mostly been related to atrophy of the iris at the site of the haptics, or IOL decentration or disenclavation of one of the haptics. To date, however, there are few randomized clinical trials comparing this lens to other lens alternatives in eyes exhibiting insufficient capsular or zonular support for placing the lens in the ciliary sulcus. In the future, prospective studies with large samples should be performed to gain insights into the long-term safety of retropupillary placed iris-claw lenses, and for comparisons with the various other techniques of lens fixation.

Retropupillary Iris-Claw Intraocular Lenses: A Literature Review

Retropupillary iris-claw intraocular lenses (ICIOLs) have been increasingly chosen by surgeons nowadays as a primary or secondary procedure of IOL implantation in eyes with insufficient capsular or zonular support. They have gained popularity due to their simple fast technique, favourable functional outcomes, and safety. The transition in the ICIOL fixation from prepupillary to a more biologically appropriate retropupillary position and change in the optic design from biconvex to convex-concave have provided better visual outcomes and improved safety. A peer-reviewed literature search was conducted in Medline (PubMed), Embase, and Cochrane Library using the keywords "retropupillary iris claw" and "iris claw". The search yielded 310 articles that were screened. Forty-three articles on retropupillary ICIOLs were finally found to be relevant and reviewed in full-text versions. The functional outcomes following retropupillary implantation of ICIOLs have been acceptable in eyes with no ocular co-morbidities otherwise. However, the indications for surgery may affect the outcomes. The major postoperative complications directly associated with ICIOLs include pupil ovalization and redislocation. Nevertheless, the rate of disenclavation depends on the experience and skill of the surgeon. This review is based on a literature review, and it focuses on the preoperative evaluation, surgical technique, postoperative outcomes, and associated complications. Prospective randomized trials with a larger sample size and longer follow-up are needed for comparison with other techniques of IOL fixation and confirmation of long-term safety profile.

Intraocular lens implantation in the absence of capsular support: scleral-fixated vs retropupillary iris-claw intraocular lenses

Cataract surgery via phacoemulsification with intraocular lens (IOL) placement in the capsular bag is the gold standard in the presence of adequate capsular support. However, when capsule and/or zonular fibers are weak or absent, alternate fixation strategies are required. Common alternative options include retropupillary iris-claw IOLs (RP-IC IOLs) and scleral-fixated IOLs (SF IOLs). In the present review of 87 articles with 2174 eyes implanted with RP-IC IOLs and 2980 eyes with SF IOLs, we discuss the published literature with respect to safety and efficacy. Although the studies reporting outcomes of these IOLs have been performed in patients with different concomitant conditions, visual and refractive outcomes were found to be comparable between RP-IC IOLs and SF IOLs. RP-IC IOL implantation seemed to provide equivalent or a potentially lower rate of complications than SF IOL implantation. Data from the literature also suggest that the surgical technique of RP-IC IOL implantation is relatively simpler with correspondingly shorter surgical times.

Iris-Claw Intraocular Lens Implantation in Various Clinical Indications: A 4-Year Study

An iris-claw intraocular lens (IOL) has been widely used as a secondary implant in aphakic patients. The study presents the results of implanting the anterior chamber iris-claw Artisan IOL in cases of where an appropriate posterior capsular support is lacking. The study included 132 patients subjected to primary IOL implantation during complicated cataract surgery with damage to the posterior capsule (I), secondary implantation in aphakia (II), secondary implantation during penetrating keratoplasty (III), and secondary implantation during pars plana vitrectomy with luxated IOL extraction (IV). We analyzed the records of best-corrected visual acuity (BCVA), spherical equivalent (SE), intraocular pressure (IOP), and corneal endothelial cell count (cECC), taken before and 1, 2, 3, and 4 years after the surgery. BCVA depended on the time after IOL implantation and the primary indication. Four years post-surgery, the SE values were the lowest in group III. IOP was the same in all groups both before and after the surgery, but 4 years after the surgery IOP values in group IV were higher than in group III. The cECC decreased every year after the surgery in all groups, but four years after the IOL implantation, the lowest cECC values were observed in group IV. At the same time, all groups of patients showed improved BCVA, stable refraction, and a low percentage of postoperative complications.

The Influence of Decentration on Higher-Order Aberrations in Artisan Aphakic Intraocular Lens Implantation Eyes

Purpose

To characterize the influence of decentration on higher-order aberrations of Artisan aphakic intraocular lens implantation eyes. Setting. Department of Ophthalmology and Vision Science, Eye and ENT Hospital of Fudan University, Shanghai, China.

Design

Retrospective case series.

Methods

Twenty-three eyes of 18 patients were retrospectively examined. Location of the IOL was imaged using a slit-lamp, and decentration (the distance from the center of a pupil to the geometric center of the IOL) was measured using the AutoCAD 2007 software. Ocular and internal higher-order aberrations were measured using the wavefront analyzer KR-1W (Topcon) and their correlation with decentration were analyzed. Coma, spherical, 3rd-, 4th-order, trefoil, tetrafoil aberrations, ocular, and internal higher-order aberrations were calculated for a 4.0 mm pupil diameter.

Results

The mean age of patients was 33.6 ± 21.4 years (ranging from 7 to 72 years). The mean follow-up period was 28.2 ± 10.5 months (ranging from 12 to 52 months). The mean postoperative best-corrected visual acuity (BCVA) was 0.19 ± 0.19 logMAR (range −0.18–0.52). The mean decentration was 0.57 ± 0.28 mm (range 0.15–1.21 mm). There was no correlation between Artisan IOL decentration and ocular higher-order aberrations, internal higher-order aberrations, coma, spherical, 3rd-, 4th-order, trefoil, and tetrafoil aberrations, respectively. There was a positive correlation between Artisan IOL decentration and 2nd-astig aberrations when 2nd-astig aberrations were less than 0.1.

Conclusions

The position of Artisan IOLs showed slight decentration and the amounts of decentration were not large enough to influence higher-order aberrations.

Trocar-assisted, flanged sutureless scleral-fixated intraocular lens implantation combined with silicone oil injection after penetrating keratoplasty surgery

We describe a combined technique of trocar-assisted sutureless scleral-fixated intraocular lens implantation and silicone oil injection at the same session. Two 3 mm scleral tunnels were created 2 mm away from and parallel to the limbus with the 23-gauge vitrectomy trocars entering the sclera transconjunctivally at an angle of approximately 10° at the 3 o'clock and 9 o'clock meridians. After the 3-piece foldable IOL was delivered to the anterior chamber through the corneal incision, the tip of one of the IOL haptics was grasped with a 23-gauge serrated retinal forceps entered through the trocar located at the 3 o'clock meridian. Then the haptic was removed from the scleral tunnel together with the trocar out of the globe. The same procedure was applied to the other haptic. A transconjunctival secure 10-0 nylon suture was placed at the scleral tunnel entry site around the haptic. The ends of the haptics were cauterized to make a flange. The resultant flanges of the haptics were pushed back and fixed into the scleral tunnels. Perfluorooctane was taken out of the eye with vitreoretinal surgery and the silicone was injected into the eye to prevent hypotonia. No complications were seen intraoperatively or postoperatively. After 1-month follow-up period, IOL was seen stabilized.

A study of the mechanical forces on aphakic iris-fixated intraocular lenses

Iris-fixated aphakic intraocular lenses (IFIOL) are used in cataract surgery, when more common intraocular lenses cannot be adopted because of the absence of capsular bag support. These lenses can be implanted either on the poste- rior or the anterior surface of the iris. In this work we study whether one of these options is preferable over the other from the mechanical point of view. In particular, we focus on the forces that the IFIOL transmits to the iris, which are asso- ciated with the risk of lens dislocation. We study the prob- lem numerically and consider aqueous flow induced by sac- cadic rotations in the cases of an IFIOL in the anterior and posterior side of the iris. The IFIOL considered is the Arti- san Aphakia +30.0 D lens (IFIOL) produced by Ophtec BV. We perform the simulations in OpenFOAM. We find that the forces transmitted by the aphakic IFIOL to the iris are sig- nificantly higher in the case of posterior implantation. This suggests that lens implantation on the posterior surface of the iris might be associated with a higher risk of lens disloca- tion, when an inadequate amount of iris tissue is enclavated during implantation.

[Aphakic Artisan/Verisyse IOLs as retropupillary implants : Video article]

The retropupillary implantation of an iris claw intraocular lens (IOL) is an uncomplicated and fast technique for rehabilitation of aphakic eyes without any capsular structures and is presented in a video in the online version of this article. A complete anterior pars plana vitrectomy as shown in our case or an extensive preceding anterior vitrectomy as well as an intact iris are prerequisites. Special instruments for the implantation and fixation of the IOL are available to optimize the operative procedure. In addition to a rapid operating time the advantages of a trained surgeon are low complications rates and fast rehabilitation. For eyes with a defective iris diaphragm, ischemic vitreoretinopathy and uveitis, other implantation techniques should be selected.

Retropupilar positioning of foldable iris-claw intraocular lens for correction of aphakia with no capsular support

Summary

Iris-claw intraocular lens (ICIOL) for aphakia needs a large 5.4 mm corneal incision for its implantation. The technique needs corneal suture, associated with some postoperative astigmatism. Foldable ICIOL is used in phakic patients undergoing refractive surgery and has the advantage of a sutureless small corneal incision. We report a case of a high myopic patient with dislocated intraocular lens (IOL) and no capsular support. Dislocated IOL with its capsular bag was released with three-port, 23-gauge vitrectomy; placed in the anterior chamber; sliced; and extruded through a 3.2-mm corneal incision, where a foldable ICIOL was introduced and placed retropupillary. This technique achieved a stable fixation of the IOL. Retropupillary implantation of a foldable ICIOL on aphakic patients has advantages over that of a polymethylmethacrylate (PMMA) ICIOL due to smaller corneal incision. The technique may be safe and easy to perform.

Purpose

The purpose of this report was to describe the technique of retropupillary implantation of a foldable iris-claw intraocular lens (ICIOL) in a patient with dislocated intraocular lens (IOL) in mid vitreous cavity.

Methods

Foldable ICIOL (Artiflex^® Myopia Model 401) is used in phakic patients undergoing refractive surgery and has the advantage of a sutureless small corneal incision. We report a case of a high myopic patient with dislocated IOL and no capsular support. The calculation was a −5.0 D IOL for retropupilar position, and a foldable ICIOL was introduced through a 3.2-mm corneal incision and placed retropupillary.

Results

The technique was easy to achieve. IOL was properly positioned retropupillary and maintained stable. There was no ocular hypertension and no anterior chamber flare or iris atrophy.

Conclusion

Retropupillary implantation of a foldable ICIOL on aphakic patients has advantages over that of a PMMA ICIOL due to smaller corneal incision. The technique may be safe and easy to perform.

Retropupillary iris claw intraocular lens implantation in aphakia for dislocated intraocular lens

Background

Nowadays, dislocated intraocular lenses (IOLs) and inadequate capsular support are becoming a challenge for every ophthalmic surgeon. Explantation of dislocated IOL and iris claw IOL (ICIOL) are the techniques that have been used in our ophthalmic department. The aim of this study is to report our technique for retropupillar ICIOL.

Methods

This study is a retrospective case series. A total of 105 eyes with dislocated IOL from the patients at the Department of Ophthalmology in Santa Maria Hospital, a tertiary reference hospital in Lisbon, Portugal, from January 2012 until January 2016, had been analyzed. Of these 105 eyes, 66 eyes had dislocated one-piece IOL and 39 eyes had dislocated three-piece IOL. The latter underwent iris suture of the same IOL and were excluded from this study. The remaining 66 eyes with dislocated one-piece IOL underwent pars plana vitrectomy, that is, explantation of dislocated IOL through corneal incision and an implantation of retropupillary ICIOL. Operative data and postoperative outcomes included best corrected visual acuity, IOL position, intraocular pressure, pigment dispersion, clinical signs of endothelial cell loss, and anterior chamber depth.

Results

The mean follow-up was 23 months (range: 6–48 months). The mean preoperative best corrected visual acuity was 1.260±0.771 logMAR, and postoperative best corrected visual acuity was 0.352±0.400 logMAR units. Mean vision gain was 0.909 logMar units. The patients had the following complications: 1) retinal detachment was found in one patient, 2) corneal edema was found in three patients, 3) high intraocular pressure was observed in twelve patients, 4) subluxation of the IOL was observed in one patient, and 5) macular edema was found in three eyes.

Conclusion

The results demonstrate that retropupillary ICIOL is an easy and effective method for the correction of aphakia in patients not receiving capsule support. The safety of this procedure must be interpreted in the context of a surgery usually indicated in complicated cases.

Long Term Clinical and Visual Outcomes of Retrofixated Iris Claw Lenses Implantation in Complicated Cases

Aims:

To evaluate the visual outcomes and complications after implantation of retrofixated iris claw (RFIC) lens in various challenging situations.

Settings and Design:

Retrospective, single centre, 8 year clinical audit.

Materials and Methods:

A retrospective analysis of cases who underwent RFIC lens implantation alone (group 1) or in combination with vitreoretinal (VR), corneal or glaucoma procedures (group 2) was performed. The main outcomes evaluated were corrected distant visual acuity (CDVA) and postoperative complications. The mean follow up was 13.09±6.8 (range 6-24) months.

Results:

The study involved 100 eyes of 83 patients with mean age of 51.1±25.4 years. Group 1 included 59 eyes and group 2 had 41 eyes. In group 1, the mean CDVA improved from 0.86±0.81 to 0.38±0.51 LogMAR (p<0.001) with 72.8% eyes having gain in lines (≥ 2 lines) of CDVA with safety index of 1.73. The mean CDVA in group 2 improved from 0.71±0.65 to 0.38±0.34 LogMAR (p=0.003) with 65.8% eyes having gain in lines (≥ 2 lines) of CDVA with a safety index of 1.54. Group 2 showed a higher complication rate of 36.59% compared to group 1 (20.34%). Significant complications noted were secondary glaucoma (8%), disenclavation of haptic (4%), subluxation of RFIC lens (1%).

Conclusion:

The visual outcome with RFIC lenses when combined with other intraocular procedures is mainly affected by the complexity of co-existing pathologies .The complications are more related to the combined procedures performed rather than RFIC lens implantation alone. This may still be acceptable when complication profile of other intraocular lenses is evaluated in similar challenging situations.

[Retropupillary iris claw intraocular lens implantation technique for aphakia]

BACKGROUND

Overview of the retropupillary implantation of iris claw intraocular lenses (Artisan®,Ophtec, Groningen, Niederlande and Verisyse(TM),AMO, Santa Ana CA).

MATERIAL AND METHODS

A literature search and review of implantation techniques, patient selection, potential complications and management strategies.

RESULTS

This approach has the advantage of a simple implantation technique, an anatomically correct implantation site (as compared to endocapsular implantation) and a relatively low complication rate. An intact iris is, however, a prerequisite for this technique. Ischemic vitreoretinopathies, such as diabetes or vascular occlusive entities, as well as uveitis might be considered as contraindications.

CONCLUSIONS

The retropupillary implantation of iris claw intraocular lenses is an interesting and especially time-effective rehabilitation technique for aphakia.