Visual outcome and complications after posterior iris-claw aphakic intraocular lens implantation

Visual Improvement and Lowered Intraocular Pressure After Surgical Management of In-The-Bag Intraocular Lens Dislocation and Aphakia Correction; Retrospective Analysis of Scleral Suturing versus Retropupillary Fixated Iris-Claw Intraocular Lens During a 5-Year Period

Purpose

We compare and evaluate the visual outcome and complication rate of two different techniques of surgical management of in-the-bag intraocular lens (IOL) dislocation or aphakia correction. In addition, we evaluate possible risk factors for IOL dislocation or aphakia.

Patients and Methods

This retrospective case series reviewed medical records for all patients who had undergone surgery for IOL dislocation or aphakia during a 5-year period at a single ophthalmic center in Sweden. The two most common procedures, scleral suturing of dislocated in-the-bag IOL and retropupillary fixation of iris-claw IOL, were further analyzed. Main outcome measures were best-corrected visual acuity (BCVA), reoperations, and complications.

Results

The study comprised 110 eyes, including scleral suturing procedures (n=35) and retropupillary iris-claw IOL (n=75). There was a significantly higher rate of dense cataract (p=0.030) and posterior capsular rupture (PCR), (p=0.016) among iris-claw cases at the primary cataract extraction with pseudoexfoliations in about two-thirds of patients in both groups. All eyes in the scleral suturing group had an IOL dislocation. In the iris-claw group, 23 eyes (30.7%) were aphakic following complicated cataract surgery with PCR. No intraoperative complications occurred in any eyes during the secondary IOL procedure. Both groups showed significant improvement in BCVA, yet there was no significant difference between groups in postoperative BCVA (p=0.263). However, the scleral suturing group experienced a significantly larger improvement in BCVA due to worse BCVA preoperatively (p=0.005). Intraocular pressure decreased significantly after both repositioning and exchange surgery (p=0.002 and 0.010 respectively), but improvement between groups was not significantly different (p=0.264).

Conclusion

Both surgical methods resulted in significantly improved BCVA and lowering of IOP and can be considered safe with limited complications. The outcome was similar between groups. Pseudoexfoliation prevalence was high in both groups indicating that it may be a risk factor for either aphakia or late IOL dislocation.

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.

Aetiology and Management of IOL Dislocations

Early (< 3 months) intraocular lens (IOL) dislocation occurs due to insufficient fixation in the capsular bag, while late dislocation (≥ 3 months) is due to increasing insufficiency of the zonular apparatus. Iris-fixated IOL (IFIOL) and suture- or sutureless-fixated scleral IOL (SFIOL) are currently the most commonly used methods when IOL exchange is indicated. Different methods of scleral fixation with or without sutures have been described. The most important techniques are summarised in this paper. IFIOL and SFIOL allow comparable visual outcomes but differ in their risk profile. The decision of which method to use should be made case by case and in accordance with the surgeon's preference.

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

BACKGROUND

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Predictive Factors and Management of Macular Edema after Retropupillary Iris-Claw Intraocular Lens Implantation in Aphakia: National Multicenter Audit-Report 2

The aim of this multicenter, national clinical audit is to evaluate the predictive factors and management of postoperative macular edema (ME) after retropupillary iris-claw intraocular lens (RICI) implantation and pars plana vitrectomy (PPV). Preoperative, surgical and postoperative data were collected. Number and type of intravitreal injections (IT) administered (anti-VEGF or dexamethasone implant), visual acuity (VA), intraocular pressure (IOP) and central retinal thickness (CRT) assessed by OCT were collected at 1, 3, 6 and 12 months. From 325 eyes (325 patients), 11.7% (38/325) developed postoperative ME. Previous complicated cataract surgery with no capsular support was the only significant predictive factor for developing postoperative ME (OR 2.27, 95% CI 1.38-4.52, p = 0.02) after RICI implant. Mean time to ME development was 11.4 ± 10.7 weeks, and mean CRT peaked at 3 months follow-up. Different treatment options were non-steroidal anti-inflammatory (NSAIDs) drops (31.6%, 12/38), dexamethasone (DEX) implant (50%, 19/38), anti-VEGF (7.9%, 3/38) or combined IT (10.5%, 4/38). Cumulative probability of ME resolution was higher in the group treated with IT than in the group treated with topical NSAIDs (85.2% vs. 58.3%, p = 0.9). Performing RICI implantation after complicated cataract surgery is a risk factor for the development of postoperative ME. DEX implants may be an effective treatment for postoperative ME in these cases.

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.

Optical Coherence Tomography Position Analysis of Retropupillary Iris-Fixated Intraocular Lens in Iris Tissue

Purpose

The aim of this study was to evaluate a micrometer-accurate analysis of the retropupillary Verisyse® intraocular lens (IOL) (Ophtec, Groningen NL; Santa Ana, USA) enclavation in the iris tissue.

Methods

A retrospective consecutive case series was conducted at the Department of Ophthalmology, University Hospital Mainz. Patients with an optical coherence tomography (Spectralis®, Heidelberg Engineering®; Heidelberg, Germany) examination after retropupillary Verisyse® IOL implantation were included retrospectively. The enclavation geometry was measured using the Eye-Explorer® from Heidelberg Engineering® (Heidelberg, Germany). Seventeen measuring positions were determined nasally and temporally at the corresponding enclavation points.

Results

72 eyes of 67 patients after implantation of a retropupillary Verisyse® IOL were analyzed. The average age was 68 ± 17.2 years (63% female; 38% male). The analysis of the position of the Verisyse® IOL showed highly homogeneous data in all measured points. The depth of the anterior chamber showed a positive correlation with width of the posterior deflection of the iris tissue behind the enclavation (Pearson r: 0.321, p=0.041). The offset of the haptics showed greater deviations, and the lens diopter implanted was higher (r = 0.337, p=0.007).

Conclusion

This is the first study that analysis the exact enclavation of retropupillary implanted Verisyse® IOL. It provides new information about the intrastromal course of the haptics in the iris tissue. It could be shown that the haptics do not run parallel in the iris tissue, but are anchored in the iris tissue with an average offset of 95 µm. This rebuts previous assumptions about the intrastromal course and provides new information.

Prospective analysis of Artisan aphakia intraocular lens implantation for nontraumatic ectopia lentis in children

PURPOSE

To report long-term outcomes of iris claw aphakia intraocular lens (IOL) implantation for nontraumatic ectopia lentis (EL) in children.

METHODS

In this prospective study, children who underwent Artisan Aphakia IOL placement were included if they have a minimum of 1-year follow-up after implantation. Main outcome measures were: best-corrected distance visual acuity, reoperations, change in central corneal thickness (CCT), and corneal endothelial cell counts (ECC).

RESULTS

The Artisan Aphakia IOL was implanted in a total of 76 eyes of 43 patients (68 eyes of 34 patients with EL). 56 eyes of 28 patients have been followed long enough to meet the inclusion criteria for this report. The average age at Artisan Aphakia IOL implantation was 11.1 years (range of 2-20 years). Average follow-up was 3.59 years, and 23% of patients have >5 years' follow-up. Mean best-corrected visual acuity improved from 0.36 (20/46) to logMAR 0.18 (20/30) after implantation (P = 0.02). Five reoperations were needed in 4 patients, 3 (7%) related to post-implantation trauma. Average preoperative CCT was 580 μm; estimated mean increase in CCT at the 5-year postoperative visit was 11.9 μm higher (P = 0.047). Average preoperative ECC was 3178 cells/mm²; estimated mean loss of ECC at the 5-year postoperative visit was not significantly different from zero (187.7 cells/mm² [P = 0.102]).

CONCLUSIONS

The Artisan Aphakia IOL, used in the absence of capsular support, had an acceptable safety profile in our patients.

OUTCOMES OF RETROPUPILLARY IRIS CLAW INTRAOCULAR LENS IMPLANTATION COMBINED WITH PARS PLANA VITRECTOMY

PURPOSE

To report 12-month visual outcomes, incidence of intraocular pressure (IOP) changes and postoperative complications after pars plana vitrectomy with retropupillary implantation of an iris claw intraocular lens (IOL) in aphakic eyes after complicated cataract surgery and eyes with a dislocation of the IOL.

METHODS

This is a retrospective analysis of eyes undergoing implantation of an iris claw IOL combined with pars plana vitrectomy from 1st of January 2009 until 30th of June 2018 after complicated cataract extraction with capsular loss (Group A) or dislocation of an IOL (Group B). Corrected distance visual acuity was analyzed in logarithm of the minimum angle of resolution (logMAR) units, IOP was recorded in mmHg.

RESULTS

Eyes in Group A (n = 49) improved from a preoperative median visual acuity of 0.523 logMAR (Snellen 20/65) to 0.201 logMAR (Snellen 20/30), P < 0.01. Eyes in Group B (n = 126) showed stable median visual acuity, preoperative 0.301 logMAR (Snellen 20/40) versus postoperative 0.222 logMAR (Snellen 20/30), P > 0.05. During 12 months in Group A, IOP >21 mmHg occurred in 9 (18.4%) eyes; no eye had an IOP <6 mmHg. In Group B, IOP >21 mmHg occurred in 15 (11.9%) eyes, IOP <6 mmHg in 5 (4%) cases. None of the eyes in Group A and B had IOP >21 mmHg or <6 mmHg at 12 months follow-up.

CONCLUSION

The retropupillary implantation of an iris claw IOL with pars plana vitrectomy provides adequate visual rehabilitation and seems to be safe in IOP changes.

Retrospective study of secondary implantation of retroiridial fixation lenses in patients without capsular support: functional results and complications

INTRODUCTION

The correction of aphakia when there is no adequate capsular support remains a therapeutic challenge. The use of retroiridial fixation lenses has been extended given their lower complication rate compared to other available options.

MATERIAL AND METHODS

Retrospective study including all cases operated with an Artisan® retropupillary aphakia implant.

RESULTS

33 eyes were included out of a total of 28 patients. The follow-up period has been 38.55 months (1-96). 32.3% had a lens dislocation and 67.7% had an intraocular lens dislocation. The previous mean best corrected visual acuity (BCVA) was 1.18 ± 0.79 logMAR and post-intervention 0.36 ± 0.62 (p < 0.01). 93.8% of the patients presented a final BCVA equal to or better and 62.5% an improvement of 3 or more lines. The most frequent complication was corectopia (31.3%) and hypotony in the immediate postoperative period (21.9%). An epiretinal membrane (ERM) developed in 18.8% and cystic macular oedema (CME) in 9.4%. The presence of complications in the postoperative period did not statistically influence the final BCVA.

CONCLUSIONS

The retropupillary Artisan® lens allows the correction of aphakia with satisfactory visual results and a low rate of complications.

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.

Retropupillary Iris Fixation of an Artisan Myopia Lens for Intraocular Lens Dislocation and Aphakia in Eyes with Extremely High Myopia: A Case Series and a Literature Review

Introduction

To describe the outcomes of retropupillary iris fixation of an iris claw Artisan Myopia intraocular lens (IOL), and to review literature on retropupillary iris fixation of iris claw models for myopia for the correction of aphakia and IOL dislocation in eyes with extremely high myopia.

Methods

Single-center, retrospective case series. Three patients (three eyes) with pathological myopia underwent retropupillary iris fixation of the iris claw Artisan Myopia model 204 for the correction of aphakia and IOL dislocation. After IOL power calculation, we found that the Artisan Aphakia IOL was not available for these patients. One patient had a history of previous extracapsular cataract extraction and two patients exhibited IOL–bag complex dislocation. The target lens power was calculated using ultrasound biometry and the Sanders–Retzlaff–Kraff theoretical and T2 formulae, with an A-constant of 103.8. All surgeries were performed by a single surgeon. Visual outcomes were assessed at 12–48 months after surgery.

Results

The mean axial length was 34.33 ± 0.21 mm. The power of the implanted Artisan IOLs ranged between − 4.00 and − 3.00 diopter. The corrected distance visual acuity, measured in logarithm of the minimum angle of resolution units, improved after surgery in all eyes, from 0.60 ± 0.36 logMAR before surgery to 0.40 ± 0.43 logMAR after surgery at 12 months postoperatively and remained stationary thereafter. There were no postoperative complications.

Conclusions

Retropupillary iris fixation of Artisan Myopia IOLs may be a safe and effective surgical treatment option for the correction of aphakia and IOL dislocation in patients with extremely high myopia.

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.

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

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

Scleral-fixated intraocular lens implants-evolution of surgical techniques and future developments

Varied options are available for the implantation of secondary intraocular lens implants in the absence of zonular or capsular support. Loss of the capsule can occur in the context of complicated cataract surgery, trauma or inherited conditions such as Marfan syndrome or pseudoexfoliation. Approaches to overcome this include optical measures such as the use of spectacles or contact lenses, and surgical therapy incorporating the use of anterior chamber, iris-fixated or scleral-fixated lenses. Surgical techniques to implant scleral-fixated lenses have undergone various modifications, since the first publication of sutured intrascleral fixation described in the 1980s. However, despite the advances in surgical techniques, studies are limited either by their retrospective nature, small sample size and most importantly small duration of follow-up. This comprehensive review aims to amalgamate the evolution of various surgical techniques with regards to intrascleral lens fixation and suggests areas for future development.

RETROPUPILLARY IRIS-CLAW INTRAOCULAR LENS AND PARS PLANA VITRECTOMY IN APHAKIA MANAGEMENT: A National Multicenter Audit

PURPOSE

To evaluate the outcomes and safety of retropupillary iris-claw intraocular lens implantation and associated pars plana vitrectomy.

METHODS

Multicenter, national audit of 325 eyes (325 patients). Demographics, surgical details, and complications are described. Visual acuity, intraocular pressure, and central retinal thickness assessed by optical coherence tomography were collected at 1, 3, 6, and 12 months after surgery. Kaplan-Meier curves were created to assess the cumulative probability of postoperative visual acuity and intraocular pressure levels, macular edema development, and corneal decompensation.

RESULTS

The cumulative probability of the final visual acuity ≤0.3 logarithm of the minimum angle of resolution (≥20/40 Snellen) was 75.6% at 12-month follow-up. The probability of intraocular pressure >21, ≥25, and ≥30 mmHg was 48.1%, 33.1%, and 19.0%, and the probability of intraocular pressure-lowering drops was 50.9% at 12 months. Glaucoma surgery was required in 4.3% of the eyes (14/325). The cumulative probability of macular edema was 20.5% at 12 months and was greater in complicated cataract surgery than in intraocular lens-luxation eyes (26% vs. 16.7%, P = 0.04). Corneal transplantation was required in 2.8% of the eyes (9/325).

CONCLUSION

This study on 325 eyes with aphakia or intraocular lens dislocation managed with the retropupillary iris-claw intraocular lens technique provides clinical outcomes in a real-world scenario, reporting relevant data for patient counseling and preoperative discussions.

Technique of re-enclavation of post-traumatic disenclaved haptic of posterior iris claw lens in a vitrectomised eye

A 58-year-old woman presented to us with sudden onset diminution of vision for 10 days following trauma while using mobile phone. Patient had a history of posterior iris claw implantation 3 years ago. On examination, the patient was aphakic and intraocular lens (IOL) was seen enclaved on nasal side and disenclaved on temporal side on ultrasound biomicroscopy. Patient underwent surgery for re-enclavation of temporal haptic by lifting the IOL using 23-gauge pars plana trocar. Patient had a postoperative uncorrected visual acuity of 6/9 and best-corrected visual acuity of 6/6 with refraction. Re-enclavation of partially disenclaved posterior iris claw lens is a minimally invasive technique to restore visual acuity in such cases.

Refractive Outcomes of Retropupillary Fixated Iris-Claw Lens for Exchange of the Dislocated Intraocular Lens Using Modified Scleral Incisions

Purpose

To evaluate refractive outcomes after retropupillary iris-claw intraocular lens (IOL) implantation and to compare postoperative astigmatism from (1) a conventional 5.5-mm sclerocorneal incision, (2) an L-shaped scleral tunnel incision, and (3) a frown scleral tunnel incision.

Methods

This was a retrospective study of eyes undergoing dislocated IOL exchange for a retropupillary iris-claw IOL. Uncorrected and corrected distance visual acuity (UDVA and CDVA) and postoperative complications were evaluated until postoperative months 24. The refractive outcomes and the surgically induced astigmatism (SIA) vector were compared between groups.

Results

The medical records of 107 eyes from 107 patients with mean age of 65.31 ± 12.15 years were reviewed. Eyes with a frown incision showed the best UDVA, followed by those with L-shaped and conventional incisions (P = 0.003). Eyes with an L-shaped incision or frown incision had a lower SIA than that of the conventional incision group at postoperative 6 months (mean ± standard deviation [SD] SIA, 0.86 ± 0.85 D, 0.63 ± 0.37 D, and 1.70 ± 1.27 D for frown incision, L-shaped incision, and conventional incisions, respectively; P = 0.004).

Conclusion

The frown incision and L-shaped incision induced a significantly smaller SIA than the conventional incisions, which was associated with better UDVA postoperatively.

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.

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.

Long-term surgical outcomes of primary retropupillary iris claw intraocular lens implantation for the treatment of intraocular lens dislocation

We aimed to investigate the efficacy and safety of primary retropupillary iris claw intraocular lens (R-IOL) implantation in patients with complete intraocular lens (IOL) dislocation. In this single-center retrospective case series, we reviewed the medical records of patients who underwent R-IOL implantation surgery with pars plana vitrectomy for the treatment of IOL dislocation between September 2014 and July 2019. The primary outcome was change in visual acuity (VA) up to 24 months postoperatively. The secondary outcomes included changes in intraocular pressure (IOP), refractive errors, and endothelial cell count (ECC) over the same period. Data of 103 eyes (98 patients) were analyzed. The mean uncorrected VA was significantly improved at one month postoperatively (− 0.69 logMAR, P < 0.001), compared to the preoperative value. IOP (− 2.3 mmHg, P = 0.008) and ECC (− 333.4 cells/mm², P = 0.027) significantly decreased one month post-surgery and remained stable thereafter. Postoperative mean spherical equivalents were similar to the prediction error throughout the follow-up period. IOP elevation (n = 8, 7.8%), cystoid macular edema (n = 4, 3.9%), and dislocation of the R-IOL (n = 10, 9.7%) were managed successfully. Overall, primary R-IOL implantation with pars plana vitrectomy is effective and safe for correcting IOL dislocation due to various causes.

Surgical Outcome of Refixation versus Exchange of Dislocated Intraocular Lens: A Retrospective Cohort Study

We compared the surgical outcomes and complications of refixation vs. exchange of dislocated intraocular lenses (IOLs) in patients who underwent transscleral suture fixation combined with pars plana vitrectomy for the treatment of IOL dislocation. A total of 83 eyes (n = 83 patients) with postoperative follow-up of ≥6 months were evaluated: 40 received refixation of dislocated IOL (refixation group) while 43 received IOL exchange (exchange group) treatment. Treatment outcomes, including best-corrected visual acuity (BCVA), spherical equivalent, corneal cylinder, intraocular pressure (IOP), central macular thickness (CMT), and corneal endothelial cell density (ECD), and postoperative complications were retrospectively reviewed. BCVA improvement at 6 months after surgery was comparable between the groups. Postoperative decrease in corneal ECD was significantly greater in the exchange group than in the refixation group, but no significant differences were found in spherical equivalent, corneal cylinder, IOP, or CMT changes. The exchange group experienced significantly more frequent postoperative vitreoretinal complications, such as retinal detachment, choroidal effusion, cystoid macular edema, and secondary epiretinal membrane, than the refixation group. Without any reason to extract the dislocated IOL, reuse of the dislocated IOL would be a better surgical option for transscleral suture fixation to protect corneal endothelial cells and prevent postoperative vitreoretinal 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.

Endothelial keratoplasty with anterior chamber intraocular lens versus secondary posterior chamber intraocular lens

AIM

To describe the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with an anterior chamber intraocular lens (ACIOL) compared to secondary posterior chamber (PC) IOL.

METHODS

This was a retrospective comparative cohort study. The clinical data of 82 eyes from 82 consecutive patients with pseudophakic (PBK) or aphakic bullous keratopathy (ABK) who either underwent DSAEK with retained or secondary ACIOL (n=23) or DSAEK with IOL exchange and/or secondary PCIOL (retropupillary iris-claw IOL, n=25; intrascleral-fixated IOL, n=29; or sulcus IOL, n=5) were analysed. The main outcome measures were graft survival and complications up to 5 years.

RESULTS

The graft survival in the secondary PCIOL group was superior than the ACIOL group over 5 years (year 1, 100.0% vs 100.0%; year 3, 94.7% vs 75.0%; year 5, 91.1% vs 60.6%, p=0.022). The presence of an ACIOL was a significant risk factor associated with graft failure (HR, 4.801; 95% CI, 1.406 to 16.396, p=0.012) compared to a secondary PCIOL. There was no significant difference in the rate of graft detachment and elevated intraocular pressure between the groups. There were five cases (9.3%) of IOL subluxation or dislocation in the retropupillary iris-claw and intrascleral-fixated IOL groups.

CONCLUSIONS

Eyes that underwent DSAEK with ACIOL in situ had poorer long-term graft survival compared with those with secondary PCIOL. Intraocular lens exchange was not associated with a higher complication rate. In ABK or PBK eyes with ACIOL, we recommend performing IOL exchange and/or secondary PCIOL implantation combined with endothelial keratoplasty.

[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.

Sekundäre Linsenimplantation: chirurgische Techniken und Ergebnisse

Es stehen verschiedene alternative chirurgische Optionen zur Verfügung, um eine sekundäre Intraokularlinse (IOL) in Augen mit unzureichender Kapselunterstützung zu implantieren. Erfolgreiche Techniken umfassen die Implantation einer irisfixierten IOL (IFIOL), einer kammerwinkelgestützten Vorderkammerlinse (ACIOL) oder verschiedene Variationen zur Sklerafixierung (SFIOL). Jede dieser Methoden hat sich als sicher und effektiv erwiesen, weist jedoch verfahrensspezifische Einschränkungen auf. Jüngste Studien zeigen, dass die Entwicklung neuer chirurgischer Techniken diesen Patienten weiterhin sichere und reproduzierbare Behandlungsmöglichkeiten bietet. Obwohl die Implantation von sekundären IOLs ohne Kapselunterstützung von vielen Faktoren, einschließlich der Präferenz des Chirurgen, abhängt, sind nahtlose sklerafixierende Techniken für die chirurgische Gemeinschaft von wachsendem Interesse. Das Bestreben nach kürzeren und weniger traumatischen Operationen sowie nach reproduzierbaren und funktionell guten Ergebnissen, fördert dabei die Entwicklung von neuen Operationstechniken, Intraokularlinsen und Instrumenten. Diese Übersichtsarbeit gibt einen Einblick in alte und neue Behandlungsmethoden zur Korrektur von Aphakie mit sekundären Intraokularlinsen

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.

Re-Enclavation of a Dislocated Retropupillary Fixated Iris Claw Lens: A Case Report

A male patient, 63 years of age, presented with dislocation of a retropupillary fixated iris claw lens due to nasal haptic disenclavation. During re-enclavation the intraocular lens dislocated again. To avoid further dislocation, both superior fingers of the haptics were pushed through the iris tissue to achieve more stable support of the haptic ends. This method of fixation appeared to be well tolerated.

Surgical Outcomes of Retropupillary-Fixated Iris-Claw Intraocular Lens

Purpose:

To assess the visual outcome and complications following retropupillary-fixated iris-claw intraocular lens (IOL) implantation.

Methods:

For this retrospective, non-comparative study, chart review of patients who underwent retropupillary iris-claw IOL implantation for the correction of aphakia from July 2014 to October 2018 and had a minimum postoperative follow-up of 2 months was carried out. Postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), and complications were noted.

Results:

One hundred and twenty-two eyes of 122 patients (mean follow-up: 7.48 ± 5.2 months, range, 2 months-3.5 years) were enrolled in the study. The mean logMAR CDVA improved from 1.36 ± 0.52 preoperatively to 0.5 ± 0.42 postoperatively, at the last follow-up visit (P < 0.0001). The final CDVA improved in 110 eyes (90.2%), remained unchanged in 8 eyes (6.6%), and worsened in 4 eyes (3.3%). In cases of pre-existing cystoid macular edema (CME) or excessive intraoperative manipulations, 0.05 ml of 4 mg intravitreal triamcinolone acetonide (IVTA) was injected at the end of the surgery. Twenty eyes (16.4%) had transient ocular hypertension (OHT), 6 eyes (4.9%) had persistent OHT, and 2 eyes (1.6%) progressed to glaucoma. Choroidal detachment was noted in 2 eyes (1.6%), CME in 6 eyes (4.9%), 2 eyes (1.6%) had retinal detachment, 20 eyes (16.4%) had significant ovalization of pupil, 8 eyes (6.6%) had one haptic disenclavation, 1 eye (0.8%) had corneal decompensation, and 1 eye (0.8%) had endophthalmitis.

Conclusions:

Retropupillary iris-claw IOL provides good visual rehabilitation with a few complications. Its ease of insertion and short surgical time makes it a good option to correct aphakia in patients with an inadequate capsular support.

Secondary intraocular lens implantation: Complication rates, visual acuity, and refractive outcomes

PURPOSE

To compare complication rates, visual acuity, and refractive outcomes of secondary intraocular lens (IOLs) implantation.

SETTING

Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA.

DESIGN

Retrospective case series.

METHODS

All secondary IOLs placed by the anterior segment service were reviewed. Preoperative data, operative reports, and data from each subsequent postoperative visit were evaluated. Patients were divided into 5 groups based on the final IOL position: (1) sulcus with optic capture, (2) sulcus without optic capture, (3) anterior chamber (AC), (4) iris-fixated, and (5) transscleral-sutured. Complication rates, visual acuity, and refractive outcomes were compared for each group.

RESULTS

The sulcus with and without optic capture groups had the lowest complication rates and best visual acuity outcomes. There was no difference in final corrected distance visual acuity (CDVA) between the transscleral-sutured IOL, iris-fixated IOL, and AC IOL groups, although the AC IOL group had the lowest rates of early postoperative complications and a significant improvement in vision. The transscleral-sutured IOL group had the highest complication rates, and 25% of patients in the iris-fixated IOL group lost 2 or more lines of CDVA.

CONCLUSIONS

When a secondary IOL cannot be placed within the capsular bag, sulcus with optic capture is the best alternative, followed by sulcus without optic capture. There was no difference in visual acuity outcomes between transscleral-sutured IOLs, iris-fixated IOLs, and AC IOLs. Anterior chamber IOLs resulted in fewer early complications.

[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.

Long-Term Outcomes after Surgery for Late In-The-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial

PURPOSE

To compare the long-term efficacy and safety of 2 operation methods for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel group surgical clinical trial.

METHODS

During a 3-year period, 104 patients (104 eyes) were assigned one group for IOL repositioning by scleral suturing (n = 54) or one group for IOL exchange by retropupillary fixation of an iris claw IOL (n = 50). A single surgeon performed all operations using an anterior approach. Patients were examined before surgery and at 6 months and 1 and 2 years after surgery. The present study included the 66 patients (63%) who completed the 2-year follow-up, and the main outcaome measurement was corrected distance visual acuity (CDVA) 2 years after surgery.

RESULTS

After 2 years, the mean CDVA was 0.20 ± 0.29 logarithm of the minimum angle of resolution (logMAR) units (range, -0.18 to 1.10) in the repositioning group and 0.22 ± 0.30 logMAR (range, -0.10 to 1.22) in the exchange group (P = .69). A CDVA of 20/40 or better was achieved by 76% of all patients. Four eyes (12%) had cystoid macular edema in the repositioning group compared with 5 eyes (15%) in the exchange group. Two eyes underwent redislocation (1 in each group). There were no cases of endophthalmitis or retinal detachment.

CONCLUSIONS

There were no significant differences between the visual acuity using IOL repositioning and that using IOL exchange 2 years after surgery. The two methods were equally efficient and safe from a long-term perspective and are both considered acceptable treatments.

Transscleral sutureless intraocular lens versus retropupillary iris-claw lens fixation for paediatric aphakia without capsular support: a randomized study

PURPOSE

To compare results of sutureless transscleral intraocular lens (IOL) fixation to retropupillary iris-claw lens implantation in cases of paediatric aphakia without capsular support.

METHODS

Thirty eyes of children with insufficient capsular support for IOL implantation were randomized to undergo sutureless transscleral IOL fixation or iris-claw lens fixation. The primary outcome was best-corrected visual acuity (BCVA). Secondary outcomes included operative time, astigmatism, central corneal thickness, endothelial cell count (ECC), IOL decentration and tilt, central foveal thickness and complications.

RESULTS

There was a significant improvement in BCVA at all follow-up visits, with no significant difference between both groups. 53.3% in the transscleral-fixated IOL group and 80% in the iris-claw IOL group had a final BCVA ≥0.3. The operative time was significantly shorter in the iris-claw IOL group (p = 0.001). IOL decentration and tilt were higher in the transscleral-fixated IOL group, but the difference was not significant. The ECC was reduced by 14.6% in the transscleral-fixated IOL group and 11% in the iris-claw group at 6 months, with no significant difference between both groups (p = 0.5). In the transscleral-fixated IOL group, two eyes developed ocular hypertension and two eyes had IOL decentration, while in the iris-claw IOL group, 1 eye developed glaucoma, three eyes had haptic disenclavation, and one eye had retinal detachment.

CONCLUSION

Both techniques yielded a comparable visual outcome. Retropupillary iris-claw lens fixation is a shorter procedure and technically easier than sutureless transscleral fixation, but the risk of disenclavation should be considered especially in younger age groups. Scleral fixation is the only option in case of severe iris damage, but may be associated with more endothelial cell loss.

[Methods of out-of-the-bag intraocular lens implantation]

The article reviews the main modern methods of out-of-the-bag IOL implantation. Literature data shows that the most pressing question to date is comparative assessment of retropupillary iris-claw lens implantation and trans-scleral posterior chamber IOL fixation.

Visual outcome and surgical results in children with Marfan syndrome

IMPORTANCE

To determine visual and surgical results in children with Marfan syndrome.

BACKGROUND

Marfan syndrome involves ocular complications which can lead to visual disturbance and amblyopia. Data about the visual and surgical results in children with Marfan syndrome is vital for the clinical management of these patients.

DESIGN

Retrospective data analysis.

PARTICIPANTS

Eighty-two eyes of 41 patients with a genetically proved diagnosis of Marfan syndrome.

METHODS

Medical records of patients with Marfan syndrome were reviewed between 2007 and 2017. Ocular complications, visual acuity (VA) of patients with/without lensectomy and surgical method were evaluated.

MAIN OUTCOME MEASURES

VA outcomes of patients with Marfan syndrome with/without surgical repair of ectopia lentis.

RESULTS

In 27 (66%) of the 41 patients a bilateral subluxation of the lens was visible and 14 (52%) patients received lensectomy. The mean age at initial presentation was 12.3 ± 9 years and mean follow-up was 3 years (range 1-7). VA varied from 1.2 to -0.1 logMAR at first examination. At initial presentation, mean VA was 0.1 ± 0.7 logMAR in patients with a normal lens status (n = 14) and 0.3 ± 0.5 logMAR in patients with subluxation of the lens (n = 27) (P < .01). VA improved from 0.2 ± 0.5 logMAR to 0.1 ± 0.5 logMAR (P = .06) in children with subluxation of the lens who did not need a lensectomy (n = 12) and from 0.5 ± 0.5 logMAR to 0.2 ± 0.5 logMAR (P = .02) in patients who were referred to lensectomy with/without secondary lens implantation.

CONCLUSIONS AND RELEVANCE

In Marfan syndrome subluxation of the lens was found in the majority of children. Improvement of VA resulted in children with subluxation of the lens and following lensectomy.

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 of Two Modified Sutureless Techniques of Scleral Fixation of Intraocular Lens

BACKGROUND AND OBJECTIVE

To compare the visual outcome and complications of two different sutureless scleral-fixated intraocular lens (IOL) implantation techniques, that is, intrascleral IOL fixation technique and modified Yamane's technique of scleral fixation of IOL.

PATIENTS AND METHODS

Patients who underwent scleral fixation of IOL (SFIOL) from June 2015 to February 2017 with more than 6 months of follow-up were examined retrospectively. Improvement in visual acuity (VA), intraocular pressure (IOP) measurements, endothelial cell count, central macular thickness (CMT), and intraoperative/postoperative complications were compared at 6 months follow-up.

RESULTS

Seventy eyes were analyzed. The mean follow-up was 10.5 months ± 1.5 months. The final visual outcomes in both groups, modified intrascleral IOL fixation technique (Group A, n = 30) and modified Yamane's technique (Group B, n = 40), were comparable. The indications for surgery were aphakia (n = 15), subluxated/dislocated cataract (n = 31), and dislocated/subluxated IOL (n = 24). The majority of the eyes (92%) improved to VA 0.3 logMAR units or better. The uncorrected distance visual acuity (UDVA), endothelial cell density, and CMT at the 6-month follow-up were comparable in both groups. Postoperatively, transient IOP rise occurred in 18 eyes, retinal detachment in one eye, vitreous hemorrhage in one eye, cystoid macular edema in two eyes, and mild IOL decentration in two eyes.

CONCLUSION

Both techniques have favorable visual outcomes; however, modified 27-gauge needle-assisted Yamane's technique is technically superior because of its transconjunctival approach and less surgical time, and its needle-assisted approach for haptic externalization prevents haptic damage during externalization. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e129-e134.].

A new technique of needle-guided retropupillary fixation of iris-claw intraocular lens

The authors developed a new surgical technique of retropupillary implantation of an iris-claw intraocular lens (RP-ICIOL). RP-ICIOL is an alternative surgical option to the scleral-fixation technique for the treatment of aphakia without capsular support. Several studies have shown that RP-ICIOL is efficient and safe. However, although it is easier to perform than scleral fixation, it presents some critical issues related to the enclavation procedure. The success of the correct enclavation without excessive surgical manipulations, with subsequent pigment dispersion and without pupil distortion, is highly related to the surgical skills of the individual surgeon. The new technique proposed by the authors consists of using a guide needle to facilitate the enclavation, and to make this surgical procedure standard. The new technique was performed in 26 patients affected by aphakia without capsular support with encouraging functional and anatomical results.