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Alternative posterior iris IOL fixation offers advantages, surgeon says
The natural pressure of the aqueous humor ‘squeezes’ the IOL against the posterior surface of the iris, preventing tilt and glare.
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FLORENCE – An alternative technique of IOL fixation on the posterior surface of the iris offers several advantages in some cases, according to one surgeon speaking at the Florence Symposium.
Cesare Forlini, MD, showed on video how this technique – which was first developed by Andreas Mohr, MD – can be used in aphakic patients when anatomical damage prevents IOL implantation in the bag or in the ciliary sulcus.
In case 1, retinal detachment and IOL subluxation had occurred after ocular trauma. This highly myopic patient had been previously treated with PRK. Endoscopic examination via the pars plana explained the cause of subluxation.
“Thanks to endoscopy we recognized that the cause was a traumatic rupture of the haptic of the IOL, and so we excluded the possibility of repositioning the dislocated IOL and evaluated two alternative strategies. Scleral fixation of a new posterior chamber IOL would have required a series of fairly complicated intraocular maneuvers, while iris fixation appeared to be safer and easier to perform in combination with vitreoretinal surgery,” Dr. Forlini said.
Vitrectomy was performed with the use of triamcinolone acetonide and replacement of the vitreous body by a silicone oil tamponade. Then a standard Ophtec/Advanced Medical Optics Artisan/Verisyse iris-fixated lens was introduced with forceps through a 4.5-mm corneal incision at 12 o’clock. The lens was then gently pushed through the dilated pupil and positioned on the posterior iris surface.
“Through the anterior surface of the iris, you can see the shape of the lens, feel where the holes of the haptics are positioned and achieve the enclavation by pushing the iris through them with a hook or a Barraquer spatula,” Dr. Forlini said.
In case 2, an iris-fixated IOL was implanted in a patient after posttraumatic luxation of the lens nucleus into the vitreous body.
“After phacoemulsification and vitrectomy were performed via pars plana, we inserted the Artisan/Verisyse IOL through a temporal incision, positioned it on the posterior iris plane and enclavated it with a hook. Since the rim of the pupil had been damaged by the trauma, we performed a pupilloplasty using 10-0 prolene sutures,” he explained.
Results were satisfactory in both patients. The lenses were stable in the eye and ensured optimal recovery of vision.
| Case 1. Posttraumatic subluxation of IOL in a highly myopic patient with retinal detachment | |
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| Case 2. Luxation of the lens nucleus into the vitreous body | |
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Several advantages
Dr. Forlini said that in this method of implantation, the most crucial step is the centration and enclavation of the lens.
“In case you realize intraoperatively that the lens is not perfectly centered, you can disenclavate the lens with the same spatula you used for the insertion, reposition it and carry out the enclavation procedure again,” he said.
Although it is not strictly necessary, endoscopy is a helpful in the procedure, as it provides visualization of the internal conditions of the eye before surgery to assist in deciding the best approach and the intermediate and final control of IOL positioning, he said.
Dr. Forlini said posterior fixation offers several advantages. The lens is stable because the tamponade or the natural pressure of the aqueous humor “squeezes” the IOL against the posterior surface of the iris, preventing tilting of the lens and glare.
In a young patient who had been previously implanted with a phakic Artisan lens in the traditional position on the anterior surface of the iris, the lens was reimplanted on the posterior surface after a trauma.
“The subjective perception of a better quality of vision was immediate. The patient said he had less glare and more stable vision. In addition, he was happy with the better cosmetic appearance of the IOL in this almost invisible position, which also reduced the characteristic reflex of the lens optic, which is visible at short distance,” Dr. Forlini said.
“If it is possible, as shown in the two cases, this method could also be used in aphakic IOL secondary implantation together with accurate vitrectomy instead of scleral fixation,” he said.
For Your Information:
- Cesare Forlini, MD, is head of the ophthalmology department at Ravenna City Hospital. He can be reached at Presidio Ospedaliero Ravenna, Viale Randi 5, 48100 Ravenna, Italy; 39-0544-285376/270385; fax: 39-0544-280049; e-mail: forlinic@tin.it. Dr. Forlini has no direct financial interest in the products mentioned in this article, nor is he a paid consultant or employee for any companies mentioned.
- The Florence Symposium was the 10th Annual Joint Meeting of Ocular Surgery News, the Italian Association of Cataract and Refractive Surgery, the Italian Society of Ophthalmology and the International Society of Refractive Surgery held on May 12 and 13, 2005.
- Michela Cimberle is an OSN Correspondent based in Treviso, Italy.