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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 184-188

Visual outcomes and complications of posterior iris-claw intraocular lens implantation in aphakic postvitrectomized eyes


1 Vitreo-Retina Services, Kochi, Kerala, India
2 Little Flower Hospital and Research Centre, Kochi, Kerala, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Awaneesh M Upadhyay
Little Flower Hospital and Research Centre, Angamaly, Kochi - 883 572, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_101_17

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  Abstract 


Purpose: To evaluate refractive outcome, anatomical outcome, complications of posterior chamber iris-claw aphakic intraocular lens (IOL) implantation after pars plana vitrectomy.
Methods: A retrospective analysis of consecutive 25 eyes of 25 pts (12 males & 13 females) without capsular support in which we performed posterior chamber iris-claw implantation after pars plana vitrectomy. Retro-pupillary iris claw lens were either implanted in the same procedure along with vitrectomy (15 eyes, Group A) or later in different procedure (10 eyes, Group B) in post vitrectomised eyes. Posterior vitrectomy procedures were performed with 23- or 25-gauge techniques for different associated anterior or posterior segment indications. Visual outcomes, anatomical outcome, stability of the implants, and complications were analysed.
Results: The mean patient age was 62.3 years(range, 21–78 years) in group A; 60.1 years (range, 19-80 years) in group B. The mean follow-up time was 4.12 months (range, 1-12 months). In Group A 6 eyes had lens dislocation aphakia (5 traumatic, 1 surgical) & 7 IOL dislocation aphakia (3traumatic, 4 surgical). In Group B 5 eyes had lens dislocation aphakia(4 traumatic,1 surgical) and 2 IOL dislocation aphakia(1 traumatic,1 surgical). At the end of the follow up the mean post-operative best-corrected LogMAR visual acuity was 0.244±0.25 in group A; 0.286±042 in group B which was statistically significant as compared preoperatively. Intergroup best corrected visual acuity comparisons at the end of follow up were not statistically significant. Similarly within group spherical equivalent decreased statistically when compared to the preoperative values. Between group comparisons, spherical equivalent values were not significant. Intra-op anterior chamber collapse was not seen in any case. Disenclavation of iris claw lens was not seen in any case. No corneal edema was observed. 1 case of uveitis was observed. 1 case of post-op macular edema was observed. 3 cases had increased post-op intraocular pressure.1 case had post-op vitreous hemorrhage which resolved spontaneously, retina attached in all cases.
Conclusion: In summary posterior chamber iris-claw IOL implantation in aphakic eyes without capsular support in post vitrectomized is an effective, predictable and safe procedure.

Keywords: Aphakia, iris claw lens, postvitrectomised eyes


How to cite this article:
Upadhyay AM, Nataraj A. Visual outcomes and complications of posterior iris-claw intraocular lens implantation in aphakic postvitrectomized eyes. Kerala J Ophthalmol 2017;29:184-8

How to cite this URL:
Upadhyay AM, Nataraj A. Visual outcomes and complications of posterior iris-claw intraocular lens implantation in aphakic postvitrectomized eyes. Kerala J Ophthalmol [serial online] 2017 [cited 2018 May 25];29:184-8. Available from: http://www.kjophthal.com/text.asp?2017/29/3/184/224281




  Introduction Top


Secondary intraocular lens (IOL) implantation is often a challenging surgical procedure, as patients with aphakia usually have a history of eye trauma or complicated intraocular surgery. Further management of aphakia in a vitrectomized eye can pose some problems because of frequent lack of capsular support or changes in anatomy of the anterior chamber (AC), angle, or cornea. In these cases, an angle-or iris-supported AC-IOL,[1] a transsclerally sutured posterior chamber IOL (PC-IOL),[2] a fibrin glue-assisted sutureless PC IOL,[3] or an iris-fixated PC IOL [4] can be implanted. Due to several long-term complications such as corneal decompensation, cystoid macular edema (CME), secondary glaucoma, lens decentration, and retinal detachment (RD), placement of an AC-IOL has been reduced considerably. Trans-scleral fixation of a PC-IOL, though causes less corneal endothelial damage, is technically more challenging, requiring more surgical time, and is associated with a high incidence of intra- and post-operative complications.[5] Previous studies have established that iris-claw Artisan IOL implantation is an effective method for the correction of the aphakia compared to sutured scleral fixation and angle-supported AC IOLs.[6]

Concerning the location of implantation of iris-claw IOL, the data have conflicting results.[7] These IOLs could be applied to AC over the iris or retropupillary location. Retropupillary iris-claw lens is fixed to the mid-periphery of the iris, enclavation system allows centration of the IOL on the pupillary axis, further precision in IOL power calculation better with iris-claw fixation than with transscleral fixation.[8] Therefore, the purpose of this study was to evaluate refractive outcome, anatomical outcome, and complications of PC iris-claw aphakic IOL implantation after pars plana vitrectomy.


  Materials and Methods Top


A retrospective analysis of consecutive 25 eyes of 25 patients (12 males and 13 females) without capsular support, in which we performed PC iris-claw implantation after pars plana vitrectomy. Patients with aphakia and no capsular support following pars plana vitrectomy from January 2015 to May 2016 were included in this study. The primary indication for pars plana vitrectomy was (a) intraocular foreign body (IOFB), (b) lens drop (trauma/surgical complication), (c) IOL drop (trauma/surgical complication), and (d) traumatic RD/vitreous heam with proliferative vitreoretinopathy.

Iris-claw implantation was further divided into two groups: Group A – primary procedure where iris-claw implantation was done along with vitrectomy or Group B - secondary procedure where implantation was done later after an interval of vitrectomy. Posterior vitrectomy procedures were performed with 23- or 25-gauge techniques. Inclusion criteria were aphakia without capsular support, intact iris diaphragm, and no intraocular silicone oil and attached retinas. Exclusion criteria were large iris defects, chronic uveitis, proliferative diabetic retinopathy, and retinal disorders (macular scars and cystoid degenerations).

At presentation, clinical and demographic features (such as age, gender, and etiology of aphakia) of the patients were noted. IOP which measured with Goldmann applanation tonometry, Snellen's best corrected visual acuity (BCVA), spherical equivalent (SE), slit-lamp biomicroscopy examination, and fundus examination were evaluated preoperatively and at 1st week, 1st month, and 3rd month postoperatively by the same examiner.

Surgical procedure

Iris-claw IOL used was a single piece, nonfoldable biconvex, polymethyl methacrylate IOL of 5.0 mm optic and 8 mm or 9 mm overall length [Figure 1].
Figure 1: Iris-claw intraocular lens

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Lens power was calculated by optical biometry using the IOL Master version 5 (Carl Zeiss Meditec, Jena, Germany), with an A-constant of 115.0. The optic power was calculated using the SRK/T formula with the aim of achieving emmetropia. All patients had a pars plana vitrectomy through a standard 23-gauge or 25-gauge transconjunctival system using a CONSTELLATION Vision system (Alcon Laboratories, Inc.). The vitrectomy was performed using a RESIGHT 500 Fundus viewing system. After systematic posterior detachment of the vitreous, the vitrectomy was performed up to the extreme periphery to limit the risk for traction during extraction of the dislocated material. All patients were operated on under general or local anesthesia. In cases of nucleus dislocation or a lens fragment, the vitrectomy was followed by ablation of the dislocated material using a phaco fragmatome in patients with a high-density fragment or a vitreous cutter if the fragments were soft. When a fragmatome was used in a 23-gauge approach, superior sclerotomy on the right side was widened using a 20-gauge myringo-vitreal-retinal knife and sutured at the end of the procedure. If the IOL was dislocated in the vitreal cavity, complete vitrectomy was followed by opening the AC, which was filled with an ophthalmic viscosurgical device (OVD). This was followed by explantation of the lens raised in the AC using a membrane forcep extracted through a 6.0 mm beveled corneal incision. Superior peripheral iridectomy was performed in all using vitreous cutter. After verification of the retinal periphery with the widefield lens system, the two superior sclerotomies were closed temporarily. The infusion was left in place and set at a lesser flow to stabilize the IOP during implantation. Intracameral pilocarpine was used to constrict the pupil. The OVD was injected into the AC to protect the corneal endothelium. Two paracenteses were created at the 3 o'clock and 9 o'clock positions. The IOL was inserted through a 6.0 mm corneal incision centered on the 12 o'clock position and then rotated to align on the horizontal position. Using a lens-fixation forceps, the posterior iris-claw IOL was slipped through the pupillary area and then centered over the pupil behind the iris. At the same time, through the paracentesis, an IOL dialer was used for enclavation of the iris by applying gentle pressure over it through the slotted center of the IOL haptic. Then, hands were switched, and the same maneuver was performed through the other paracentesis. The AC was cleared of all OVD at the end of the intervention. The corneal incision was sutured using 10-0 nylon. Sclerotomies and conjunctiva were sutured with 8-0 polyglactin (Vicryl). At the end of surgery, betamethasone and gentamycin were injected subconjunctivally. All the patients were prescribed prednisolone acetate and moxifloxacin drop four times/day.

Statistical analysis

All the data were analyzed using MEDCALC version 12.5 program. Data were expressed as a mean ± standard deviation. Afterward checking if the data have a normal distribution, paired samples t-test was used to compare the pre- and postoperative parameters. Statistical significance was set at P < 0.05.


  Results Top


A total of 25 eyes of 25 aphakic eyes (12 males and 13 females) without capsular support had implanted PC iris claw after pars plana vitrectomy. Group A (pupillary iris claw lens were implanted in the same procedure along with vitrectomy) was 15 (60%) eyes and Group B (later in a different procedure, following vitrectomy) was 10 (40%) eyes. Mean age for Group A was 62.3 years (range: 21–78 years) and for Group B was 60.1 years (range: 19–80 years) and the mean follow-up was 4.12 months (range: 1 to 12 months) with minimal follow-up of 3 months.

In the Group A of 15 eyes, in which pupillary iris-claw lens was implanted in the same procedure along with vitrectomy, 6 (40%) eyes had lens dislocation (5 dislocations were caused following trauma and 1 dislocation following surgery). Seven (46.67%) eyes had IOL dislocation (three were caused following trauma and four dislocations following surgery). Two (13.3%) had traumatic RD. Thus, a total of 10 (66.67%) eyes of the 15 had a history of trauma [Figure 2].
Figure 2: Causes for iris claw lens implantation in Group A

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Similarly, in the Group B where iris-claw lens implantation was done later in a different procedure, following vitrectomy of ten eyes, five (50%) eyes had lens dislocations (four had dislocation following trauma and 1 following surgery). Two (20%) eyes had IOL dislocation (one following trauma and one following surgery). Two eyes (20%) underwent iris claw implantation having a history of pars plana vitrectomy with metallic IOFB removal. One (10%) eye had implantation following traumatic RD surgery with vitreous hemorrhage. Thus, of the ten eyes in Group B, a total of eight (80%) eyes had a history of trauma [Figure 3]. In this group, the mean age for implantation of iris-claw lens was 2.3 months after the primary procedure (range: 1–7 months).
Figure 3: Causes for iris claw lens implantation in Group B

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Best-corrected visual acuity

When evaluating the BCVAs in both groups, there was an improvement on subsequent follow-ups with statistically significant increase when compared with preoperative seen in the 3rd month, also significant improvement was noted at 3rd month compared with 1st month postoperative in both the group values (P < 0.05) [Table 1] and [Table 2]. Visual acuity improvement of ≥20/40 (0.3 LogMAR) was seen in 13 eyes (86.66%) in Group A and 7 eyes (70%) in Group B. Between-group comparisons of the best-corrected visual acuity values were not significant [Table 3].
Table 1: BCVA improvements at 1st month, 1 month and 3rd month

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Table 2: Intra group BCVA comparisons at 1st week, 1 month and 3rd month

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Table 3: Inter group BCVA comparisons at 1st week, 1 month and 3rd month)

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Refractive outcomes

Mean SE was 10.88 ± 0.812 D in Group A and 10.725 ± 1.591 D in Group B preoperatively. When evaluated postoperatively, SE decreased to −0.18 ± 0.734/−0.307 ± 0.86 in Group A and B, respectively, at 3rd month postoperatively. There was statistically significant decrease when compared to the preoperatively and for each 1st week, 1st, 3rd month values (P < 0.05); however, these decreases were stabilized since 1st week postoperative. Similar to BCVA, between-group comparisons, SE values were not significant [Table 4], [Table 5], [Table 6].
Table 4: Spherical equivalent decrease at 1st month, 1 month and 3rd month

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Table 5: Intra group spherical equivalent comparisons at 1st week, 1 month and 3rd month

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Table 6: Inter group BCVA comparisons at 1st week, 1 month and 3rd month

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Complications

  1. Intraoperative: AC collapse was not seen in any of the groups. Moderate hyphema occurred after iridectomy in two patients (Group A) which resolved spontaneously over 1 week with symptomatic treatment
  2. Postoperative complications: Intraocular pressure (IOP) – There was no statistically significant difference in the mean IOP levels during subsequent follow-ups from the baseline (P = 0.0612). Further IOP increase was seen in a total of 3 (12%) eyes (2 [13%] Group A and 1 [10%] Group B). This IOP was controlled with topical antiglaucoma drugs (timolol/dorzolamide). Postoperative uveitis was seen in 4 (16%) eyes (3 [20% Group A] and 1 [10% Group B]) during the 1st-month follow-up which adequately resolved over 2–3 weeks with topical steroids and cycloplegics. There was no recurrence seen on subsequent follow-up. Pupillary distortions were seen in 6 (24%) eyes (4 [26.7%] Group A and 2 [20%] Group B). Disenclavation of iris-claw lens was not seen in any groups. Corneal edema was also not observed in any patients. CME was seen in 1 (4%) eye (Group A) – at 2-month postoperative which resolved with topical anti-inflammatory eye drops over 1 month. Postoperative vitreous hemorrhage in 1 (4%) eye resolved spontaneously (Group A). Retina was attached in all cases.



  Discussion Top


In our study, posterior iris-claw lens implantation in vitrectomized eyes showed good efficacy in visual outcomes and low complications. In both the respective Group A and Group B, there was significant improvement in vision (P < 0.05) after surgery. Further intergroup comparisons of final visual outcomes and refractive outcomes were not significant. Thus, it can be deduced that simultaneous iris-claw lens implantation in aphakic postvitrectomized eyes is equally effective as delayed implantation yielding excellent refractive results. Further combined implantation and vitrectomy also reduce the number of interventions for the patient and provide faster visual rehabilitation by correcting aphakia earlier. In our study, trauma was the most common etiologic factor which resulted in aphakia in 18 (72%) eyes (66.67% - Group A and 80% - Group B) as compared to a study by Labeille et al.[9] which had 54% complicated cataract and only 22% trauma as etiology. In our study, the improvement in BCVA of ≥20/40 (0.3 LogMAR) was seen in a total of 20 (80%) eyes (86.67% - Group A and 70% - Group B) which was higher as compared to a study by Labeille et al. (68.8%)[9] and comparable to a study by De Silva et al.(88.7%).[10] Operative complications of intraoperative AC collapse and related complications were not seen as infusion pump maintained the chamber. The postoperative complication rate in our patients was comparable to rates published in other series and are generally related to a preexisting eye disease or predisposing factor rather than to the IOL implantation itself. IOP rise was seen in 3 (12%) eyes (2 [13%] Group A and 1 [10%] Group B) but was not significant. This rise could be because of steroid use in the postoperative period. Further prophylactic iridectomy done in all our cases would have helped to keep the intraocular pressure under normal limits. Therefore, we recommend to systematically performing an intraoperative, peripheral iridectomy in all cases, and thorough anterior vitrectomy if vitreous is present in the AC. Although IOL disenclavation or dislocation is frequently mentioned in studies of iris-claw IOLs, these complications were not seen in our study. Pupillary distortions seen in six (24%) eyes improved with subsequent follow-ups and did not require any interventions. Complications of RD were not seen in any case. The nonrandomized nature of the study, few sample size, and the relatively short follow-up are limitations of our study. Further measurements of endothelial cell loss in posttraumatic aphakic IOL implantation were not included in our study so more surgical precaution seems to be required. Studies with a larger number of patients and a longer follow-up are needed to determine the long-term visual outcomes, endothelial cell count, and probable long-term complications.


  Conclusion Top


PC iris-claw IOL implantation in aphakic eyes without capsular support in postvitrectomized is an effective, predictable, and safe procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dadeya S, Kamlesh, Kumari Sodhi P. Secondary intraocular lens (IOL) implantation: Anterior chamber versus scleral fixation long-term comparative evaluation. Eur J Ophthalmol 2003;13:627-33.  Back to cited text no. 1
    
2.
Hara S, Borkenstein AF, Ehmer A, Auffarth GU. Retropupillary fixation of iris-claw intraocular lens versus transscleral suturing fixation for aphakic eyes without capsular support. J Refract Surg 2011;27:729-35.  Back to cited text no. 2
    
3.
Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S, et al. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg 2008;34:1433-8.  Back to cited text no. 3
    
4.
Höh H, Ruprecht K, Nikoloudakis N, Palmowski A. Preliminary results following implantation of iris-suture-fixated posterior-chamber lenses. Ger J Ophthalmol 1993;2:70-5.  Back to cited text no. 4
    
5.
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. 5
    
6.
Hsing YE, Lee GA. Retropupillary iris claw intraocular lens for aphakia. Clin Exp Ophthalmol 2012;40:849-54.  Back to cited text no. 6
    
7.
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. 7
    
8.
Patil KB, Meleth P, Shanker MP. Pars plana vitrectomy with posterior iris claw implantation for posteriorly dislocated nucleus and intraocular lens. Indian J Ophthalmol 2011;59:497-500.  Back to cited text no. 8
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9.
Labeille E, Burillon C, Cornut PL. Pars plana vitrectomy combined with iris-claw intraocular lens implantation for lens nucleus and intraocular lens dislocation. J Cataract Refract Surg 2014;40:1488-97.  Back to cited text no. 9
    
10.
De Silva SR, Arun K, Anandan M, Glover N, Patel CK, Rosen P, et al. Iris-claw intraocular lenses to correct aphakia in the absence of capsule support. J Cataract Refract Surg 2011;37:1667-72.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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