Iris-claw intraocular lenses to correct aphakia in the absence of capsule support

A New Technique with Scleral Grooves for Sutureless Scleral Fixation of the Carlevale Intraocular Lens

INTRODUCTION

A novel technique is described employing scleral grooves to facilitate sutureless scleral fixation of the Carlevale intraocular lens (CIL). We describe its use in a series of 47 patients with aphakia.

METHODS

A retrospective study of all patients with aphakia who underwent CIL implantation with the new technique by a single surgeon during 1 year. The novelty of this technique consists in the creation of two partial-thickness linear sclerotomies (grooves), 180° apart, 2 mm from and parallel to the limbus. In the middle of each groove a full-thickness sclerotomy is performed to facilitate externalization of the CIL anchors. The groove allows the anchor to plug the full-thickness sclerotomy and to rest within the sclera without protrusion. Reported outcomes include pre-operative/post-operative visual acuity, post-operative spherical equivalent and surgical complications. Follow-up was a minimum of 6 months.

RESULTS

Forty-eight eyes of 47 patients with aphakia with a mean age of 74 years (range 31-90 years) are included. The commonest causes of aphakia were intraocular lens (IOL) subluxation,with or without exfoliation (54.2%), complicated cataract surgery (29.2%), crystalline lens luxation (6.3%) and trauma (4.1%). All CILs inserted with the new technique stayed successfully in situ during follow-up. Median pre-operative best-corrected visual acuity (0.75 logMAR; range 0.1-2.7) significantly improved to 0.5 logMAR post-operatively (p < 0.001). Moreover, 78% and 65% of the operated cases were within 1.0 and 0.5 diopters, respectively, from intended refraction. The most common complications were transient cystoid macular oedema (8.3%) and transient intraocular pressure rise (8.3%), all of which resolved within 2 months.

CONCLUSIONS

The proposed modification of sutureless scleral fixation of the CIL appears safe and effective. In our experience it is less time consuming and easier to perform than previous techniques and may therefore offer a useful future option.

New Device for the Correction of Aphakia Without Capsular Support

PURPOSE

This study describes a prototype developed for aphakia without capsular support (AWCS) and its proof of concept.

METHODS

This descriptive study used a 3D software to create and analyze virtual prototypes before manufacturing. A nylon-6/nylon-6.6 copolymer filament and a 3D printer were used for prototyping. A device implantation technique was developed using a 23-gauge hypodermic needle. Two opposing markings, 2 mm posterior to the limbus, were made to determine the location of the scleral punctures and the final position of the device. After adequate centralization and positioning of the device, its haptics were cut and cauterized to generate thermal modeling of the extremity and allow the thickening of the tips (flange), serving as an anchoring mechanism to the sclera. The efficacy and adequacy of the technique and device were then evaluated.

RESULTS

Vitreous tissue extrusion was not observed during the sclerotomy. The device was well fixed to the sclera; however, adequate IOL stability and centralization still needed to be achieved. The surgeon evaluated the adequacy of all the other devices' characteristics.

CONCLUSIONS

The development of a technology prototype for correcting AWCS was possible. Although the proposed prototype met most of the established concept guidelines, the stability of the IOL position remains challenging.

Modified Carlevale Intraocular Lens Fixation Technique: Two Vitrectomy Ports As Lens Plug Fixation Sites

PURPOSE

To describe and evaluate the effectiveness of the modified Carlevale intraocular lens (IOL) fixation technique, using two vitrectomy ports as lens plug fixation sites.

MATERIALS AND METHODS

This prospective, consecutive, interventional study examined 60 eyes in 60 patients, who underwent 25- or 23-gauge vitrectomy for an IOL subluxation/luxation, lens dislocation, or aphakia, with Carlevale IOL implantation.

RESULTS

Postoperatively, transient ocular hypotension was observed in four eyes. The mean refractive prediction error was -0.27 ± 0.78 diopters. No postoperative complications, such as retinal detachment, endophthalmitis, or IOL dislocation, were observed in the 4-month follow-up.

CONCLUSION

This new technique may be simple, fast, and effective because of fewer scleral wounds and fewer postoperative complications.

Outcomes of three-piece rigid scleral fixated intraocular lens implantation in subjects with deficient posterior capsule following complications in manual small incision cataract surgery

Objective

To evaluate the surgical visual outcomes of three-piece rigid scleral fixated intraocular lens (SFIOL) implantation in subjects with deficient posterior capsule following complications of cataract extraction.

Design

Retrospective 4-year cohort study.

Participants

Data from 174 eyes that underwent SFIOL combined with pars plana vitrectomy (PPV) between January 2018 and March 2022 and follow-up exams were included.

Methods

Demographic characteristics including primary indications for surgery, history of trauma, laterality, baseline and best-corrected visual acuity (BCVA), refraction as spherical equivalent (SE), intraocular pressure (IOP), duration of follow-up, and complications were analyzed.

Results

The mean preoperative BCVA was 1.38 ± 0.46 logarithm of the minimum angle of resolution (logMAR), which improved significantly to 0.37 ± 0.22 logMAR. The baseline refractive status measured in spherical equivalent (SE) was 4.1 ± 6.2 Diopters (D), and the postoperative status was -0.4 ± 0.97 D. Early postoperative complications included hypotony (n = 1; 0.57%, vitreous hemorrhage (n = 3; 1.72%), elevated IOP (n = 8; 4.59%), mild dilated pupil (n = 1; 0.57%) and corneal edema (n = 16; 9.19%). Late complications included in this study were retinal detachment (n = 1; 0.57%), cystoid macular edema (CME) (n = 1; 0.57%), primary glaucoma (n = 1; 0.57%), secondary glaucoma (n = 13; 7.47%), zonular dehiscence (n = 3; 1.72%), retinal pigment epithelium (RPE) changes (n = 3; 1.72%), choroidal coloboma (n = 2; 1.14%), posterior dislocation of posterior chamber IOL (PCIOL) (n = 1; 0.57%), corneal decompensation (n = 1; 0.57%), retinal hemorrhage (n = 1; 0.57%), macular hole (n = 1; 0.57%), chronic uveitis (n = 1; 0.57%), mild non-proliferative diabetic retinopathy (NPDR) (n = 3; 1.72%), and mild NPDR with diabetic macular edema (DME) (n = 1; 0.57%).

Conclusion

Integrating IOL implantation with vitrectomy various posterior segment complications were resolved in the same setting without attempting a second surgery.

Light- and drug-induced pupillary dynamics in eyes with a retropupillary iris-claw intraocular lens

PURPOSE

We evaluated the pupillary characteristics and response to light and drugs in eyes with posterior chamber (PC) placement of iris-claw intraocular lens (IC-IOL).

METHODS

In this cross-sectional, comparative study, we included adults with an IC-IOL implanted in the PC of a single eye. We excluded patients with ocular trauma, postoperative IC-IOL displacement or complications, and extended iris atrophy. We used anterior segment optical coherence tomography to perform light-controlled pupillography, measure the pupil diameter (PD), and estimated the pupil circularity under mesopic conditions. PD was also assessed under photopic, scotopic, pharmacological mydriasis, and miosis conditions. The results were compared to those of the fellow eye, phakic, or regular pseudophakic.

RESULTS

The IC-IOL and control groups included 30 eyes each. The most frequent reasons for IC-IOL implantation were complicated cataract (37%) and dislocated/luxated prior IOL (33%). Compared to the control group, the IC-IOL group had lower visual acuity, a smaller PD under scotopic conditions (p = 0.0010) and after pharmacological mydriasis (p < 0.0001), and a larger PD after pharmacological miosis (p < 0.0001). Mesopic pupil circularity was comparable between the groups. We also considered ongoing extraocular treatments with possible effects on iris motility.

CONCLUSIONS

The pupillary size and profile were similar between the groups in mesopic light. Reduced mydriasis was noted in response to light and drugs, while the degree of miosis was reduced in response to inducing drugs in the IC-IOL compared to the control group. This study complements previous results concerning the PC placement of IC-IOLs by adding original observations on drug-induced pupil motility.

Trans-Scleral Plugs Fixated FIL SSF IOL: A Review of the Literature and Comparison with Other Secondary IOL Implants

Purpose. To revise the current literature on FIL SSF (Carlevale) intraocular lens, previously known as Carlevale lens, and to compare their outcomes with those from other secondary IOL implants. Methods. We performed a peer review of the literature regarding FIL SSF IOLs until April 2021 and analyzed the results only of articles with a minimum of 25 cases and a follow-up of at least 6 months. The searches yielded 36 citations, 11 of which were abstracts of meeting presentations that were not included in the analysis because of their limited data. The authors reviewed 25 abstracts and selected six articles of possible clinical relevance to review in full text. Of these, four were considered to be sufficiently clinically relevant. Particularly, we extrapolated data regarding the pre- and postoperative best corrected visual acuities (BCVA) and the complications related to the procedure. The complication rates were then compared with those from a recently published Ophthalmic Technology Assessment by the American Academy of Ophthalmology (AAO) on secondary IOL implants. Results. Four studies with a total of 333 cases were included for results analysis. The BCVA improved in all cases after surgery, as expected. Cystoid macular edema (CME) and increased intraocular pressure were the most common complications, with an incidence of up to 7.4% and 16.5%, respectively. Other IOL types from the AAO report included anterior chamber IOLs, iris fixation IOLs, sutured iris fixation IOLs, sutured scleral fixation IOLs, and sutureless scleral fixation IOLs. There was no statistically significant difference in the rates of postoperative CME (p = 0.20), and vitreous hemorrhage (p = 0.89) between other secondary implants and the FIL SSF IOL, whereas the rate of retinal detachment was significantly less with FIL SSF IOLs (p = 0.04). Conclusion. The results of our study suggest the implantation of FIL SSF IOLs is an effective and safe surgical strategy in cases where there is a lack of capsular support. In fact, their outcomes seem to be comparable to those obtained with the other available secondary IOL implants. According to published literature, the FIL SSF (Carlevale) IOL provides favorable functional results with a low rate of postoperative complications.

Surgical management of aphakia

Despite the safety and efficacy of cataract surgery, intraoperative complications can hamper the ability to place an intraocular lens in the capsular bag. With vast numbers of cataract surgeries performed daily, complications occur often enough that every ophthalmologist should be equipped with techniques to manage aphakia. Medical management of aphakia used to be commonplace but these techniques have their disadvantages including thick bulky lenses, poor cosmesis, and aniseikonia. Surgical management of aphakia overcomes these disadvantages and offers patients the possibility of a spectacle and contact lens-free lifestyle. This article reviews the various options of surgical management of aphakia and their advantages and disadvantages. Comparison of outcomes between techniques and a protocol for deciding between techniques is presented.

Tilt and decentration of posterior and anterior iris-claw intraocular lenses: a pilot study using anterior segment optical coherence tomography

BACKGROUND

Information on the centration and tilt of iris-claw intraocular lenses (IC-IOLs) is limited. In this study, we tested the capacity of an anterior segment optical coherence tomography (AS-OCT) instrument to measure decentration and tilt of anterior and posterior IC-IOLs through an integrated software.

METHODS

The present observational, cross-sectional study was conducted at University Eye Clinic of Parma (Parma, Italy). The CASIA2 swept-source AS-OCT (Tomey Corp.) was used to measure the tilt and decentration of posterior and anterior IC-IOLs in patients implanted at least 6 months in advance. After failure with full-automation, semi-manual IOL tracing was applied. In-the-bag (IB) contralateral IOLs, when present, were measured automatically. The Bland-Altman method was used to evaluate the agreement between repeated measurements (2 images for each study eye). The amount and direction of tilt and decentration were recorded and plotted into polar charts for evaluation.

RESULTS

A total of 21 patients were included: 14 with posterior and 7 with anterior IC-IOL fixation. In 17 eyes (81%), the AS-OCT provided a repeatable measurement of tilt and decentration. All contralateral eyes with IB IOL were automatically measured. The median decentration was 0.67 mm, 0.24 mm, and 0.24 mm in posterior IC-IOLs, anterior IC-IOLs, and IB IOLs group, respectively. The median tilt was 5.0°, 5.6°, and 5.6° for posterior IC-IOLs, anterior IC-IOLs, and IB IOLs, respectively. Tilt direction was mainly temporal, while decentration was inferior-temporal with posterior IC-IOLs and scattered with anterior IC-IOLs and IB IOLs.

CONCLUSIONS

The semi-manual tracing function of the CASIA2 AS-OCT provides repeatable and affordable measurements of the decentration and tilt of IC-IOLs in both the anterior and posterior chamber. Data from the former group were similar to the IB group.

Refractive error induced by intraocular lens tilt after intrascleral intraocular lens fixation

PURPOSE

To investigate the spherical shift of intraocular lens (IOL) tilt after intrascleral fixation.

METHODS

We retrospectively reviewed the medical records of patients who underwent flanged intrascleral IOL fixation with transconjunctival 25- or 27-gauge pars plana vitrectomy at the Department of Ophthalmology of the Jikei University Hospital. The minimum follow-up duration was 3 months. Second-generation anterior segment optical coherence tomography (CASIA2; TOMEY) was used to obtain the values of tilt and decentration of the intrasclerally fixated IOL and postoperative anterior chamber depth. We investigated the relationship between refractive error and various parameters, such as IOL tilt and decentration, axial length, and keratometry. In addition to our clinical investigation, we conducted optical simulations using Zemax to evaluate the spherical shift of the IOL tilt by means of the through-focus response and change in spherical equivalent power.

RESULTS

The study involved 72 eyes of 67 patients. The degree of IOL tilt was correlated with the amount of refractive error (Spearman's rank correlation coefficient [CC] = - 0.32; P = 0.006). In particular, a tilt angle greater than 10° strongly affected the refractive error. The postoperative anterior chamber depth also correlated with the refractive error (CC = 0.50; P < 0.001), as opposed to decentration (CC = - 0.17; P = 0.15), axial length (CC = - 0.08; P = 0.49), and keratometry (CC = - 0.06; P = 0.64). Optical simulations also revealed a myopic shift that exponentially increased as the tilt became greater.

CONCLUSION

IOL tilts that are greater than 10° induce refractive error.

Visual and refractive outcomes following secondary intraocular lens implantation

PURPOSE

To analyze the visual and refractive results after secondary IOL implantation using different surgical techniques - iris-claw aphakic IOL through a corneal incision or scleral tunnel, and 3-piece IOL into the ciliary sulcus.

PATIENTS AND METHODS

Retrospective study including patients that were submitted to secondary IOL implantation from January 2017 to December 2019 at the Department of Ophthalmology of Hospital de Braga, Portugal. We collected demographic data (age, surgical indication, comorbidities, surgical technique, IOL implanted, and intra and postoperative complications) and visual and refractive data [preoperative and 3-month, 6-month, and 12-month postoperative corrected-distance visual acuity (CDVA), spherical equivalent (SE), manifest cylinder, and intraocular pressure].

RESULTS

128 eyes from 123 patients were included. The most frequent surgical indications were IOL subluxation/luxation (62.5%) and intraoperative posterior capsular rupture (23.4%). CDVA improved from 1.26 ± 0.51 to 0.47 ± 0.49 logMar (p < .001). CDVA was significantly better in the 3-piece into the ciliary sulcus IOL group than both other groups. The final SE was -0.68 ± 0.94 diopters. The mean manifest refractive cylinder remained stable until the 6th month after the surgery (p = .454) and improved in the last 6 months of follow-up (p = .015). In the postoperative period, the cylinder was higher in the corneal incision iris-claw aphakic IOL group and lower in the 3-piece IOL into the ciliary sulcus group (p < 0,05). The corneal incision iris-claw aphakic IOL group presented the most postoperative complications.

CONCLUSION

All techniques showed satisfying results. The 3-piece IOL into the ciliary sulcus group showed the best visual and refractive performance, followed by the scleral tunnel iris-claw IOL group and the corneal incision iris-claw IOL group.

Novel Sutureless Scleral Fixated IOL for Inadequate or Absent Capsular Support

Purpose. To evaluate the clinical outcome and safety profile of a new sutureless scleral fixation (SSF) technique using a single-piece foldable acrylic Carlevale intraocular lens. Methods. In this case study, 27 eyes of 27 patients were implanted with an SSF single-piece IOL because of inadequate or absent capsular support. The hand-shake technique used during surgery was combined with the creation of scleral pockets in order to secure the IOL haptics. The BCVA was evaluated in the 1st and 6th month in every patient and in the 12th and 24th months, when possible. Also, we evaluated the improvement achieved in spherical equivalent values from baseline to the 6th month after the procedure. Intraoperative and postoperative complications were assessed. Results. The mean age was 69.1 ± 14.9 years, and the mean follow-up was 13.6 ± 4.8 months. Indications of scleral-fixated IOL included dislocated posterior chamber IOL (40.7%), dislocated anterior chamber IOL (11.1%), subluxated traumatic cataract (18.5%), subluxated nontraumatic cataract (18.5%), and aphakia (11.1%). Concurrent PPV was performed on eight of the eyes (32%). The mean preoperative logMAR BCVA increased from 0.85 ± 0.59 baseline to 0.44 ± 0.30 one month after surgery $\left(p<0.01\right)$ and 0.36 ± 0.34 $\left(p<0.003\right)$ six months after surgery. The baseline refractive status expressed in SE was 4.3 ± 6.4 D, and the postoperative status was −0.5 ± 0.99 D. Postoperative complications included vitreous hemorrhage (7.4%), hypotony (7.4%), transient IOP elevation (3.7%), and postoperative cystoid macular oedema (3.7%). The IOL was very well centered and stable in every case during the follow-up period. Conclusion. The use of the SSF technique with implantation of a single-piece foldable acrylic Carlevale IOL seems to be a safe and effective alternative method that provides good preliminary results in cases where capsular support is inadequate or absent. Long-term stability results would be required to evaluate the benefit of this novel surgical approach in order to compare it with other existing methods.

Scleral Fixation of a Hydrophobic Acrylic Intraocular Lens with Eyelets Using 8-0 Polypropylene Suture

Purpose

To report clinical outcomes of a scleral fixation technique of a hydrophobic acrylic intraocular lens with eyelets using 8-0 polypropylene suture.

Methods

Nine eyes of nine patients who underwent combined pars plana vitrectomy and sclera fixation of an intraocular lens using this technique were analyzed.

Results

The mean follow-up period was 7.11 months (range, 6–12 months), and there was a significant visual improvement at 6 months after surgery. The mean logarithm of the minimum angle of the resolution changed from 0.54 at baseline to 0.29 at postoperative 6 months (p = 0.016). The mean postoperative spherical equivalent at 6 months was −0.90 ± 0.90 diopters, and the mean predictive error was −0.49 ± 0.62 diopters.

Conclusions

Postoperative visual and refractive outcomes were favorable, and the positions of intraocular lenses were well centered in all cases. This technique could be a useful alternative for surgeons without easy access to Gore-Tex suture.

Supporting IOL'S in a Deficient Capsular Environment: The Tale of No "Tails"

Purpose

To evaluate the efficacy and safety of the following three distinct surgical procedures for secondary IOL implantation without capsular support: Iris-claw lens, flanged transscleral fixated IOLs (Yamane technique), and sutureless transscleral hook IOL fixation (Carlevale IOL).

Materials and Methods

In this retrospective comparative study, three different sutureless IOL implantation techniques were compared in patients without any capsular support. Visual acuity and outcomes were analyzed in 24 eyes of 23 patients (14 male and 9 female). Study included 13 iris-claw lenses (Artisan Ophtec), 6 flanged transscleral fixated IOLs (Yamane technique using a MA60MA Alcon Inc IOL), and 5 transscleral Carlevale IOLS (Carlevale IOL, Soleko, Italy).

Results

logMAR mean best-corrected visual acuity (BCVA) improved from 0.49 ± 0.19 to 0.19 ± 0.10 at three months after surgery (p < 0.05). Postoperative BCVA was similar in all three groups, and no intergroup difference was noted. Three eyes (12.5%) had a raised IOP >25 mmHg, 2 eyes (8%) presented a subluxated/dislocated IOL, 4 eyes (16%) had corneal edema longer than 7 days, 3 eyes (12.5%) had irregular pupil profile, 2 eyes (8%) had vitreous hemorrhage, 7 eyes had (29%) corneal astigmatism over 3 diopters, and one patient (4%) developed cystoid macular edema (CME).

Conclusions

All three surgical procedures can be considered adequate to correct aphakia in patients without capsular support with significant improvement in visual acuity and low complication.

Modification of intraocular lens insertion using 4-flanged fixation with a standard cartridge and a 2.4 mm corneal incision in eyes with no capsular support

A modification of intraocular lens (IOL) implantation, using the 4-flanged IOL fixation technique, through a 2.4 mm corneal incision using a standard cartridge and injector, is presented. An IOL with 4 eyelets is used, through which a 6-0 polypropylene suture is threaded on one side and then loaded into a provided cartridge and inserted to the anterior chamber through a 2.4 mm corneal incision. Using the handshake technique, the suture ends are eventually threaded through the eyelets and secured outside the eye with the creation of 4 flanges. This technique was used in 6 eyes of 5 consecutive patients with the absence of capsular support. During all follow-up visits, the IOLs were well centered and stable, and the flanges were buried in the sclera and covered with the conjunctiva. No complications were recorded. This modification simplifies the technique and reduces the well-known complications of large corneal incisions.

Clinical outcome and endothelial loss following prepupillary and retropupillary implantation of iris claw intraocular lenses

PURPOSE

Iris claw intraocular lenses (IOLs) were successfully used for the management of aphakia in patients that lack capsular support. The aim of this study was to compare the clinical outcome of prepupillary and retropupillary implantation of these IOLs.

METHODS

The files of the 26 patients that had an iris claw IOL implantation between 2010 and 2020 were retrospectively reviewed. Detailed ophthalmological examination findings including corrected distance visual acuity (CDVA), intraocular pressure, endothelial cell counts, slit lamp and dilated fundus examination findings were specifically tabulated. Intraoperative and postoperative complications were also specifically recorded.

RESULTS

There were 18 patients in the prepupillary implantation group and eight patients in the retropupillary implantation group. Age and gender distribution were similar between the groups. CDVA significantly increased in prepupillary and retropupillary implantation groups (p = 0.001 and p = 0.012, respectively). Median endothelial cell loss was 6.7% in prepupillary group and 7.2% in retropupillary group. The only intraoperative complication was iridodialysis (n = 1). Postoperative complications included retinal detachment (n = 1), cystoid macular edema (n = 2) and IOL tilt (n = 1). All of these complications occurred in the prepupillary implantation group.

CONCLUSION

Prepupillary and retropupillary implantation of iris claw IOLs resulted with similar visual gain and endothelial loss rates in a follow-up time of 6 months. There was an insignificant trend toward a reduced complication rate following retropupillary implantation.

Late in-the-bag intraocular lens dislocation

This review aimed to evaluate the cumulative incidence, patient characteristics, predisposing conditions, and treatment outcomes for late in-the-bag intraocular lens (IOL) dislocation. Literature searches in PubMed (MEDLINE), Embase, and Cochrane Library Central database identified 1 randomized clinical trial, 1 prospective case series, 2 prospective cohort studies, and 36 retrospective studies of this condition, which showed that the cumulative incidence was 0.5% to 3%, it occurred on average 6 to 12 years after cataract surgery, and mean patient age was 65 to 85 years. Pseudoexfoliation syndrome, myopia, and previous vitreoretinal surgery were the most common predisposing conditions. Studies indicated that IOL repositioning and IOL exchange provided similar visual outcomes and were equally safe. The long-term visual outcome seemed satisfactory. However, the quality of evidence regarding treatment was in general quite low. More studies of late in-the-bag IOL dislocation are needed, and in particular, different surgical techniques should be included in high-quality clinical trials.

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.

FIL-SSF Carlevale intraocular lens for sutureless scleral fixation: 7 recommendations from a serie of 72 cases. MICA study (Multicentric Study of the Carlevale IOL)

PURPOSE

Lacking a standard technique, the surgical management of aphakia without capsular support remains to be optimized. The goal of this study is to analyze results for the Carlevale FIL-SSF intraocular lens and propose surgical recommendations.

PATIENTS AND METHODS

The P1.5 Collective performed a retrospective analysis, with a minimum follow-up of 6 months, of the records of 72 implantations of the Carlevale FIL-SSF intraocular lens, specifically designed for sutureless scleral fixation in the ciliary sulcus.

RESULTS

The most common indication was exchange of a posterior chamber intraocular lens (70.8%). The surgery lasted a mean of 53.4minutes due to the creation of scleral flaps. The implant was damaged in 12.5% of cases. Visual acuity was improved in 83.3% of cases. The postoperative spherical equivalent was -0.3 diopters, with no change in corneal astigmatism. The implant was centered and stable in all cases. Two cases (2.8%) of cystoid macular edema were observed and resolved over six months.

DISCUSSION

A number of advantages of the Carlevale FIL-SSF intraocular lens make it a safe and effective solution for correction of aphakia in the absence of capsular support. It requires a longer than usual surgical procedure, and the implant must be handled with care. From their experience, the authors propose 7 recommendations to accelerate the learning curve.

CONCLUSION

In light of the results of this study, we propose the Carlevale FIL-SSF intraocular lens as the new standard for the correction of aphakia without capsular support, but other studies are necessary to determine its exact place within the heirarchy of other available techniques.

Comparison of retropupillary fixated iris claw lens versus sclera fixated lens for correction of pediatric aphakia secondary to ectopia lentis

AIM:

To evaluate the postoperative visual acuity and complications in eyes with ectopia lentis in children who underwent lens removal and then implantation of retropupillary fixated iris claw lens versus scleral fixated intraocular lens (SFIOL) implantation.

MATERIALS AND METHODS:

A retrospective analysis of pediatric cases who presented with lens subluxation secondary to ectopia lentis and who underwent lens extraction (57 eyes of 38 patients) with either retropupillary iris fixated intraocular lens (IOL) implantation (Group A – 36 eyes of 20 patients) and SFIOL implantation (Group B – 21 eyes of 18 patients) was done over a period of 5 years from March 2010 to February 2015. The main outcome measures were preoperative and postoperative best-corrected visual acuity (BCVA) and secondary postoperative complications.

RESULTS:

The study patients were divided into two groups: Group A patients were implanted with retropupillary iris claw lens whereas Group B patients were implanted with SFIOL. The mean age of presentation was 12 years, the mean follow-up period was of 24 months (range 14–36 months), and the median follow-up period was 26 months in both the groups. An improvement in the mean BCVA (LogMAR) was seen in both the groups. In Group A, the mean BCVA improved from 1.5 ± 0.2 preoperatively to 0.3 ± 0.2 postoperatively, whereas in Group B, the mean BCVA improved from 1.5 ± 0.3 preoperatively to 0.3 ± 0.2 postoperatively (P < 0.001). None of the eyes in either of the groups had any serious complications such as glaucoma, uveitis, cystoid macular edema, or endophthalmitis.

CONCLUSION:

Retropupillary iris fixation and scleral fixation of IOL are both safe and viable options for the correction of ectopia lentis in pediatric age group.

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.

Via pars plana anterior iris enclavation IOL fixation

AIM

To describe a via pars plana anterior iris enclavation intraocular lens (IOL) fixation technique.

METHODS

A total of 35 consecutive aphakic vitrectomised patients (average age 71.12±10.12y) underwent pars plana vitrectomy (PPV) and via pars plana anterior iris enclavation IOL fixation.

RESULTS

The mean preoperative best corrected visual acuity (BCVA) was 0.11±0.14 logMAR, the mean postoperative BCVA was 0.07±0.11 logMAR. The preoperative mean spherical equivalent was 7.22±4.21 D. The final mean spherical equivalent was -0.25±0.15 D. No eyes had hypotony, retinal or choroidal detachment or endophthalmitis.

CONCLUSION

This technique may be a safe and useful in the case of aphakia, and a prospective study would be useful to confirm this findings.

Retropupillary iris-claw intraocular lens implantation in aphakic patients

Purpose:

To evaluate the outcomes of implantation of an iris-claw intraocular lens (IC-IOL) in retropupillary position in aphakic patients.

Methods:

We conducted a prospective interventional study, including 36 aphakic eyes with inadequate capsular support. The postoperative examination included best-corrected visual acuity (BCVA), intraocular pressure (IOP) measurement, central corneal thickness (CCT), and anterior segment examination with emphasis on the anterior chamber reaction and shape of pupil. Follow-up was done for 3 months.

Results:

Thirty-six eyes of 34 patients, including 22 right eyes and 14 left eyes were included. Indications for surgery were complicated cataract surgery in 38.9% (n = 14), aphakia in 27.8% (n = 10), pseudophakic bullous keratopathy in 16.7% (n = 6), dislocated posterior chamber IOL (PCIOL) in 11.1% (n = 4), IC drop in 2.8% (n = 1), and subluxated PCIOL in 2.8% (n = 1). Postoperatively, the visual acuity improved by at least two lines in 32 (88.9%) and worsened in four (11.1%) eyes at the end of three months. Mean postoperative IOP at the end of the third month was 12.42 mmHg (standard deviation [SD] 2.57; range 11.55–13.29 mmHg). The mean postoperative CCT at the end of the third month was 542.42 microns (SD 13.77; range 537.76–547.07 microns). Sixteen eyes (44.4%) had horizontally oval pupil, eleven eyes (30.6%) had round pupil, and nine eyes (25%) had irregular pupil. Twenty-three eyes (63.9%) presented with significant anterior chamber reaction and seven eyes (19.4%) had corneal stromal edema on postoperative day 1.

Conclusion:

Our study demonstrated that retropupillary IC-IOL implantation in eyes without adequate capsular support is an effective and safe procedure with a good visual outcome and fewer complications.

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.

Retrospective analysis of visual outcomes in retropupillary iris-suture-fixated rigid intraocular lens in a tertiary eye center in southern India

PURPOSE

To report clinical outcomes of retropupillary iris-suture-fixated rigid intraocular lens (IFIOL) SETTING: Tertiary care ophthalmic hospital DESIGN: Retrospective study METHODS: This study included all eyes undergoing IFIOL with a minimum follow-up of 6 months between April 2017 and January 2019. Patients with preexisting anterior or posterior segment pathologies causing defective vision, uveitis or history of previous intraocular surgeries with exception of cataract surgery were excluded from the study. Data were retrieved from electronic medical records, and we documented demographics, history, position of cataractous lens or IOL, primary/secondary surgery and its complications. Postoperative visual acuity, pupillary response, diplopia, centration of IOL, inflammation were also recorded at the baseline visit and at 1 month, 3 months and 6 months postoperatively.

RESULTS

One hundred and ten eyes of 110 patients that underwent IFIOL were evaluated. Twenty-two patients (20%) underwent primary IFIOL, whereas 67 (60.9%) patients had secondary IFIOL. In 18 patients (16.36%), IFIOL was done to reposition decentered/dislocated IOLs. At the final follow-up, there was a significant improvement in corrected distance visual acuity (CDVA) with 87 patients (79.09%) achieving CDVA of 6/12 or better. IFIOL was stable and centered in 101 eyes (91.81%). Two patients (1.81%) had intraoperative complications. Postoperative iritis was seen in 7 patients (6.36%), and 4 patients (3.63%) had rise in IOP.

CONCLUSION

This is a safe, reliable, reproducible technique for aphakia rehabilitation and decentered IOL stabilization with good clinical outcome, especially in a limited resource setting.

[Evolution of IOL exchange. Part 2. Modern problems of IOL exchange]

The review discusses modern problems of intraocular lens (IOL) exchange. Making an adequate choice between IOL reposition and IOL exchange in pseudophakic patients with problems of lens fixation remains a largely unsolved issue. The literature data shows a noticeable increase in the number of supporters of retropupillary fixation of an iris-claw lens during the exchange procedure.

A Simple Modified Way of Glueless, Sutureless Scleral Fixation of an IOL: A Retrospective Case Series

PURPOSE

To evaluate the outcome and viability of a modified self-sealing scleral pocket technique for scleral fixation of an intraocular lens (IOL).

DESIGN

Retrospective interventional case series.

METHODS

A retrospective, interventional case series in which 81 eyes underwent this modified technique, performed in the previous 4 years. Cases included a dislocated IOL and an absent posterior capsule or subluxated cataract. Two diagonally opposed paralimbal, curved self-sealing scleral pockets were made 3 mm away from the limbus along with a vitrectomy. A multipiece IOL was used, and the haptics were fixed under the scleral pockets inside a linear scleral tunnel underneath the superficial scleral flap. The conjunctiva was opposed by using cautery. Postoperatively, anterior segment optical coherence tomography (AS-OCT) was performed in order to detect intrascleral hyper-reflective cross-section of the haptics and optic tilt. The optic position was re-evaluated using ultrasound biomicroscopy (UBM). Main outcomes were mean pre- and postoperative best corrected visual acuity (BCVA), postoperative astigmatism. Postoperative AS-OCT was performed to detect the position of the haptics and optics. UBM was done to recheck any optic tilt.

RESULTS

Mean pre- and postoperative BCVA were LogMAR 1.2 ± 0.59 and LogMAR 0.47 ± 0.3 (P < 0.001). Mean postoperative astigmatism was 1.27 ± 1.02 Dcyl. In AS-OCT, an intrascleral hyper-reflective shadow signified stable haptics without any optic tilt. UBM also showed a stable position of the IOL optic without any tilt.

CONCLUSIONS

This modified, simple way of scleral fixation of an IOL decreases the duration of surgery with minimal complication.

Artisan iris-claw intraocular lens implantation in vitrectomised eyes

OBJECTIVES

To present the visual acuity (VA) results and complication rates following Artisan intraocular lens (IOL) insertion in vitrectomised eyes.

METHODS

Outcome data were collected for all vitrectomised patients who had undergone Artisan IOL insertion between January 2014 and May 2019 at Moorfields Eye Hospital. All those with follow-up greater than 2 months were included in the analysis.

RESULTS

Sixty-nine eyes from 61 patients were included. Average follow up was 2 years. Fifty-five (80%) eyes had at least one ocular comorbidity prior to Artisan IOL insertion. At final follow up 46 (67%) eyes had best-corrected VA better than 6/12. Sixty-three eyes (91%) either gained or maintained VA. Mean post-operative spherical equivalent was -0.2D. Two (3%) lenses became de-enclavated requiring further surgery. Two (3%) eyes developed acute post-operative cystoid macular oedema. Two (3%) required additional topical IOP-lowering therapy to their pre-operative glaucoma regimen. One eye had mild corneal oedema, which persisted for 1 year following surgery and subsequently resolved.

CONCLUSIONS

Artisan IOL insertion is a safe and effective option for the surgical correction of aphakia in vitrectomised eyes lacking capsular support. Refractive results comparable to posterior chamber IOL placement can be achieved with these lenses.

Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the visual acuity results and complications of different surgical techniques for intraocular lens (IOL) implantation in the absence of zonular support.

METHODS

Peer-reviewed literature searches were conducted last in PubMed and the Cochrane Library in July 2019. The searches yielded 734 citations of articles published in English. The panel reviewed the abstracts of these mostly retrospective case series studies, and 45 were determined to be relevant to the assessment objectives. Three articles were rated as level II evidence, and 42 articles were rated as level III evidence.

RESULTS

Eight different types of IOL fixation techniques with at least 6-month follow-up were evaluated: anterior chamber IOL (ACIOL), iris-claw IOL, retropupillary iris-claw IOL, 10-0 polypropylene iris-sutured posterior chamber IOL (PCIOL), 10-0 polypropylene scleral-sutured PCIOL, 8-0 polypropylene scleral-sutured PCIOL, CV-8 polytetrafluoroethylene, and intrascleral haptic fixation (ISHF). Eight articles reported data comparing 2 techniques. The 45 studies had insufficient statistical power to compare the techniques conclusively. A qualitative analysis of similar types showed that trends in visual acuity outcomes were not inferior to those of ACIOL implantation, but the severity of preoperative pathologic features was not controlled for. Compared with ACIOL, complications of cystoid macular edema were higher in 10-0 polypropylene iris-sutured PCIOL and 8-0 polypropylene scleral-sutured PCIOL. Non-anterior chamber IOL techniques were less likely to report chronic uveitis. Chronic glaucoma was highest in the 8-0 polypropylene scleral-sutured PCIOL group. Although retinal detachment was infrequent overall, it was twice as common in both iris- and scleral-sutured PCIOLs (except CV-8 polytetrafluoroethylene suture) compared with nonsutured methods: ACIOL, iris-clipped IOL, and ISHF PCIOL.

CONCLUSIONS

The evidence reviewed shows no superiority of any single IOL implantation technique in the absence of zonular support. The various techniques seem to have equivalent visual acuity outcomes and safety profiles. Each technique has its own profile of inherent risk of postoperative complications. Surgeons must educate patients on the importance of close, long-term follow-up as a result of the uncertain nature of these techniques. Large prospective studies are needed to confirm the long-term complication profiles of these various IOL implantation techniques.

Comparison of flanged intrascleral intraocular lens fixation versus iris claw intraocular lens fixation: A retrospective study

Purpose

To compare the visual outcome and complications of retropupillary fixated iris claw intraocular lens (IOL) and sutureless intrascleral IOL fixation using the flanged fixation technique at 1 year.

Methods

In this retrospective study, eyes that underwent either iris claw or flanged SFIOL from January 2016 to July 2017 with a minimum of 1-year follow-up were enrolled. Improvement in visual acuity, intraocular pressure measurements, endothelial cell count, central macular thickness, and complications were compared between and within groups at 6 weeks, 3 months, and 1 year postoperatively.

Results

Data from 150 eyes were analyzed (n = 90 in the iris claw group and n = 60 in the flanged SFIOL group). Posterior capsular rent was the most common indication for IOL implantation (n = 51, 34%). The iris claw and SFIOL groups were comparable in terms of demographics and baseline characteristics. There was significant improvement in uncorrected distance visual acuity (UCDVA) at 6 weeks in both groups (P = 0.77), and at 1 year, the UCDVA was comparable between groups (0.36 ± 0.32 in the iris claw group and 0.30 ± 0.28 in the SFIOL, P= 0.75). Transient elevation of intraocular pressure was seen slightly more in eyes with SFIOL (17%), while ovalization of the pupil was the main sequelae seen in the iris claw group (20%).

Conclusion

Both iris claw IOL fixation and SFIOL using flange are viable options for surgical correction of aphakia. Visual outcomes are excellent at 6 weeks and are maintained till 1-year follow-up, and complication rates are acceptably low, although ovalization of pupil is common with iris claw IOLs.

Sutureless intrascleral fixation using different three-piece posterior chamber intraocular lenses: a literature review of surgical techniques in cases of insufficient capsular support and a retrospective multicentre study

We present a literature review of surgical techniques of intraocular lens placement in eyes with insufficient capsular support, focusing on the most recent publications, together with a retrospective multicentre consecutive case series analysis of 103 eyes undergoing pars plana vitrectomy and sutureless intrascleral (SIS) fixation of a standard three-piece PCIOL. Many different approaches appear in the literature without any specific procedure achieving superior outcomes. Advantages and disadvantages vary between techniques. Common complications related to IOL fixation techniques were as follow: anterior chamber IOL: transient/permanent corneal oedema (9-66.6%), uveitis (1.1-39.3%); iris-fixated IOL: pupil ovalization (16-47.7%); and sutured scleral-fixated IOL: suture breakage/exposure (6.1-11%), vitreous haemorrhage: (5.5-16.6%). In our retrospective case series, indications for surgery were postoperative aphakia in 50 eyes (49%), IOL dislocation in 38 eyes (37%) and natural lens dislocation in 15 eyes (14%). Scleral tunnels for haptic fixation were created with (28 eyes, 27.2%) or without (75 eyes, 72.8%) 25 gauge trocar cannulas. Complications included transient hypotony (n = 20; 19.4%), corneal decompensation (n = 7; 6.7%), IOL dislocation (n = 6; 5.8%), cystoid macular oedema (n = 5; 4.8%), vitreous haemorrhage (n = 4; 3.8%) and retinal detachment (n = 4; 3.8%). Mean best corrected visual acuity improved from logMAR 0.65 to 0.36 at the final visit (p = 0.001). In conclusion, SIS fixation provides good anatomical and functional outcomes; however, complications can occur. The number of surgical approaches for IOL dislocation described in the literature indicates that optimal treatment remains to be found.

Use of Techniques for Scleral and Iris Fixation in Secondary Implantation of Intraocular Lenses

Scleral and iris fixation of intraocular lenses (IOL) are useful in the treatment of surgical or traumatic aphakia, luxation, and subluxation of IOL if the patient does not present appropriate capsular support. However, there is no consensus in the literature about which of these 2 methods is safer and better. The authors performed a literature review searching the main postoperative outcomes obtained with the use of each surgical method. Scleral and iris fixation of IOL are efficient in correction of the patients' visual acuity, even though each technique presents distinct complications which depend especially on the experience of the surgeon with the performed surgical method. It is important to understand that individuals submitted to scleral or iris fixation present previous preoperative complications in their eyes. Besides, both procedures are very complex, involving intense manipulation of the eye globe. The success rate of these surgical techniques is highly variable and has a close relation to the preoperative conditions of the patient's eye and the improvement of the surgeon's learning curve.

Iris-claw intraocular lens for aphakia: Can location influence the final outcomes?

PURPOSE

To describe the demographic data, evaluate the long-term refractive and anatomical outcomes, and report the incidence of complications of anterior iris (prepupillary) and posterior iris (retropupillary) fixation of the Artisan aphakia iris-claw intraocular lens (IOL).

SETTING

Complejo Hospitalario Universitario de Santiago de Compostela, Spain.

DESIGN

Retrospective case series.

METHODS

Patients who had iris-claw IOL implantation were divided into 2 groups: Group 1 (prepupillary) and Group 2 (retropupillary). The corrected distance visual acuity (CDVA), anatomical changes, endothelial cell count (ECC), presence of cystoid macular edema (CME), and operative and postoperative complications were determined.

RESULTS

The study comprised 95 eyes of 95 patients. Fifty-seven patients had prepupillary implantation and 38 patients had retropupillary implantation. Indications for surgery were IOL luxation or subluxation (n = 24), lens luxation or subluxation (n = 17), trauma (n = 15), aphakia (n = 30), and other (n = 9). The CDVA improved significantly in both groups and there were no differences between them. A significant ECC reduction was observed in both groups, with no differences between them. The incidence of CME was 16.1% (21.8% in the prepupillary group and 7.9% in the retropupillary group at 3 months and 8 months, respectively), although the difference was not statistically significant. Other postoperative complications were rare and no differences were found between groups.

CONCLUSIONS

Irrespective of location, the iris-claw IOL provided good visual outcomes with few complications. However, prepupillary IOL implantation seemed to contribute to greater endothelial cell loss and earlier onset of CME.

[Morphofunctional changes and complications after out-of-the-bag intraocular lens implantation]

The article reviews morphofunctional changes and complications after using modern methods of out-of-the-bag implantation of the intraocular lens (IOL). Literature data shows that the smallest morphofunctional changes in intraocular structures and the best results are obtained after retropupillary implantation of an iris-claw lens and transscleral fixation of posterior chamber IOL.

Dislocated Intraocular Lens Extraction and Iris-Claw Lens Implantation in Vitrectomized and Non-vitrectomized Eyes

Objectives:

To compare the outcomes and complications of dislocated intraocular lens (IOL) extraction and secondary iris-claw IOL (ICIOL) implantation in vitrectomized and non-vitrectomized eyes.

Materials and Methods:

This retrospective study included 19 vitrectomized eyes and 11 non-vitrectomized eyes that underwent dislocated IOL extraction and secondary anterior chamber ICIOL implantation between June 2014 and September 2017 and had at least one year of follow-up.

Results:

There were no significant differences between the groups in terms of demographic data, operative time, baseline anatomic and functional measurements, or postoperative changes in these measurements (all p>0.05). Postoperative best corrected visual acuity was significantly higher than preoperative values in both groups (both p<0.05). Complication rates did not differ between the groups (all p>0.05). In both groups, endothelial cell density was significantly lower at postoperative 1 year compared to preoperative measurements. There was no significant difference between groups regarding endothelial cell loss (p=0.49). One vitrectomized eye had corneal decompensation. Other complications included hyphema, transient increase of intraocular pressure, secondary glaucoma, pupillary irregularity, and dislocation of ICIOL. Mean operative time was 26.4±5.9 minutes.

Conclusion:

Dislocated IOL extraction and secondary anterior chamber ICIOL implantation is a safe treatment option in both vitrectomized and non-vitrectomized eyes.

The effects of complicated cataract surgery on iris structure and anterior chamber angle

PURPOSE

To evaluate iris structure in aphakic eyes scheduled for placement of a secondary intraocular lens.

METHODS

Twenty-eight aphakic eyes of 28 patients who were scheduled for secondary intraocular lens implantation between January 2012 and January 2017 at Beyoglu Eye Training and Research Hospital after a complicated cataract surgery were recruited in this study. The phakic fellow eyes of the patients were defined as a control group. Iris thickness was assessed using anterior segment optical coherence tomography at 750μm (IT750) and 2000μm (IT2000) from the scleral spur. Moreover, maximum iris thickness (ITM) and anterior chamber angle parameters such as trabecular iris surface area at 500 and 750μm (TISA500, TISA750), angle opening distances at 500 and 750μm (AOD500, AOD750) and anterior chamber depth (ACD) were also evaluated.

RESULTS

Mean IT750, IT2000 and ITM readings and were significantly lower in the aphakic eyes compared to the healthy eyes (P=0.04, P=0.01, P=0.01 respectively). Anterior chamber parameters (TISA500, TISA750, AOD500 and AOD750) and ACD were significantly increased in aphakic eyes following complicated cataract surgery compared to healthy fellow eyes (all P<0.001).

CONCLUSIONS

Complicated cataract surgery leading to aphakia results in decreased iris thickness and increased anterior chamber depth. These findings might be helpful in the selection of the type of surgery for placement of a secondary IOL.

Comparative analysis of retropupillary iris claw versus scleral-fixated intraocular lens in the management of post-cataract aphakia

Purpose:

To compare the visual outcomes and complications between the eyes receiving retropupillary iris claw intraocular lens (IOL) and scleral-fixated IOL (SFIOL) for post-cataract aphakia.

Methods:

Medical records of consecutive patients who had iris claw IOL and SFIOL surgery from January 2010 to March 2015, with > 1 year of follow up were retrospectively analyzed. The surgical technique was based on individual surgeon preference. The best-corrected distance visual acuity (BCDVA), previous surgery, surgical technique, and complications were analyzed.

Results:

Retropupillary iris claw IOL was fixated in 48 eyes (46%) and SFIOL was performed in 56 eyes. Iris claw was performed more frequently at the time of primary cataract surgery (56%) compared to SFIOL (14%) (P < 0.001). At 1 month postoperative, BCDVA was significantly better in the SFIOL group [0.7 ± 0.5 logarithm of minimum angle of resolution (logMAR) in iris claw vs. 0.3 ± 0.2 logMAR in SFIOL, P < 0.001] but this difference did not persist at 1 year (0.4 ± 0.4 logMAR in iris claw vs. 0.3 ± 0.2 logMAR in SFIOL, P = 0.56). Eyes with iris claw IOL experienced significantly more postoperative iritis (17%), intraocular pressure spikes (10%), and ovalization of the pupil (16%).

Conclusion:

Retropupillary iris claw IOL fixation is as safe as SFIOL for visual rehabilitation of post-cataract aphakia. Visual rehabilitation following iris claw IOL might take longer than SFIOL. Ovalization of the pupil is the commonest adverse effect reported with this type of IOL design.

Five-year follow-up of secondary iris-claw intraocular lens implantation for the treatment of aphakia: Anterior chamber versus retropupillary implantation

BACKGROUND

Though several procedures of IOL implantation have been described (sutured scleral fixation, intra-scleral fixation, angle-supported anterior chamber, and anterior chamber or retropupillary iris-claw IOLs), there are no randomized trials which are comparing different techniques. Hence, the surgical treatment of aphakia still remains controversial and challenging. The purpose of this study was to compare the long-term efficacy and the rate of complications of anterior versus posterior Iris-claw intraocular lenses (IOL) implantation to correct for the treatment of aphakia without sufficient capsule support.

METHODS AND FINDINGS

Consecutive eyes having secondary implantation of aphakic iris-fixated IOLs with a follow-up of at least 5 years were considered. Mean correct distance visual acuity (CDVA) changes, percentage of eyes with CDVA improvement, mean corneal endothelial cell density (CECD) loss and the rate of other complications were used for statistical analysis. The study evaluated a total of 180 eyes (Group A: 87 anterior chamber iris-claw fixation, Group B: 93 retropupillary iris-claw implantation) of 180 consecutive different patients, with aphakia of various reasons. CDVA improved significantly in both groups after surgery (P<0.001, ANOVA), and was remarkably higher than baseline in both groups from first week and during the entire follow-up (P<0.001, Tukey's Honest Significant Difference). There was no statistically significant difference in CDVA between the two groups during each follow-up visits (P = NS, unpaired t-test) and in the CDVA improvement percentage between the two groups (P = 0.882, Chi-square test). No significant changes in CECD were noted after surgery in both groups (ANOVA Group A: P = 0.067, Group B: P = 0.330P). No intra-operative complications occurred in both groups. There was no statistically significant difference in the rate of complications between the two groups (P = NS, Chi-square test), except for pigment precipitates which were higher in Group A (P<0.05, Chi-square test).

CONCLUSIONS

Five-year follow-up shows that secondary implantation of aphakic IOLs is effective and safe for the correction treatment of aphakia in eyes without capsule support.

Comparison between Refractive Outcome of Primary Piggyback Intraocular Lens versus Secondary Lens Iris Claw Lens in Posterior Microphthalmos

Purpose

To compare the refractive outcome of 2 different methods of intraocular lens implantation in cases of posterior microphthalmos, primary piggyback IOLs versus secondary iris claw lenses.

Methods

This study was a retrospective interventional comparative study that included 60 eyes of 30 patients. The included patients had bilateral microphthalmos with high axial hyperopia and had undergone a lens-based surgical procedure for hyperopia correction. The included patients were equally divided into two groups. The first group had undergone refractive lens exchange (RLE) with primary piggyback IOL implantation. The second group undergone RLE with maximum available IOL power implanted followed by a secondary implantation of Artisan iris-fixated IOL (Ophtec B.V., Groningen, the Netherlands).

Results

The 2 groups were highly comparable to each other regarding the mean age, axial length (AL), manifest refraction (MR), and K readings. Postoperatively, there was a statistically significant difference between the 2 groups regarding the manifest refraction spherical equivalent (MRSE), mean absolute error (MAE), and uncorrected distance visual acuity (UDVA). There was no significant difference between the 2 groups regarding the CDVA. At 36 months, 20% and 73% of the eyes were within ±0.5 D of intended refraction at 36 months in 1ry piggyback and 2ry Artisan groups, respectively. Fifty-three percent and 93% of the eyes were within ±1.0 D of intended refraction at 36 months in 1ry piggyback and 2ry Artisan groups, respectively (p=0.001).

Conclusion

Secondary procedure with implantation of iris-fixated intraocular lens yielded very good results for treatment of axial hyperopia in cases of posterior microphthalmos. The primary piggyback IOL showed less satisfactory results with cases of under correction and the possible complication of interlenticular opacification. Both groups showed good safety parameters.

Modern methods of fixation of rear-camera intraocular lenses after facoemulsification of the cataract complicated by the violation of capsule support of the lumber

The review of domestic and foreign literature sources examining different methods of fixation of posterior chamber intraocular lenses after phacoemulsification of cataract, complicated capsular support of the lens is presented. There is a sufficiently widespread of transscleral suturing of the IOL and the prospect of developing IOL fixation in corneal layers.

Comparative Analysis of the Safety and Functional Outcomes of Anterior versus Retropupillary Iris-Claw IOL Fixation

Purpose

To compare the functional and clinical outcomes of the iris-claw intraocular lens (IOL) placed on the anterior versus posterior surface of the iris.

Patients and Methods

A multicenter, retrospective study. Data on eyes that underwent anterior or retropupillary iris-claw IOL implantation because of inadequate capsular support secondary to complicated cataract surgery, trauma, and dislocated/opacified IOLs since January 2015 were analyzed. For study inclusion, evaluation results had to be available in the medical records both preoperatively and at 1 and 12 months after implantation. The following parameters were compared between the groups: best-corrected distance visual acuity (BCDVA), spherical and cylindrical refractive error, endothelial cell density (ECD), central macular thickness (CMT), and percentage and type of postoperative complications.

Results

In total, 60 eyes of 60 patients aged 73 ± 13 years were included: 28 eyes (47%) involved anterior, and 32 eyes (53%) retropupillary, iris-claw IOL fixations. Preoperatively, the groups were similar in all parameters except for a significantly higher proportion of retropupillary fixations in patients who had previously experienced a closed-globe trauma (p=0.03). The groups showed comparable improvements in BCDVA after surgery (final BCDVA: 0.34 ± 0.45 vs. 0.37 ± 0.50 logMAR in the anterior and retropupillary placement groups, respectively). During follow-up, no group difference was observed in refractive error or CMT. Both groups experienced similarly marked ECD loss and showed similar incidence of postoperative complications, with cystoid macular edema being the most common complication. Multivariable linear regression showed that BCDVA at 1 month was the best predictor of the final BCDVA.

Conclusions

Anterior chamber and posterior chamber iris-claw IOL fixations proved equally effective and safe for aphakic correction in eyes with inadequate capsular support.

Cystoid macular oedema and iris-fixated intraocular lens treated with intraocular lens exchange: A case series and review

This series of case reports describes six eyes from five patients that underwent intraocular lens (IOL) exchange with scleral-fixated IOLs for cystoid macular oedema associated with iris-fixated IOLs between 2005 and 2015. Macular oedema was assessed using ocular coherence tomography (OCT). The six eyes in this series were treated by IOL removal and implantation of a scleral-sutured IOL with four points of fixation in the sulcus. Visual acuity improved in all six eyes. On OCT, macular oedema resolved after 3 months in all eyes. There were no surgical complications from the IOL exchange. One eye had a pupilloplasty and another had a diaphragm IOL to treat a major iris impairment from prior surgeries. The cause of cystoid macular oedema in these cases remains controversial but has been well recognized in eyes with iris-sutured IOLs. The absence of sutures with posterior fixation of an iris claw IOL prevents progressive corneal endothelial cell loss but does not prevent macular oedema, even in vitrectomized eyes. In conclusion, macular oedema resolved and visual acuity improved after implant exchange with a secondary scleral-fixated IOL in these cases. This procedure should be considered as a solution to persistent symptomatic cystoid macular oedema from an iris-fixated implant.

[Assessment of astigmatism associated with the iris-fixated ARTISAN aphakia implant: Anterior fixation versus posterior fixation, study of postoperative follow-up at one year]

PURPOSE

The goal of our retrospective, single-center study of a case series was to compare the total, corneal, and internal astigmatism, and the visual acuity at one year after combined or stand-alone surgery consisting of iris fixation of an iris-claw intraocular lens (ARTISAN aphakia) in aphakic patients, according to whether the lens was fixated to the anterior (n=21) or posterior (n=51) surface of the iris.

RESULTS

We did not find a significant difference between these two types of fixation for any of the studied variables. The surgically induced astigmatism was 1.67 D at 176° in group A versus 1.19 D at 11° in group P.

CONCLUSION

Although this surgery creates additional corneal astigmatism, it has not been proven that it differs depending on the type of fixation of the iris-claw. If we adhere to the notion that the posterior fixated iris-claw decreases the risk of endothelial decompensation in case the implant becomes disenclavated, then reverse iris fixation of the iris-claw makes sense.

Comparison of the Techniques of Secondary Intraocular Lens Implantation after Penetrating Keratoplasty

Aim

To conduct a retrospective analysis of secondary IOL implantation in patients who underwent PK with no simultaneous IOL implantation.

Materials and Methods

The retrospective study of the secondary implantation of IOLs was conducted in 46 eyes that underwent a primary operation with PK and cataract/lens extraction with no IOL implantation due to capsule rupture or combining corneal or intraocular complications. The minimum period from PK was 12 months. All secondary IOL implantations were performed from January 2011 to August 2017. Aphakic postkeratoplasty patients were treated using one of the surgical techniques for secondary IOL implantation. In-the-bag IOL implantation was possible if the posterior capsule was complete. If the lens capsule remnants were sufficient to provide secure IOL support, an in-the-sulcus IOL implantation was performed. Scleral fixation was offered in eyes with extensive capsular deficiency or the presence of the vitreous body in anterior chamber. BCVA and expected and achieved refraction were evaluated; we included using two biometry devices, and results were compared.

Results

The corrected distance visual acuity (CDVA) before surgery ranged from 0.1 to 0.8 (mean 0.54 ± 0.17). After secondary IOL implantation, CDVA ranged from 0.2 to 0.8 (mean 0.43 ± 0.14) at postoperative 1 month and from 0.3 to 0.9 (mean 0.55 ± 0.15) at postoperative 6 months (p < 0.05). Comparison of the final refraction using two methods of biometry showed no statistically significant difference in the group that underwent scleral fixation of the IOL, similar to the findings for the in-the-bag and in-the-sulcus IOL implantation groups. In the scleral-fixation group, p=0.55 for the USG biometry technique and p=0.22 for the OB technique. p values for the IOL-implantation group were p=0.49 and p=0.44, respectively.

Conclusion

Both implantation methods are safe for the patients. Final refraction is depending on the technique and indication to keratoplasty. Both biometry techniques deliver precise data for IOL choice.

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.

Comparisons of Visual and Surgical Outcomes after Reuse or Replacement of Dislocated in-the-Bag Intraocular Lens

Purpose

To compare the visual and surgical outcomes after a reuse or a replacement of a dislocated in-the-bag intraocular lens (IOL).

Methods

This was a retrospective, nonrandomized case series at a single ophthalmological institution. Cases with an in-the-bag dislocation of an IOL were treated by pars plana vitrectomy and the reuse or the replacement of the IOL. The lens was held by intrascleral fixation of the haptics of the IOL under both conditions. The same dislocated IOL was reused in 6 eyes (group A) or it was replaced with another IOL in the other 9 eyes (group B). The pre- and postoperative parameters analyzed included the visual acuity, refractive error, corneal endothelial cell density, and intraocular pressure (IOP).

Results

There was no significant difference between the two groups in the postoperative visual acuity (P = 0.388), refractive error (P = 0.955), IOP (P = 0.529), and endothelial cell loss (P = 0.940). A breakage or a tilting of the IOL was observed and required replacement in three eyes in the reuse group (P = 0.044).

Conclusions

Half of the cases with reused in-the-bag dislocated IOL had a breakage or a tilting of the IOL. The replacement of the in-the-bag dislocated IOL is better than the reuse of the IOL with intrascleral haptics fixation.

[Outcomes of intraocular lens implantation in the absence of capsular support: a review of current literature]

Тhe prevalence of complications associated with the deficiency or absence of capsular support in cataract patients is 5-15%. Moreover, approximately 20% of patients have an inconspicuous zonular weakness, which is often left undetected preoperatively.

AIM

to classify and comparatively analyze the latest published data on the outcomes of various kinds of complicated cataract surgery.

MATERIAL AND METHODS

Analysis of available literature on the subject of research published in 2003-2016.

RESULTS

The method of sutured scleral fixation of the intraocular lens (IOL) is the most fully covered in the current literature. It has been used long enough and is, therefore, well tested. Its typical complications include sutures degradation, hemorrhage, and inflammation. Sutureless fixation of the IOL, which has become more common in recent years, is free of complications associated with degradation of the sutures. However, studies on the long-term results of this technique are few and most of them were conducted in a small clinical material.

CONCLUSION

Basing on the present analysis, one may conclude that at the current level of surgery, sutureless scleral and iridal fixation of the IOL is more preferable in terms of possible postoperative complications.

Clinical spectrum and surgical outcomes in spherophakia: a prospective interventional study

PurposeTo study the varied clinical presentations of patients with spherophakia, their management using surgical methods, and the clinical outcomes.Patients and methodsA prospective interventional study of 13 patients of spherophakia who presented to us from January 2014 and were followed up over the course of their treatment, and the data were documented for analysis.ResultsIn all, 26 eyes of 13 patients were reviewed and the median age of presentation was 12±12.05 years. All patients had a bilateral presentation with 22 eyes having lenticular myopia with a mean refractive error of -11.5±12.945 DS. Ten eyes presented with glaucoma of which six had raised intraocular pressure (IOP) >21 mm Hg. A total of 23 eyes underwent lens extraction for dislocation/subluxation. Lens extraction helped lower overall IOP. Refractive rehabilitation was done with ACIOL, posterior chamber intraocular lens (PCIOL) with capsular tension ring, and scleral-fixated intraocular lens (SFIOL) in respective cases with ACIOLs being the most commonly used option.ConclusionsSpherophakia is a rare condition, which exhibits a varying degree of lenticular myopia, glaucoma, and subluxation of the crystalline lens. Lensectomy with proper rehabilitation using ACIOL, PCIOL, or SFIOL is a method of managing subluxation and unacceptable myopia. Lensectomy may also be a viable option of controlling glaucoma alongside medications and glaucoma surgery for the management of glaucoma in such cases.