Foldable scleral fixation IOL best choice, surgeon says

The new lens offers excellent ease of implantation, compliance and stability. Outcomes are optimized with the use of endoscopy.

Issue: May 1, 2003

ByMichela Cimberle

ROME – A new, foldable IOL for scleral fixation offers an alternative to rigid implants. It is equally stable but more adaptable and easier to implant in complicated cases of ocular trauma, according to Cesare Forlini, MD, head of Ravenna Eye Clinic, Italy.

The lens, which was presented at the winter meeting of the European Society of Cataract and Refractive Surgeons, is the Ultima, designed by Migliorati and Brusini (Udine, Italy) and produced by Corneal.

“I have used it in eight patients, and I have found it is a great improvement on rigid implants. Personally, I am going to adopt it as my only choice from now on,” Dr. Forlini said.

Lens with many advantages

The advantages of being foldable are many. The lens can be implanted through an incision of 4.2 to 4.5 mm.

“This is particularly important in eyes that have been or are going to be vitrectomized,” Dr. Forlini said. A reduced incision size prevents iris pigment dispersion, reduces astigmatism and the risk of infection.

The other main advantage is that in case of a narrow and rigid reconstructed pupil, which is not rare in traumatized eyes, the lens can be inserted easily, without reopening or straining the pupil.

“I have had one such case, and I was able to insert the lens through that very small aperture without any problem. Once unfolded, the lens found its perfect shape and position inside the eye,” he said.

The large diameter and all-round haptic design of the lens ensure a wide contact and a stable holding on the sclera, he added. All four holes in the haptics can be used for fixation, but two are usually sufficient.

“I have used a two-point fixation in all my cases, and I have obtained a perfect stability, saving surgical time,” he said.

The procedure for scleral fixation is similar to that used with rigid lenses. The lens is allowed to partially fall in the eye, and then captured by two predisposed sutures.

The hydrophilic acrylic lens material is particularly suitable for eyes where vitreoretinal problems may require the use of silicone oil.

“The lens can be used also in the first stages of surgery, with silicone oil still in the eye, because acrylic compounds don’t attract silicone,” Dr. Forlini said. “Surgical maneuvers, also at the level of the retina, can be carried out undisturbed. Moreover, thanks to its shape, the lens acts as a barrier to avoid silicone oil passage in the anterior chamber in cases of altered iris. Last, it is useful in post-traumatic cases because the lens fits any shape of the ciliary bodies, thus ensuring optimal centering and stability.”

Endoscopy optimizes results

In all his cases Dr. Forlini adopted an endoscopy-assisted surgical procedure, which he said is an invaluable help in treating traumatized eyes, where the anatomical structures have been upset in many unpredictable ways.

“Endoscopy should be used before surgery to evaluate the internal state of the eye and, consequently, the kind of implant to use. Thanks to it, we can make sure that what is left of the capsule at the level of the ciliary body is enough to allow for a safe fixation of the lens. We can also see where the best points for suturing the IOL are,” he said.

Intraoperatively, endoscopy optimizes surgical precision, and guides the surgical maneuvers to obtain a well-centered and stable fixation of the IOL.

“It’s no more a blind surgery, but a visible, controlled procedure at all stages,” Dr. Forlini said.

In case of secondary refractory glaucoma, which is not rare in heavily traumatized eyes, cyclodestruction of the ciliary body can be carried out. Also in this case, the endoscopic system is an effective instrument to evaluate the extension and the efficacy of the treatment.

First case: Post-traumatic aphakia and pupil reconstruction with multiple 10-0 prolene sutures. Endoscopic evaluation of the ciliary body before IOL implantation.	The sutures are passed through the lens loops.	The IOL is folded before implantation.
The IOL is inspected before implantation.	The IOL is implanted through a 4.5-mm incision in near-clear cornea.	Final control. The IOL has been implanted without any trauma through a narrow and rigid reconstructed pupil.

For Your Information:
Cesare Forlini, MD, is head of Ravenna Eye Clinic. He can be reached at Reparto Oculistico Ospedale Civile di Ravenna, V.le Randi 5, 48100 Ravenna, Italy; (39) 054-428-5376/285394; fax: (39) 054-421-7226/285307; 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 for any companies mentioned.
Corneal can be reached at 31 Rue des Colonnes, 75012 Paris, France; (33) 1-43-42-9393; fax: (33) 1-43-07-0190; e-mail: export@corneal.com.