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 Table of Contents  
SURGICAL CORNER
Year : 2020  |  Volume : 32  |  Issue : 1  |  Page : 66-69

CM T - FLEX IOL an innovative design for subluxated lens secondary to trauma


Department of Vitreoretina, M. N Eye Hospital, Tondiarpet, Chennai, Tamil Nadu, India

Date of Submission09-Nov-2019
Date of Acceptance21-Dec-2019
Date of Web Publication17-Apr-2020

Correspondence Address:
Dr. P A. P. Aysha
M. N Eye Hospital, 781th Road, Tondiarpet, Chennai - 600 021, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_77_19

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  Abstract 

Here, we report a case of a 42-year-old male who came with complaints of blurring of vision in the left eye since 3 months which was progressive in nature. He gave a history of road traffic accident 7 months back following which he developed defective vision. On examination, his unaided visual acuity in the right eye was 6/9 and left eye was 3/60 with pinhole improvement of 6/9 and subluxated cataractous lens in the left eye. He was managed with pars plana lensectomy, vitrectomy, and new foldable Acryflex-T intraocular lens (IOL) (CM T-FLEX) scleral fixated IOL. Two partial-thickness limbal-based scleral flaps of 2.5 mm × 2.5 mm were created 180° apart; sclerotomies were made using 23 gauge needle 1.5 mm away from the limbus. The new Acryflex T–Flex IOL implantation was performed through the 2.8 mm clear corneal incision, and specially designed T-shaped IOL haptics were externalized with the 23 gauge PraNiv T Flex forceps under the scleral flap. Fibrin glue was used to close the scleral flaps and conjunctiva. Postoperative period was uneventful; at the end of 1-month, the patient regained a best-corrected visual acuity of 6/6 with good stable centration of IOL.

Keywords: CM T Flex intraocular lens, lens dislocation, lensectomy, suturelessintrascleral fixation, trauma, vitrectomy


How to cite this article:
Nivean M, Nivean P, Nishanth S, Aysha P A. CM T - FLEX IOL an innovative design for subluxated lens secondary to trauma. Kerala J Ophthalmol 2020;32:66-9

How to cite this URL:
Nivean M, Nivean P, Nishanth S, Aysha P A. CM T - FLEX IOL an innovative design for subluxated lens secondary to trauma. Kerala J Ophthalmol [serial online] 2020 [cited 2020 May 28];32:66-9. Available from: http://www.kjophthal.com/text.asp?2020/32/1/66/282660




  Introduction Top


The management of subluxated lenses has remained a controversial issue for many years. Jarrett retrospectively analyzed the indications for surgical intervention in a series of 114 cases of subluxated or dislocated lenses.[1] Both intracapsular and extracapsular cataract extraction have been documented for the management of subluxated lenses. Techniques used include discission, aspiration, and cryoextraction.[2] Recently, several authors have reported using pars plana lensectomy for subluxated lenses with good surgical outcome.[3],[4] In recent years, transscleral suture fixation of posterior chamber intraocular lens (IOL) has become an alternative to anterior chamber IOL (ACIOL) implantation in eyes lacking capsular support.[5] Sutured scleral fixated IOLs (SFIOLs) have been used for over 3 decades with good outcomes,[6] albeit at a risk of suture disintegration over the long term. Recently, sutureless SFIOLs have become popular and can be fixated using different techniques such as the Scharioth's technique,[7] Agarwal's glued SFIOL,[8] Yamane's double flange technique,[9] or Baskaran's X-Nit technique.[10] Many modifications of these techniques have also been described using needles, trocars, flaps, sutures, and glue. Iris fixated IOLs, including haptic suturing to the iris stroma and retropupillary iris-claw IOL placement, has also been described with results similar to sutureless SFIOLs. However, the scleral fixation of an IOL can also lead to many complications, such as a decrease in the corneal endothelial cell density,[11],[12] refractive error after surgery,[13] IOL dislocation, vitreous hemorrhage, infection through the suture,[14] and retinal detachment.


  Case Report Top


A 42-year-old male presented to our hospital with a complaints of blurring of vision of 3 months' duration in the left eye. He gave a history of road traffic accident 7 months back. On ocular examination, best-corrected visual acuity in the right eye was 6/9 and N6 and left eye was 3/60 which is improving with pinhole to 6/9. On slit-lamp examination, right eye was normal and left eye showed inferior corneal opacity of 1 × 1 mm with vitreous in AC, mid dilated pupil and subluxated lens [Figure 1]. Fundus examination of both eyes was normal.
Figure 1: Preoperative picture

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The patient was planned for pars plana lensectomy, vitrectomy, and foldable hydrophilic CM T-FLEX SFIOL in the left eye.

Preoperative workup such as axial length, keratometry, intraocular pressure, pachymetry, anterior segment optical coherence tomography, specular microscopy and biometry was done using SRK T Formula and A constant 118.0 with target refraction of emmetropia.

Written consent for the surgery was taken.

Under peribulbar anesthesia using the Ashwin Glued IOL marker 0°–180° was marked. This is the important step as it ensures the centration and torsional stability of the IOL. Conjunctival peritomy was done on either side and bipolar cautery used to cauterize the bleeders. Two partial-thickness limbal-based scleral flaps about 2.5 mm × 2.5 mm created on either side of the markings. A 23 gauge trocar was placed in the inferotemporal quadrant for the infusion to prevent hypotony during procedure and through the side port dilute triamcinolone acetonide injected and anterior vitrectomy was performed. Two sclerotomies with 23 gauge needle are made from 1.5 mm from the limbus on either side under the sclera flap. A 2.8mm clear corneal incision is made using the keratome; the new CM T flex IOL which is a foldable hydrophilic lens with a specialized T-shaped haptics was loaded in the cartridge and placed in the injector [T Flex [Figure 2]. The IOL is injected through the cornea gently so that T junction of the IOL comes out first which makes it easy to grasp using the specially designed PraNiv T flex forceps through one sclerostomy site; usually, the head or the neck is grasped and then the IOL is injected gently so that trailing haptic is kept at the wound, now the forceps is gently brought through the sclerostomy and then we can see the pop after pull of the T -flex (PAP-Maneuver). Now, using the NiShi grasping forceps through the side port the arm of the IOL is held and using the handshake technique the T junction is transferred to the second forceps and brought out through the other sclerostomy site. AC is formed by air bubble, the infusion cannula is removed, sclera bed is made dry and fibrin glue is used to seal the sclera flap and conjunctiva [Figure 3].
Figure 2: CM T - FLEX intraocular lens

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Figure 3: Surgical steps

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On postoperative day 3, cornea was clear with mild congestion of the conjunctiva covering the flap and AC showed 1+ cells and flare, iris was round and regular and stable T flex IOL in situ [Figure 4]. At the end of the 1st month, unaided visual acuity was 6/18 (P), which is improving to 6/6 with −2.75DS with normal conjunctiva over the sclera flap with clear cornea and quiet AC [Figure 5] and well-positioned T flex IOL as shown in ultrasound biomicroscopy [Figure 6].
Figure 4: Day 3 postoperative picture

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Figure 5: First month postoperative picture

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Figure 6: Ultrasound biomicroscopy showing well-centered T Flex intraocular lens

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  Discussion Top


All types of ocular trauma can lead to lens damage-causing traumatic cataract, traumatic subluxation of lens, with or without posterior capsular damage or zonular dialysis. In such situations, most of the cases will not have adequate capsular/zonular support to implant a posterior chamber IOL in the bag or the ciliary sulcus. In such cases, an IOL can be placed in the AC, as closed or open-loop ACIOLs, in iris as retro-iris-fixated IOLs and with sutures or sutureless (Glued) trans-SFIOL. There are high risks of severe corneal endothelial cell loss, chronic low-grade uveitis in cases with implanted ACIOL and iris fixated IOL.[15]

We present here in our first experience with injector implantation of foldable CM T FLEX IOL for scleral fixation. It is made up of hydrophilic material which contains 26% water with a refractive index of 1.460. The optical diameter of CM T Flex IOL is 6.00 mm and overall diameter is 13.75 mm. The angulation of IOL is 10° with a constant of 118.0.

The main advantage of this IOL is it has a T shaped design which can be brought out through the 23 gauge sclerostomy site and left under the sclera bed. There is no need of any haptic tuck and suturing, so this makes the procedure surgically easier and less time consuming and less trauma to the ocular tissue.

Kim et al. described their technique in which haptics was externalized through two adjacent corneal incisions and tied with 10/0 polypropylene suture with ab externo needle passing.[16] Their modified technique is a safe and effective but is time consuming.

Surgical treatment of aphakia with one-piece IOL may be complicated by some factors caused by limited design of the lens, such as lack of haptic angulation, bulky haptics, and sharp square edges of both haptic and optic. This condition might increase the risk of posterior iris touch and consequently iris pigment dispersion glaucoma or iris atrophy. Even so, other implant types such as iris suturing or iris enclavation may also cause these complications.[17]

Based on our experience, we would like to provide ophthalmic surgeons a simple and effective technique for secondary implantation of foldable CM T FLEX IOL through a 2.8 mm incision without using tucking or sutures for haptic externalization. This can be used in complicated cataract surgery, where inthebag IOL implantation IMPOSSIBLE.


  Conclusion Top


This new CM T flex hydrophilic foldable IOL is a good option for treating subluxated. This new specialized design does not need tucking or suturing of the haptics which makes the procedure easier, less time consuming, and minimal tissue handling leading to better postoperative results. Being hydrophilic the manoeuvre in the AC is easy, the angulation between the optic and haptic makes the position behind the iris thus not restricting the pupillary dilatation or causing any pupillary block glaucoma. The sclera flaps are closed with glue so this makes totally sutureless surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jarret WH. Dislocation of lens. Arch Ophthalmol 1967;78:289.  Back to cited text no. 1
    
2.
Jensen AD, Cross HE. Surgical treatment of dislocated lenses in the Marfan syndrome and homocystinuria. Trans Am Acad Ophthalmol Otolaryngol 1972;76:1491-9.  Back to cited text no. 2
    
3.
Malbran ES, Croxatto JO, D'Alessandro C, Charles DE. Genetic spontaneous late subluxation of the lens. A study of two families. Ophthalmology 1989;96:223-9.  Back to cited text no. 3
    
4.
Girard LJ, Canizales R, Esnaola N, Rand WJ. Subluxated (ectopic) lenses in adults. Long-term results of pars plana lensectomy-vitrectomy by ultrasonic fragmentation with and without a phacoprosthesis. Ophthalmology 1990;97:462-5.  Back to cited text no. 4
    
5.
Sellyei LF Jr., Barraquer J. Surgery of the ectopic lens. Ann Ophthalmol 1973;5:1127-33.  Back to cited text no. 5
    
6.
Sindal MD, Nakhwa CP, Sengupta S. Comparison of sutured versus sutureless scleral-fixated intraocular lenses. J Cataract Refract Surg 2016;42:27-34.  Back to cited text no. 6
    
7.
Gabor SG, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2007;33:1851-4.  Back to cited text no. 7
    
8.
Narang P, Agarwal A. Glued intrascleral haptic fixation of an intraocular lens. Indian J Ophthalmol 2017;65:1370-80.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology 2017;124:1136-42.  Back to cited text no. 9
    
10.
Baskaran P, Ganne P, Bhandari S, Ramakrishnan S, Venkatesh R, Gireesh P. Extraocular needle- guided haptic insertion technique of scleral fixation intraocular lens surgeries (X-NIT). Indian J Ophthalmol 2017;65:747-50.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Ohtani S, Miyata K, Ono K. Outcome of sulcus fixation of the posterior chamber lens. Jpn J Clin Ophthalmo 2000;54:531-5.  Back to cited text no. 11
    
12.
Krause L, Bechrakis NE, Heimann H, Salditt S, Foerster MH. Implantation of scleral fixated sutured posterior chamber lenses: a retrospective analysis of 119 cases. Int Ophthalmol. 2009;29:207-12.  Back to cited text no. 12
    
13.
Tsuiki E, Taniguchi H, Kitaoka T. Evaluation of transscleral fixation of intraocular lens. Ganka Rinsyo Ihou 2004;98:1077-80.  Back to cited text no. 13
    
14.
Choi KS, Park SY, Sun HJ. Transscleral fixation by injector implantation of a foldable intraocular lens. Ophthalmic Surg Lasers Imaging 2010;41:272-5.  Back to cited text no. 14
    
15.
Narang P, Narang S. Glue-assisted intrascleral fixation of posterior chamber intraocular lens. Indian J Ophthalmol 2013;61:163-7.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Kim SJ, Lee SJ, Park CH, Jung GY, Park SH. Long-term stability and visual outcomes of a single-piece, foldable, acrylic intraocular lens for scleral fixation. Retina 2009;29:91-7.  Back to cited text no. 16
    
17.
Wagoner MD, Cox TA, Ariyasu RG, Jacobs DS, Karp CL; American Academy of Ophthalmology. Intraocular lens implantation in the absence of capsular support: A report by the American Academy of Ophthalmology. Ophthalmology 2003;110:840-59.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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