Small-incision insertion of artificial iris prostheses

Artificial iris: state of the art

Surgical correction of traumatic aniridia aims to improve the quality of vision, compartmentalize the anterior and posterior chamber, and re-establish a satisfying cosmetic appearance. Various types of prosthetic iris devices (PIDs) are available, which differ in technical difficulty of implant and design: artificial iris (AI)-intraocular lens prosthesis, endocapsular capsular tension ring-based PID, and customized AI. The choice depends on the preexisting clinical condition after severe ocular trauma and on patient functional and cosmetic expectations. This systematic review of the literature compared anatomical and functional outcomes of various types of PIDs. Of 185 articles found in the literature, 70 fulfilled the eligibility criteria. 5 subgroups of PIDs were Ophtec, artificial iris from Ophtec BV, Morcher GmbH, HumanOptics AG, and other prosthesis. Both glare and aesthetic outcome improved postoperatively; in comparison with other PIDs, intraocular pressure rise was higher in the Morcher group (40%), whereas prosthesis dislocation was higher in the Ophtec group (39%).

Novel surgical technique of sutureless artificial iris and intraocular lens scleral fixation using Yamane technique

Purpose

To describe a novel surgical technique of a combined implantation of an artificial iris and a scleral fixated intraocular lens (IOL) using flanged IOL haptics (“Yamane” technique).

Observations

The suturelessly implanted artificial iris-IOL-sandwich was stable with good functional as well as aesthetic results. However, our case showed a postoperative intraocular pressure rise.

Conclusions

The presented case demonstrates that a visual as well as cosmetical rehabilitation seems to be possible even after severe, penetrating ocular trauma with profound iris defects.

Importance

The sutureless IOL scleral fixation technique can also be used in combination with a sutureless artificial iris implantation. Further studies are needed to evaluate the long-term safety profile and rates of postoperative complications.

Sutured Custom Foldable Silicone Artificial Iris Implantation Combined With Intraocular Lens Implantation and Penetrating Keratoplasty: Safety and Efficacy Outcomes

PURPOSE

To assess safety and efficacy outcomes of sutured custom silicone artificial iris and intraocular lens implantation combined with penetrating keratoplasty (triple procedure).

METHODS

Prospective consecutive surgical case series of patients who underwent the triple procedure between 2010 and 2019 at Stein Eye Institute, UCLA, followed up for 1 year minimum. Safety outcomes were changes from preoperative to last follow-up in corrected distance visual acuity (CDVA), endothelial cell count, intraocular pressure (IOP), and postoperative complications. Efficacy outcomes included changes in subjective glare (none to severe), cosmetic appearance (worse to very much improved), and visual function as assessed by the Visual Function Questionnaire-25 at 1-year follow-up.

RESULTS

Among 82 eyes implanted with an artificial iris, 14 eyes (17.1%) underwent the triple procedure. The median follow-up was 18.1 months (range 12.0-54.9 months). The median CDVA improved from 2.0 log of minimum angle of resolution (logMAR) (range 0.9-2.3 logMAR) to 0.7 logMAR (range 0.2-2.6 logMAR) (P = 0.02). Average endothelial cell count decreased 57.6% (P < 0.01). Six eyes (42.9%) experienced IOP elevations, 13 eyes (92.3%) developed iritis, and 11 eyes (78.6%) underwent secondary surgery. Graft rejection or secondary graft failure occurred in 7 eyes each (50.0%). Cosmesis improved in 12 eyes (85.7%; P < 0.01). The Visual Function Questionnaire-25 score improved from 72 to 77 (P < 0.01). Glare symptoms did not change significantly.

CONCLUSIONS

The triple procedure was effective at improving CDVA, cosmesis, and quality of life; however, it was associated with frequent postoperative complications, of which iritis, IOP elevation, and secondary graft failure were the most common.

Flexible silicone artificial iris in cases of aniridia and iris deficiencies

PURPOSE

To evaluate a customized silicone flexible artificial iris in cases of aniridia or iris deficiencies.

SETTING

Centre Hospitalier National d'Ophtalmologie, Hôpital des Quinze-Vingts, Paris, France.

DESIGN

Retrospective case series investigating cosmetic result, photophobia, endothelial cell density and intraocular pressure.

METHODS

Patients with iris deficiencies requiring cataract surgery or correction of aphakia, or pseudophakic patients, complaining of photophobia or cosmetic disturbances were implanted with the new flexible artificial iris.

RESULTS

Fifteen eyes of 14 patients were evaluated. Mean age was: 49.5 (±18.5). A total of 50% were aphakic, 22.4% pseudophakic and 28.6% phakic. Etiology was trauma (57.1%), previous surgical trauma (28.6%) and congenital aniridia (14.3%). Three months postoperatively, the mean subjective photophobia score improved by 5.2 points (P=.002) and the mean cosmesis score by 4.7 points (P=.001) on a 0 to 10 scale. Mean endothelial cell loss was 16% (P=.001). There was no further statistically significant endothelial cell loss between the 3-month follow-up and the 1-year follow-up visit (P=.320). Elevated intraocular pressure was the main complication (35.7%). Two patients with pre-existing glaucoma required cyclodestructive procedures. The artificial iris was removed in one eye because of chronic pain, elevated intraocular pressure and inflammation that resolved rapidly after removal.

CONCLUSION

Implantation of the customized artificial iris is a very good option because of its outstanding cosmetic result. However, patients with pre-existing glaucoma are not good candidates. Patients should also be warned of possible chronic inflammation necessitating explantation.

Safety and efficacy of custom foldable silicone artificial iris implantation: prospective compassionate-use case series

PURPOSE

To assess the preliminary safety and efficacy of custom silicone artificial iris implantation.

SETTING

Stein Eye Institute.

DESIGN

Prospective consecutive case series.

METHODS

Medical records of patients implanted with the artificial iris were reviewed and followed for 1 year. Safety measures included corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell count (ECC), surgical complications, secondary interventions, and adverse events (AEs). Efficacy measures included CDVA with glare, subjective daytime and nighttime glare graded from 0 to 10 (very significant), and subjective cosmetic appearance graded from 0 to 10 (very satisfied).

RESULTS

Twenty eyes (19 patients) were implanted. Safety data were mixed. CDVA improved in 13 eyes and worsened in 6. ECC decreased from 1918 ± 870 to 1405 ± 705 cells/mm (P = .02). Eight eyes experienced postoperative complications. There were 4 IOP elevations, 2 corneal decompensations, 1 case of cystoid macular edema, and 1 device dislocation. Four eyes underwent secondary surgical interventions including 2 AEs (1 glaucoma surgery and 1 device dislocation). Efficacy outcomes were excellent. CDVA with glare improved from 1.5 ± 0.6 to 0.7 ± 0.8 logarithm of the minimum angle of resolution (P < .01). Mean subjective daytime glare decreased from 8.9 ± 1.8 to 2.7 ± 2.6 (P < .01) and nighttime glare decreased from 7.9 ± 1.8 to 2.5 ± 2.7 (P < .01). Mean cosmesis improved from 2.2 ± 1.6 to 8.8 ± 2.1 (P < .01).

CONCLUSIONS

Custom artificial iris implantation was moderately risky but very effective at reducing light and glare sensitivity and in improving ocular cosmesis.

[Exchange of aniridia IOLs for customized iris IOL implants]

BACKGROUND

Three groups of iris prostheses can be distinguished for the surgical treatment of iris defects: (1) segmental iris implants, (2) combined iris diaphragm intraocular lenses (IOL) and (3) pure iris implants. Most iris reconstructions are accompanied by aphakia correction with secondary IOL implantation. Although the primary goal is to create a pupil and to improve glare perception, contrast sensitivity and visual acuity, the esthetic result is also a relevant component.

OBJECTIVE

Functional and esthetic results after replacement of an aniridia IOL implant with a custom-made artificial iris with IOL.

MATERIAL AND METHODS

In this retrospective study with seven eyes from seven patients, an iris diaphragm IOL (Morcher GmbH, Stuttgart, Germany) was exchanged for medical reasons (subluxation) against a custom-made artificial iris made of silicone (ArtificialIris, HumanOptics, Erlangen, Germany) in combination with a sutured IOL. The follow-up period was at least 3 months. Best corrected distance visual acuity (BCVA), endothelial cell count (ECC), complications, glare perception as well as esthetic outcome and patient satisfaction were evaluated.

RESULTS

The BCVA and ECC showed no statistically significant change between the preoperative and postoperative values (p > 0.05). There was a decentration of the iris IOL implant of 0.27 ± 0.19 mm three months postoperatively. On a visual analogue scale (VAS) from 1 to 10 (1 = not satisfied at all, 10 = extremely satisfied), satisfaction with the overall result was rated 8.6 ± 2.5. Subjective glare perception improved to 5.6 ± 3.5 and subjective esthetic impairment improved to 2.4 ± 2.0 on the VAS (1 = none, 10 = extremely strong). Postoperative complications included transient intraocular hypotonia in two eyes, intraocular pressure increase in two eyes, retinal detachment and transient vitreous hemorrhage in one eye each. Of the seven patients six would repeat the procedure.

CONCLUSION

Compared to a rigid aniridia IOL implant, replacement with a custom-made artificial iris in combination with an IOL provides not only a good functional result but simultaneously also an esthetically pleasing result.

Functional outcomes after combined iris and intraocular lens implantation in various iris and lens defects

BACKGROUND

To assess the functional outcomes after combined iris and intraocular lens (IOL) repair in aniridia patients.

METHODS

Retrospective observational study in 59 aniridic and aphakic eyes for ArtificialIris (AI) and IOL reconstruction. The iris prostheses were placed together with the IOL in the capsular bag using an injection system or were fixed by transscleral suturing of the IOL and AI. The primary outcomes measured were visual acuity, contrast and glare sensitivity (Pelli-Robson chart for photopic and dark adaptometer for mesopic conditions), intraocular pressure, endothelial cell density (ECD) and patient impairment.

RESULTS

Blunt trauma (37 eyes) and penetrating injuries (16 eyes) were observed more frequently than congenital aniridia (1 eye), iatrogenic causes (1 eye), aniridic state after severe iritis (2 eyes) or iris tumor (2 eyes). Monocular CDVA improved significantly (p < 0.0001) from median 0.7 logMAR (0.0-1.98) to 0.3 logMAR (- 0.08-2.0). Median pupillary area could significantly (p < 0.0001) be reduced by 79.3% from 51.27 mm² (17.91 to 98.23) to 8.81 mm² (4.16 to 8.84). Median ECD decreased from 2646.0 mm² to 2497.5 mm² (p = 0.007). Contrast and glare sensitivity improved significantly (p = 0.008) in photopic light conditions from 0.9 (0.0-1.95) to 1.35 (0.0-1.8). Patients reported to be highly satisfied with the functional improvement.

CONCLUSION

The flexible ArtificialIris seems to be a safe and effective iris prosthesis in combination with an IOL having functionally and cosmetically exceptional reconstruction options.

Slip-and-slide technique for combined small-incision artificial iris and IOL implantation

A surgical technique is described for reducing surgically induced astigmatism (SIA) during combined implantation of IOL and artificial iris. The CUSTOMFLEX ARTIFICIALIRIS was implanted in 2 patients who suffered from aphakia and complete traumatic aniridia. Implantation of the prosthesis was accompanied by insertion of an IOL that was fixed at the iris implant. Although prosthesis and IOL can be implanted through small incisions individually, the combined package usually requires a larger incision causing greater SIA. The new technique minimizes the SIA because both components are fixed together but can be inserted separately. Final assembling of the iris-IOL package is performed after separate implantation. The technique to implant the artificial iris combined with a nontoric or a toric IOL is described. The slip-and-slide technique was a safe and an effective way to implant an iris-IOL package while keeping the SIA small and reducing the incision size.

Customized humanoptics silicone iris prosthesis in eyes with posttraumatic iris loss: outcomes and complications

PURPOSE

Posttraumatic partial or total iris defects often cause significant debilitating glare, photophobia, decreased vision and cosmetic problems. Currently, the best cosmetic results can be obtained with a customized silicone iris prosthesis. However, little is known about the functional results and the rate of complication if this type of iris prosthesis is implanted into severely traumatized eyes. The aim of this study is to analyse the functional and cosmetic outcomes as well as complications after Artificial Iris implantation.

METHODS

A consecutive series of 34 patients who received a customized silicone iris prosthesis after severe globe injury with total or sub-total iris loss was analysed retrospectively. Additionally, patients were interviewed regarding change in subjective complaints.

RESULTS

Median follow-up was 24 months (range 12.0-48.8). Mean visual acuity prior to Artificial Iris implantation was 1.1 logMAR (range 0.3-2.6). Five patients (15%) had pre-existing glaucoma and eight patients (24%) had pre-existing hypotony. Visual acuity 12 months after surgery was 1.4 logMAR (range 0.2-2.6). Complications included newly diagnosed glaucoma in three eyes (9%) and hypotony in three eyes (9%), persisting intraocular inflammation or macular oedema in seven patients (21%), and corneal endothelial decompensation requiring corneal transplantation in six patients (18%). Patients' satisfaction increased by reducing glare and enhanced cosmetic appearance.

CONCLUSION

The customized silicone iris prosthesis is an individualized treatment approach with appealing cosmetic results. Therefore, especially traumatized eyes with highly different posttraumatic conditions could benefit. However, in some patients, the implantation of this device may cause an increase of intraocular pressure, corneal endothelial decompensation or persisting inflammation.

Sutureless artificial iris after phacoemulsification in congenital aniridia

PURPOSE

This article reports the first case of a sutureless artificial iris prosthesis used in combination with cataract surgery for congenital aniridia with successful visual and cosmetic results.

CASE REPORT

A 15-year-old woman with congenital bilateral partial aniridia, cataracts, and intense photophobia presented to the Cornea and Refractive Surgery Unit of the Ophthalmology Department. She was managed with an artificial iris implant (ArtificialIris, Dr. Schmidt Intraocularlinsen GmbH, Human Optics) fixed in the ciliary sulcus without any sutures after small-incision cataract surgery. At the 1-year follow-up, subjective complaints of glare and photophobia as well as binocular near visual acuity improved significantly. The cosmetic result was excellent. No postoperative complications have been recorded within this period.

CONCLUSIONS

The ArtificialIris is a promising device for treating photophobia in congenital aniridia. ArtificialIris does not require suture fixation with adequate capsular support and iris remnants.

Treatment of congenital aniridia associated with subluxated infantile cataract

A 5 year old boy was presented at Eye clinic University clinical center Tuzla with congenital aniridia in both eyes. Clinical examination revealed visual acuity of 0,08 without correction in right and 0.7 with -5.0 Dsph and -1.0 Dcyl Axx 109° in left eye. Opthalmologic examination showed bilateral aniridia associated with moderate cataract in the right and incipient cataract in the left eye. In the right eye, zonular weakness with incipient capsular displacement and esotropia of Δ6º, were noted. The patient underwent phacoemulsification, implantation of capsular tension ring and Artificial Iris implant in the capsular bag. Phacoemulsification went uneventful and early postoperative recovery was successful with no signs of aniridia-associated keratopathy development and normal values of intra ocular pressure. Patient was not motivated for operation of the left eye and it was corrected with soft contact lens. Six month after the operation visual acuity in the right eye improved to 0.9 with +1.25Dsph and maintained stable in left eye, with complete elimination of esotropia and signs of binocular vision restoration. Small incision cataract extraction with IOL and Artificial Iris implantation in one procedure can be used to correct congenital aniridia and cataract with significant visual function improvement.