Surgical Management of Paediatric Aphakia in the Absence of Sufficient Capsular Support

There are several available options for the demanding surgical correction of paediatric aphakia without sufficient capsular support. The literature suggests the implantation of a transscleral fixated posterior chamber-intraocular lens (PCIOL), an intrascleral fixated PCIOL, an iris-sutured intraocular lens (IOL), or an anterior chamber iris-claw IOL. We searched for reports on the management of paediatric aphakia in case of inadequate capsular support that delineated the diverse surgical approaches and their postoperative results. Analysis demonstrated that different complications can be encountered depending on IOL placement technique, such as suture rupture, IOL dislocation, secondary glaucoma, endophthalmitis, vitreous hemorrhage, and endothelial cell loss. However, it was shown that various IOL designs have similar visual outcomes. Taking into consideration the advantages and disadvantages of each surgical technique, ophthalmic surgeons can determine the safest and most efficient approach for paediatric aphakic patients.

Pupil dynamics after in-the-bag versus anterior and retropupillary iris-fixated intraocular lens implantation

An Intraocular Lens (IOL) fixated on the iris either anteriorly, as a phakic IOL, or posteriorly, as an aphakic IOL, can influence pupil motility. In this interventional case series study, we evaluated pupil size under different levels of illumination (scotopic = 0.04 lx, low-mesopic = 0.4 lx and high-mesopic = 4 lx) for anterior iris-claw IOL fixation for correcting myopia or hyperopia (IFPH), retropupillary iris-claw IOL fixation to correct aphakia or as treatment for late in-the-bag IOL dislocation/subluxation (IFRP), and capsular-fixation IOL in-the-bag implantation (IB). Pupil size was measured preoperatively for the IFPH- and IB-group as well as 6 months after surgery for all groups. We analyzed a total of 70 eyes: 22 eyes of 11 patients with phakic IOLs, 22 eyes of 20 patients in the IFRP group and 26 eyes of 13 patients in the IB group. Both IFPH and IB showed a smaller postoperative scotopic pupil size, compared with the preoperative values. When compared to postoperative values of IB and IFPH, IFRP showed a significantly smaller postoperative scotopic pupil size (IFPH: 5.89 ± 0.83 mm, IFRP: 4.37 ± 0.83 mm, IB: 5.34 ± 0.98 mm, p < 0.001) while no differences were seen at high-mesopic lighting. Neither of the surgical techniques seems to impair the constriction of the pupil.

The influence of intraocular lens dislocation surgical correction method on corneal endothelium

BACKGROUND:Intraocular lens (IOL) dislocation is a rare but serious complication of surgical treatment of patients with cataract. Among the factors contributing to its development, the main ones are pseudoexfoliation syndrome (PEX), high axial myopia, chronic uveitis, history of eye injury and age. There is no universal IOL dislocation correction technique. PURPOSE:To evaluate the impact on corneal endothelium of two different methods of IOL dislocation correction: IOL repositioning with transscleral suture fixation or IOL exchange to iris-claw one. MATERIALS AND METHODS:Within the study, 78 patients were examined and operated. All patients were divided into two groups: in the first group, IOL was repositioned with transscleral suture fixation, and in the second group IOL was exchanged to iris-claw IOL. Groups were equal by gender and age. Key estimated indicators were endothelial cell density and coefficient of variation reflecting the degree of polymegatism. RESULTS:Endothelial cell density was significantly lower both before surgery and at any term after it, in the group with IOL exchange, and coefficient of variation was significantly higher in the group with IOL exchange throughout this study. CONCLUSION:The choice of technique for IOL dislocation correction is the basis of success in surgical treatment. Certain preoperative examination data should be definitely considered, including the degree of dislocation, IOL type, IOP level, endothelial cell density and presence of concomitant ocular conditions.

Supporting IOL’S in a Deficient Capsular Environment: The Tale of No “Tails”

Purpose. To evaluate the efficacy and safety of the following three distinct surgical procedures for secondary IOL implantation without capsular support: Iris-claw lens, flanged transscleral fixated IOLs (Yamane technique), and sutureless transscleral hook IOL fixation (Carlevale IOL). Materials and Methods. In this retrospective comparative study, three different sutureless IOL implantation techniques were compared in patients without any capsular support. Visual acuity and outcomes were analyzed in 24 eyes of 23 patients (14 male and 9 female). Study included 13 iris-claw lenses (Artisan Ophtec), 6 flanged transscleral fixated IOLs (Yamane technique using a MA60MA Alcon Inc IOL), and 5 transscleral Carlevale IOLS (Carlevale IOL, Soleko, Italy). Results. logMAR mean best-corrected visual acuity (BCVA) improved from 0.49 ± 0.19 to 0.19 ± 0.10 at three months after surgery p < 0.05 . Postoperative BCVA was similar in all three groups, and no intergroup difference was noted. Three eyes (12.5%) had a raised IOP >25 mmHg, 2 eyes (8%) presented a subluxated/dislocated IOL, 4 eyes (16%) had corneal edema longer than 7 days, 3 eyes (12.5%) had irregular pupil profile, 2 eyes (8%) had vitreous hemorrhage, 7 eyes had (29%) corneal astigmatism over 3 diopters, and one patient (4%) developed cystoid macular edema (CME). Conclusions. All three surgical procedures can be considered adequate to correct aphakia in patients without capsular support with significant improvement in visual acuity and low complication.

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.

Iris-Claw Intraocular Lens: Anterior Chamber or Retropupillary Implantation? A Systematic Review and Meta-Analysis

Background and Objectives: Iris-claw intraocular lens (ICIOL) could be implanted in the anterior chamber (AC) or retropupillary (RP) in eyes lacking capsular and/or zonular support. Several studies have focused on comparing the efficacy and complications of these two techniques and we designed this research to review the published literatures. Materials and Methods: Peer-reviewed studies were collected through network databases (PubMed, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov) and analyzed. The primary outcome was the standardized mean differences (SMDs) of pre- and post-operative corrected distant visual acuity (CDVA). The secondary outcome was the SMDs of pre- and post-operative intraocular pressure (IOP), endothelial cell counts (ECC), and the odds ratios (ORs) of post-operative IOP elevation and cystoid macular edema (CME). Comprehensive Meta-Analysis software was utilized to conduct statistical analysis. Results: Six studies (one randomized controlled trial and five retrospective case series) were relevant and included a total of 516 eyes (255 and 261 eyes in the AC ICIOL and RP ICIOL groups, respectively). The quantitative analysis showed no significant differences in CDVA (SMD: 0.164, 95% confidence interval (CI): −0.171 to 0.500), ECC (SMD: −0.011, 95% CI: −0.195 to 0.173), and IOP elevation events (OR: 0.797, 95% CI: 0.459 to 1.383). Lesser IOP reduction (SMD: 0.257, 95%CI: 0.023 to 0.490) and a relative increase in the incidence of CME (OR:2.315, 95% CI: 0.950 to 5.637) were observed in the AC ICIOL group compared with RP ICIOL group. Conclusions: Our meta-analysis indicated that AC and RP ICIOL seem to have equivalent visual outcomes. RP ICIOL may perform slightly better with more IOP reduction and lesser CME. More randomized controlled trials, which have higher patient participation and more outcomes are needed to confirm our conclusions.