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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 3  |  Page : 91-94

Retropupillary fixated iris-claw lens: An effective alternative for aphakia


Department of Ophthalmology, Santhiram Medical College and General Hospital, Nandyal, Andhra Pradesh, India

Date of Web Publication23-Oct-2018

Correspondence Address:
Kishore Kumar Proddatoori
Department of Ophthalmology, Santhiram Medical College and General Hospital, Nandyal - 508 501, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_75_17

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  Abstract 


Context: Visual rehabilitation in aphakia has been a challenge with a wide variety of surgical options available for the ophthalmologist. We report the visual outcome with retropupillary fixated iris-claw lens secondary to intraoperative complications and secondary implantation in aphakia. Aims: This study aims to evaluate the postoperative visual acuity and complications of retropupillary fixated iris-claw intraocular lens (IOL) implantation in the management of aphakia. Settings and Design: This was a prospective interventional case series. Subjects and Methods: An interventional study on 50 eyes of 50 patients fulfilling the inclusion criteria was conducted. Preoperative visual acuity, slit-lamp examination, and fundus examination were carried out. Anterior vitrectomy and retropupillary fixation of iris-claw lens were done. The primary outcome measure was postoperative best-corrected visual acuity (BCVA) and the secondary postoperative complications were recorded at various intervals following surgery for 6 months. Results: The final BCVA in 80% of the patients at 6 months ranged from 6/12 to 6/6. The common complications noted were pupillary distortion (34%), pigment clumping over the IOL (20%), iris chaffing at the enclaved site (28%), and secondary glaucoma (12%). Retinal detachment was noted in one patient secondary to trauma after the surgery. No patient had complications such as corneal decompensation, IOL dislocation, cystoid macular edema, and endophthalmitis. Conclusions: Our study suggests that retropupillary fixated iris-claw IOL is an effective, safe, and simple procedure with minimal surgical time for visual rehabilitation in aphakia with less incidence of visually threatening complications. Its posterior location decreases the incidence of corneal decompensation. It is an effective procedure for primary implantation with intraoperative posterior capsular rent and severe zonular dialysis.

Keywords: Aphakia, iris-claw lens, posterior capsular rent, retropupillary fixation, secondary glaucoma, zonular dialysis


How to cite this article:
Proddatoori KK, Jajapuram SD, Pyda S, Zamrudh S. Retropupillary fixated iris-claw lens: An effective alternative for aphakia. J Clin Ophthalmol Res 2018;6:91-4

How to cite this URL:
Proddatoori KK, Jajapuram SD, Pyda S, Zamrudh S. Retropupillary fixated iris-claw lens: An effective alternative for aphakia. J Clin Ophthalmol Res [serial online] 2018 [cited 2018 Nov 15];6:91-4. Available from: http://www.jcor.in/text.asp?2018/6/3/91/243845



Complete visual recovery in aphakia has always been a challenge for the ophthalmologist, and the options include spectacle correction, contact lens, and surgical correction. Surgical correction of aphakia includes scleral-fixated intraocular lens (SFIOL), angle-supported anterior chamber IOL (ACIOL), and iris-claw IOL (ICIOL) which can either be fixed anteriorly or behind the iris.[1],[2] Anterior chamber IOLs, though are easy to place, are associated with increased corneal decompensation and secondary glaucoma.[3] Scleral-fixated IOLs preserve anatomical integrity, but are technically challenging and time-consuming with few intraoperative and postoperative complications such as suture erosion, IOL-related complications, and, rarely, retinal detachment.[1] Iris-claw IOLs compensate the corneal complications noted in ACIOLs and are technically less challenging and less time-consuming than SFIOL implantation.[3] Retropupillary fixation of iris-claw IOL preserves the anatomy of anterior segment and is associated with good visual outcome with a low incidence of intraoperative and postoperative complications.[4],[5]

In our study, a prospective interventional case series of retropupillary iris-fixated IOLs was taken up to evaluate the visual outcome and incidence of complications in the surgical management of aphakia with inadequate capsular support.


  Subjects and Methods Top


A prospective interventional noncomparative hospital-based study was conducted in fifty patients in a secondary eye care center in South India from June 2015 to December 2016 after approval from the institutional ethics committee. The criteria of inclusion in the study were aphakic patients secondary to previous cataract surgery, intraoperative complications, precluding adequate capsular support, zonular dialysis ≥180°, subluxated lens and IOL, and spontaneously absorbed lens. Patients with preexisting pathologies that intervened with the visual outcome such as aphakic bullous keratopathy, repaired corneal tears with aphakia, iris sphincter tears, broad iridectomies, and iridodialysis with inadequate support for the iris-claw lens, glaucoma, and posterior segment pathologies were excluded from the study. The study protocol was explained, and informed consent was obtained from all the participants. Twenty-nine patients were aphakic at the time of the surgery and 21 patients underwent primary iris-claw lens implantation secondary to intraoperative complications mentioned afore. Preoperative assessment included objective refraction, BCVA, slit-lamp examination, intraocular pressure (IOP) with Goldmann applanation tonometry, gonioscopy, and dilated fundus examination with indirect ophthalmoscopy. Ultrasound biometry in aphakic mode with IOL power calculation using SRK-II formula with an A-constant of 116.8 for retropupillary fixation was used uniformly in all the cases of secondary implantation.[3] Primary implantation of ICIOL was undercorrected by +2 D in surgeries with intraoperative complications based on the surgeon's discretion.

All the patients underwent retropupillary iris-claw IOL fixation by a single experienced surgeon using the same standard technique. Peribulbar anesthesia was given. Following automated anterior vitrectomy, previous surgical tunnel was reopened in cases with recent surgical history or a corneoscleral tunnel of 5.5 mm length at 12 o'clock was made. It was followed by two paracenteses, at 3 and 9 o'clock to introduce the Sinskey hook. Intracameral pilocarpine was injected to constrict the pupil to a diameter of at least 5 mm or less, followed by a small amount of viscoelastic (2% HPMC) on the peripheral iris. Iris-claw IOL model implanted was a biconvex polymethylmethacrylate IOL with 9 mm length and 5.5 mm optical zone was consistently used for all the patients. Iris-claw lens was inserted into the anterior chamber using lens holding forceps, rotated such that the haptics were oriented toward 3 and 9 o'clock. The optic of the IOL was held and gently tilted and pushed behind the iris and enclaved to the peripheral iris at 3 and 9 o'clock with the help of Sinskey hook introduced simultaneously through the paracentesis. No peripheral iridotomy was done during the surgery. Viscoelastic was subsequently removed, and sutures were placed with 10-0 Prolene in five patients based on the surgeon's discretion. Subconjunctival injection (0.5 ml) of gentamicin 20 mg and dexamethasone 2 mg was given immediately after surgery. The postoperative regimen consisted of topical moxifloxacin hydrochloride 0.5% and prednisolone acetate 1% tapered over 1 month. Postoperative uncorrected visual acuity and IOP was recorded on the day following surgery, BCVA, IOP, refraction, slit lamp examination and posterior segment evaluation was done at the end of 1 month, 3 months, and 6 months after the surgery to look for various complications.


  Results Top


Fifty eyes of fifty patients were analyzed in our study. The age group of the patients ranged between 37 years and 80 years with a mean of 64.2 years. The most common indication in the secondary implantation group was aphakia secondary to cataract surgery presenting to the outpatient department (65.5%, i.e., 19 of 29 patients), and the time elapsed between the previous surgery and iris-claw lens implantation varied between 4 days and 20 years in the primary implantation group and the most common indication was posterior capsular tears (48%, i.e., 10 of 21 patients). The other etiological factors contributing to primary and secondary implantation are enumerated in [Table 1] and [Table 2], respectively.
Table 1: Indications for primary iris-claw intraocular lens

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Table 2: Etiological factors for secondary implantation

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The preoperative BCVA ranged from hand movements + to 6/12. The mean BCVA at 1 month was 6/17 ± 8 letters on Snellen's visual acuity chart and the mean BCVA at 6 months was 6/11 ± 4 letters. BCVA levels measured preoperatively and postoperatively during 1 and 6 months of follow-up are elucidated in [Table 3]. All the data were analyzed using SPSS 16.0 program (IBM corp., USA). Wilcoxon signed-rank test was used to compare the preoperative and postoperative BCVA, with statistical significance considered as P < 0.05. When BCVA was compared pre- and post-operatively at 6 months, P value was found to be <0.001, and a significant increase in BCVA was noted in 48 patients between pre- and post-operative values while two patients had the same BCVA as preoperative data. The mean spherical equivalent at 1 month was + 0.25 ± 0.54D. The mean cylindrical power at 1 month was − 0.72D ± 1.2D.
Table 3: Best-corrected visual acuity before and after the surgery

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The preoperative IOP ranged between 8 and 22 mmHg with a mean of 14.6 mmHg. The mean postoperative IOP at 1 month was 14.8 mmHg and ranged between 10 and 32 mmHg. The mean postoperative IOP at 6 months was 13.9 mmHg with a range of 8–20 mmHg. Eight (16%) patients in our study developed secondary glaucoma; all except one were controlled with antiglaucoma medications by the end of the 1st month after surgery. The various demographic variables of the patients who developed secondary glaucoma are included in [Table 4]. Early postoperative rise in IOP was noted in three patients due to retention of viscoelastic. Patients were treated with either per-oral acetazolamide (Diamox) 250 mg four times daily or topical dorzolamide 1% with timolol maleate 0.5% twice daily or a combination of both oral and topical medication. Preexisting peripheral iridotomy did not seem to affect the incidence of glaucoma in our study.
Table 4: Detailed summary of patients who developed postoperative secondary glaucoma

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No intraoperative complications were encountered in our study. The most common postoperative complications noted were pupil distortion (34%), iris atrophy at the enclaved site (28%), and pigment clumping over the IOL (20%). The incidences of various postoperative complications are enumerated in [Table 5]. None of the patients developed uveitis, pseudophakic bullous keratopathy, IOL dislocation, and cystoid macular edema and endophthalmitis.[6]
Table 5: Incidence of postoperative complications

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One patient lost to follow-up after surgery and presented at 6 months with diminished visual acuity and a disenclaved haptic with inferior retinal detachment secondary to blunt trauma after surgery. Pars plana vitrectomy with silicone oil implantation and reenclavation of the IOL was done at a tertiary care center. The final BCVA at 3 months was 6/24 after the second surgery.


  Discussion Top


Surgical correction of aphakia is associated with better visual quality than aphakic spectacle correction or contact lens use.[7] The best method for secondary IOL implantation which offers the lowest complication rate and best possible visual rehabilitation has always been a matter of debate. In our study of fifty eyes that underwent retropupillary iris-claw fixation, 94% of patients achieved a final BCVA better than preoperative BCVA. Retropupillary positioning of iris-claw IOL is associated with lower risk of endothelial decompensation and a true posterior chamber location of the IOL.

Complications secondary to tissue manipulation and IOL were the most common complications noted in our study. Pupil distortion was noted in 17 patients, which occurs due to asymmetrical fixation of haptic, tight fixation of haptic, or a difference of iris tissue volume that was clamped with both haptics [Figure 1].[8] To prevent pupillary distortion, iris-claw IOL should be fixed in the peripheral part of the iris and both the claws should clamp symmetrically on the iris with equal volume of iris tissue.[9] The intraoperative iris manipulation was associated with early postoperative iritis and mild iris atrophy (14 patients) at enclaved sites with iris pigment clumping over the IOL (10 patients). No serious complications such as iridial synechiae, iris perforation, or necrosis occurred in any of the patients. The cause of accumulation of pigmented precipitates on IOL surface is unknown, but multiple factors such as inflammatory reactions, surgical manipulation of the iris, and hypotony have been suggested. All the patients responded to topical corticosteroids. Skillful operation and gentle manipulation are important aspects of the surgery and repeated tensile stimulation of iris during surgery should be avoided.
Figure 1: Postoperative image showing iris-claw intraocular lens in place with pupillary distortion and iris chaffing

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In our study, there was no significant difference in the mean preoperative IOP and the mean postoperative IOP at 6 months. Secondary glaucoma was noted in eight patients who were controlled with antiglaucoma medications. Elevated IOP was noted in three patients, immediately after surgery due to retained viscoelastic. In our study, retinal detachment was noted in one patient secondary to trauma and subsequent disenclavation of haptic. Refixation with vitrectomy and silicone oil was done at a tertiary care center. IOL disenclavation is a recognized complication of iris-claw IOL[10] and can occur due to small amount of iris tissue enclavation[10],[11] or secondary to trauma and surgeons who are in the early learning curve.

Few limitations to our study were that the endothelial cell density was not looked for pre- and postoperatively and endothelial decompensation could not be evaluated, and there is short duration of follow-up of 6 months after the surgery.


  Conclusions Top


Iris-claw IOL implantation has a lesser rate of complications with good visual acuity and a stable and safe surgical procedure for surgical correction of aphakia. The most common complications after iris-claw retropupillary fixation were pupillary distortion which was harmless but affected the pupillary dilatation and iris atrophy at the enclaved site of iris. Retropupillary fixation of iris-claw lens has a predictable visual outcome and less surgical time with fewer complications in the management of aphakia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Teng H, Zhang H. Comparison of artisan iris-claw intraocular lens implantation and posterior chamber intraocular lens sulcus fixation for aphakic eyes. Int J Ophthalmol 2014;7:283-7.  Back to cited text no. 1
    
2.
Rao R, Sasidharan A. Iris claw intraocular lens: A viable option in monocular surgical aphakia. Indian J Ophthalmol 2013;61:74-5.  Back to cited text no. 2
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3.
Schallenberg M, Dekowski D, Hahn A, Laube T, Steuhl KP, Meller D, et al. Aphakia correction with retropupillary fixated iris-claw lens (Artisan) - long-term results. Clin Ophthalmol 2014;8:137-41.  Back to cited text no. 3
    
4.
Gonnermann J, Klamann MK, Maier AK, Rjasanow J, Joussen AM, Bertelmann E, et al. Visual outcome and complications after posterior iris-claw aphakic intraocular lens implantation. J Cataract Refract Surg 2012;38:2139-43.  Back to cited text no. 4
    
5.
Helvaci S, Demirduzen S, Oksuz H. Iris-claw intraocular lens implantation: Anterior chamber versus retropupillary implantation. Indian J Ophthalmol 2016;64:45-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Brandner M, Thaler-Saliba S, Plainer S, Vidic B, El-Shabrawi Y, Ardjomand N, et al. Retropupillary fixation of iris-claw intraocular lens for aphakic eyes in children. PLoS One 2015;10:e0126614.  Back to cited text no. 6
    
7.
Simões PS, Ferreira TB. Iris-fixated intraocular lenses for ametropia and aphakia. Med Hypothesis Discov Innov Ophthalmol 2014;3:116-22.  Back to cited text no. 7
    
8.
Forlini M, Soliman W, Bratu A, Rossini P, Cavallini GM, Forlini C, et al. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: A retrospective analysis. BMC Ophthalmol 2015;15:143.  Back to cited text no. 8
    
9.
Rashad DM, Afifi OM, Elmotie GA, Khattab HA. Retropupillary fixation of iris-claw intraocular lens versus trans-scleral suturing fixation for aphakic eyes without capsular support. J Egypt Ophthalmol Soc 2015;108:157-66.  Back to cited text no. 9
  [Full text]  
10.
Lett KS, Chaudhuri PR. Visual outcomes following artisan aphakia iris claw lens implantation. Eye (Lond) 2011;25:73-6.  Back to cited text no. 10
    
11.
Hsing YE, Lee GA. Retropupillary iris claw intraocular lens for aphakia. Clin Exp Ophthalmol 2012;40:849-54.  Back to cited text no. 11
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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