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Retropupillary fixation of iris-claw lens offers alternative to scleral fixation of posterior chamber IOL
In the absence of capsular or zonular support, this method may be preferable to anterior chamber positioning or scleral fixation of a posterior chamber IOL.
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Retropupillary posterior iris fixation of an iris-claw IOL is a safe procedure and an effective option for aphakic eyes with no capsular or zonular support, according to a study.
“Ideally, IOLs are placed in the capsular bag, but there are eyes where this is not possible, such as congenital weakness of the lens zonules in various pathologies, trauma and surgical complications of cataract surgery,” Sreeni Edakhlon, MD, said at the World Ophthalmology Congress in Abu Dhabi.
Scleral fixation of a posterior chamber IOL is a common alternative, but it is a challenging technique, and the risk of complications such as IOL tilt and suture erosion is quite high, he said.
Iris-claw lenses, another option, are normally placed in the anterior chamber. However, the anterior chamber positioning of this as well as other IOLs has contraindications and entails a risk of endothelial damage.
Study
In a series of 100 eyes with inadequate capsular or zonular support, retropupillary fixation of the iris-claw lens was performed following cataract surgery. The lens was introduced into the anterior chamber through a 5.5-mm scleral tunnel incision. Viscoelastic was injected at each stage to deepen the anterior chamber and maintain space.
“Holding the optic with a lens forceps, I tilted one haptic down and pushed it under the iris. The haptic was then pushed up to tent the iris, and then using a straightened Sinskey hook, I pushed down the tented iris into the haptic claw, enclavating it. A similar maneuver was performed to enclavate the other haptic,” Edakhlon explained.
Preoperative Nd:YAG peripheral iridotomy or intraoperative peripheral iridectomy was performed in all cases. Automated anterior vitrectomy was performed in all eyes prior to implantation of the IOL.
The lens used was a PMMA IOL (Model No. PIC 5590, Excel Optics) with an overall diameter of 9 mm, an optic diameter of 5.5 mm and an estimated A-constant of 117.
Results
Follow-up was 3 years. In all eyes, postoperative best corrected visual acuity was equal or better than preoperative BCVA. There was no significant inflammation or IOP increase in any eyes. Pigment deposits on the IOL were found in 12 eyes. All the IOLs were well centered, Edakhlon said.
Disenclavation of one of the haptics occurred in two eyes in the early postoperative period because insufficient tissue had been incarcerated. Re-enclavation was successfully performed using the same technique as the primary procedure, ensuring that sufficient iris tissue was tucked in the claw.
“This technique has all the advantages of posterior chamber implantation,” Edakhlon said. “It is relatively easy to perform and has such a low risk profile that it is reasonable to think that it might replace scleral fixation as a method of choice for eyes with no capsular or zonular support.” – by Michela Cimberle
For more information:
Sreeni Edakhlon, MD, can be reached at Comtrust Eye Care Hospital, City Centre, Thalassery 670101, Kerala, India; +91 989 5618170; email: edakhlon@yahoo.com.
Disclosure: Edakhlon has no relevant financial disclosures.
Perspective
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Cesare Forlini, MD
I agree with my colleague in saying that posterior fixation of an iris-claw lens is the best, easiest and quickest technique of IOL implantation in the absence of adequate capsular support. I have used this method for more than 10 years now, and I have nearly abandoned scleral fixation or anterior IOL implantation.It is a safe and effective technique that provides an immediate solution to complicated cataract cases. The incidence of inflammatory reactions is extremely low and the patient can leave the operating room with just topical medications.
Vitrectomy, via the limbal approach in most cases, and complete removal of the residual capsule are necessary to thoroughly clean the ciliary body area. Further research to develop specific, foldable lens models is desirable to reduce the incision size for less induced astigmatism.
This is in my opinion the gold standard in the microincision vitrectomy surgery era, because we do not need to open the conjunctiva.
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