Longitudinal corneal endothelial cell loss after corrective surgery for late in-the-bag IOL dislocation: a randomized clinical trial

Visual outcomes and safety profile of retropupillary iris-claw Artisan intraocular lens implants

OBJECTIVE

The Artisan is an iris-claw intraocular lens (IOL) that can be used to correct aphakia in eyes with insufficient capsular support. This study aims to evaluate long-term visual outcomes and complications following retropupillary implantation of the Artisan IOL at a Canadian centre.

DESIGN

Retrospective chart review.

PARTICIPANTS

Patients who underwent implantation of an Artisan IOL at a tertiary Canadian center between January 2013 and December 2021.

METHODS

Retrospective chart review was performed, and clinical outcomes at postoperative follow-up visits were summarized. Outcomes included postoperative best corrected and uncorrected distance visual acuity (BCDVA and UCDVA), intraocular pressure (IOP), as well as intraoperative and postoperative complications.

RESULTS

Seventy-three eyes of 67 patients were evaluated. Mean follow-up duration was 11 months (range: 1-63 months). Common indications for Artisan implantation were IOL dislocation (n = 50; 68.5%) and aphakia (n = 23; 31.5%). Causes for IOL dislocation included idiopathic zonular weakness (n = 25; 34.2%), pseudo-exfoliation (n = 14; 19.2%), surgical complications (n = 6; 8.2%), trauma (n = 3; 4.1%), and Marfan syndrome (n = 2; 2.7%). Causes for aphakia included complicated cataract surgery (n = 20; 27.4%), ocular trauma (n = 2; 2.7%), and post-vitrectomy and lensectomy (n = 1; 1.4%). Average BCDVA (logMAR) was 0.62 ± 0.56 at preop, 0.46 ± 0.55 at 3 months postop, and 0.43 ± 0.55 at 9-12 months (p < 0.0001). Average UCDVA (logMAR) was 1.19 ± 0.68 at preop, 0.65 ± 0.60 at 3 months postop, and 0.42 ± 0.46 at 9-12 months (p < 0.0001). IOP did not differ significantly in follow-up. Pupil ovalization (n = 11, 15.1%) was the most common complication.

CONCLUSIONS

Outcomes demonstrated favourable efficacy and safety of retropupillary Artisan IOL as an option for providing adequate visual rehabilitation for patients without sufficient capsular support.

Outcomes of retropupillary iris claw lens implantation in patients with intraocular lens dislocation and low (less than 1000 cells/mm2) corneal endothelial cell density

BACKGROUND

Posterior chamber intraocular lens (IOL) dislocation is a common complication of cataract surgery. Dislocated IOLs often require surgical intervention due to the potentially severe risks of leaving this condition untreated. If a patient with extremely low corneal endothelial cell density (ECD) presents with IOL dislocation, the surgeon faces a crucial dilemma of choosing the most optimal surgical treatment option. We sought to investigate the efficacy and safety of retropupillary iris claw intraocular lens (R-IOL) implantation in patients with IOL dislocation and extremely low (< 1000 cells/mm2) ECD.

METHODS

We retrospectively reviewed the medical records of nine patients (all men) whose pre-operative ECD was < 1000 cells/mm2 and who underwent R-IOL implantation due to intraocular subluxation or total dislocation into the vitreous cavity between 2014 and 2020. We evaluated corneal endothelial function and visual outcomes after surgery.

RESULTS

Nine patients were included in this study. The mean age at diagnosis was 64.89 ± 7.15 years (range 57-76 years), and the follow-up duration was 37.93 ± 23.72 months (range 18.07-89.07 months). No patients developed bullous keratopathy during follow-up. Compared to the initial ECD, corneal thickness (CT), coefficient variation of cell area (CV) and percentage of hexagonal cells (HEX), there was no statistically significant decrease in the ECD, CV, and HEX at last follow-up (P = 0.944, 0.778, 0.445, 0.443). There was significant improvement in the mean uncorrected distance visual acuity (UDVA) at the last follow-up (average 0.13 logMAR, 20/27 Snellen) compared to the pre-operative mean UDVA (average 1.09 logMAR, 20/250 Snellen) (P < 0.01).

CONCLUSIONS

R-IOL implantation did not result in a statistically significant decline in corneal endothelial function in patients with preoperatively low ECD, and it significantly improved the mean UDVA postoperatively. R-IOL implantation appears to be a safe and effective treatment modality for intraocular lens dislocation in patients with low ECD (< 1000 cells/mm²); however, long-term follow-up studies are warranted to corroborate these findings.

Intraocular Inflammation in Eyes Operated for Late In-the-bag intraOcular lens dislocatioN (LION): A Randomized Clinical Trial

PURPOSE

To compare the intraocular inflammation after 2 surgical approaches for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel-group clinical trial.

METHODS

We randomly assigned 100 patients (100 eyes) referred to Oslo University Hospital (tertiary referral center) with late in-the-bag IOL dislocation into IOL repositioning by scleral suturing (n=49) or IOL exchange with retropupillary fixation of an iris-claw lens (n=51). Patients were examined before surgery and 2 weeks, 6 weeks, and 6 months after surgery. The main outcome measure was anterior chamber laser flare, measured with a laser flare meter as photon counts per millisecond (pc/ms).

RESULTS

Two weeks following surgery, median flare values were 28.9 pc/ms (range, 7.9-140) in the repositioning group and 31.6 pc/ms (range, 9.8-92.3) in the exchange group (P = .83). Flare levels were still elevated after 6 weeks with no difference between the groups (P = .93), whereas it decreased to baseline levels after 6 months. Six weeks following surgery, the central retinal thickness was similar (P = .97); cystoid macular edema (CME) was found in 4 and 5 patients, respectively (P = .85); and the mean best corrected visual acuity was 0.17 (95% CI 0.09, 0.25) and 0.21 (95% CI 0.09, 0.32) logarithm of the minimum angle of resolution, respectively (P = .61).

CONCLUSIONS

This study revealed similar levels of intraocular inflammation following IOL repositioning and IOL exchange. There was no significant difference regarding risk of CME and visual outcome. The prolonged elevation in postoperative flare indicates a possible requirement for an extended anti-inflammatory treatment period after these operations.

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.

Corneal endothelial cell damage after scleral fixation of intraocular lens surgery

PURPOSE

To analyze corneal endothelial cell damage after scleral fixation of intraocular lens (SFIOL) surgery.

STUDY DESIGN

Retrospective study.

METHODS

Medical records of consecutive eyes undergoing SFIOL surgery performed by a single surgeon were reviewed between January 2011 and June 2019. The patients were classified into three groups according to surgical methods: Group I, re-fixating the existing intraocular lens (IOL) or fixating a new IOL in an aphakic eye; Group II, removing the existing IOL and fixating a new IOL; and Group III, phacoemulsification and fixating a new IOL simultaneously. Preoperative and postoperative specular microscopy (SM) status were compared. Changes in SM were compared among the three groups.

RESULTS

Ninety-four eyes were included. Thirty-four eyes in Group I, 39 in Group II, and 21 in Group III. The endothelial cell density (ECD) loss in Group I was 1.5%, less than the ECD loss of 14.3% (p < 0.001) in Group II and 15.4% (p = 0.005), in Group III. In no eye was there an ECD decrease to < 1000/mm² following the surgical procedure.

CONCLUSIONS

ECD loss was related to IOL removal or phacoemulsification rather than SFIOL surgery. SFIOL using the existing IOL should be considered preferential in eyes with low ECD and dislocated IOL.

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.

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.

Comparison of long-term surgical outcomes for scleral-fixated versus retropupillary iris-claw intraocular lens

BACKGROUND

To compare the clinical features and long-term treatment outcomes of patients undergoing secondary intraocular lens (IOL) surgery with scleral-fixated (SFIOL) versus retropupillary iris-claw IOL (RPICIOL).

METHODS

Consecutive patients treated between June 2014 and December 2019 at two tertiary centres were retrospectively reviewed. The primary outcome was the best-corrected visual acuity (BCVA). Secondary outcomes included factors associated with significant corneal endothelial injury and postoperative redislocation.

RESULTS

This study included 395 eyes undergoing surgery with SFIOL (237 eyes, 60%) or RPICIOL (158 eyes, 40%), with no differences in baseline BCVA (p = 0.76) or endothelial cell density (ECD) (p = 0.39). Compared with the SFIOL group, the RPICIOL group had faster visual recovery (postoperative month 1, 20/37 vs. 20/46, p = 0.005) sustained to over 36 months (p = 0.034), favourable absolute prediction errors (within 0.5D, 67.3% vs. 54.9%, p = 0.027), and shorter operation times (52.7 vs. 60.9 min, p = 0.015). There was no difference in ECD after 12 months (P = 0.282). Over a mean follow-up duration of 33 months (152 cases >3 years, 38.5%), the SFIOL group experienced more cases of tilted/decentred IOLs (14 vs. 1, p = 0.006), suture exposure (7 vs. 0, p = 0.045), and redislocation (17.7% vs. 10.1%, p < 0.001). Multivariable regression showed that a final BCVA below 20/40 was associated with SFIOL (P = 0.007), older age (p = 0.001), intraoperative complications (p = 0.002), past history of vitrectomy/glaucoma surgery or uveitis (p = 0.046), and surgically induced astigmatism >1D (p = 0.029).

CONCLUSIONS

RPICIOL appears to be a safe and effective surgical option for secondary IOL surgery over a long-term follow-up, comparing favourably against conventional SFIOL.

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.