Technique may decrease risk of corneal damage in explantation of iris implant

Micro-instruments and smaller incisions help to gently remove an iris color implant after significant ocular complications occur.

Issue: April 25, 2015

A “slicing the pie” technique with micro-instruments and smaller incisions may decrease the risk of damage to the corneal endothelium, angle and lens when explanting NewColorIris implants, according to the authors of the technique.

Complications of the NewColorIris implant (Kahn Medical Devices), which provides cosmetic alteration of iris color, include decreased vision, glaucoma, corneal edema, hyphema and anterior uveitis. In addition, severe intraoperative and postoperative complications have been associated with removing the implant. The implant is not FDA approved.

The modified technique decreases the risk of anterior chamber shallowing and further endothelial damage while minimizing implant manipulation compared with implant removal en bloc with larger incisions or a three-piece rotation, according to corresponding author Ike K. Ahmed, MD, FRCSC.

Ike K. Ahmed

“I think the whole concept of explanting [the implant] is to do it with a minimally traumatic technique and a small-incision minimally invasive technique, and that’s important,” Ahmed, an OSN Glaucoma Board Member, told Ocular Surgery News.

Technique

In the removal technique, the surgeon makes a 2-mm temporal wound and two paracenteses. A dispersive ophthalmic viscosurgical device (OVD) is inserted, followed by a cohesive OVD injection beneath the dispersive agent anterior to the implant to create a soft-shell OVD.

The implant is cut into three sections with radial cuts using a combination of micro-graspers and intraocular microscissors. After the first radial cut, the implant is rotated 3 clock hours before the second cut is made. The resulting section is then removed. Without further rotation, the third cut bisects the remaining segment, and each portion of the “pie” of the implant is removed.

The surgeon then evaluates the need for goniosynechialysis. The OVD is manually removed from the anterior chamber, and the incisions can be closed with 10-0 nylon sutures.

Continuing complications

Even after the implant is removed, some patients require additional treatment and secondary surgery because there is a still a risk of ongoing inflammation, corneal decompensation, glaucoma or cataract formation. Ahmed suggested monitoring patients after surgery every 6 to 12 months.

“These patients often require continuous evaluation indefinitely because they often have underlying permanent issues with corneal issues or glaucoma,” he said. “[These problems] are not necessarily one-time fixes; unfortunately, they can persist and be chronic, permanent problems.”

Complications from the implant have occurred immediately after surgery to as long as 9 years postoperatively. The amount of time that the implant is in has the potential to increase the difficulty and surgical risk of the explant due to adhesions or scar tissue that may form around the implant, increased trauma to the eye or an extremely damaged corneal endothelium, Ahmed said.

“Despite some of the complications that are already out there, I think that patients are still unfortunately going to have this procedure done,” he said. “We do not recommend that. More awareness is important.” – by Kristie L. Kahl

Reference:

Arjmand P, et al. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2013.12.027.

For more information:

Ike K. Ahmed, MD, FRCSC, can be reached at Credit Valley EyeCare, 3200 Erin Mills Parkway, Unit 1, Mississauga, Ontario L5L 1W8, Canada; email: ike.ahmed@utoronto.ca.
Disclosure: Ahmed reports no relevant financial disclosures.