|Year : 2023 | Volume
| Issue : 1 | Page : 7-12
Retropupillary iris-claw lens: Helpful or not?
Rahul Singh1, Divya Ramraika2, Seemee Kapadia1, Saket Agrawal3, Moon Ramraika4
1 Department of Ophthalmology, LNCT Medical College and SEVAKUNJ Hospital, Indore, Madhya Pradesh, India
2 Department of Ophthalmology, Atal Bihari Vajpayee Government Medical College, Vidisha, Madhya Pradesh, India
3 Private practioner, Agrawal eye clinic, Mandla, Madhya Pradesh, India
4 PGMO, Department of Orthodontics, District Hospital, Damoh, Madhya Pradesh, India
|Date of Submission||04-Jan-2023|
|Date of Acceptance||30-Mar-2023|
|Date of Web Publication||28-Apr-2023|
DOMS, DNB Ophthalmology Divya Ramraika
Senior Resident, Department of Ophthalmology, Atal Bihari Vajpayee Government Medical College, Vidisha, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Aim: To evaluate the preoperative and intraoperative indications, postoperative complications, incidence of secondary glaucoma, and visual outcome in patient who underwent iris-claw implantation during cataract surgery and effect of vitrectomy on postoperative intraocular pressure (IOP). Material and Methods: A retrospective study was conducted from January 2016 to February 2020. One hundred eighty-seven eyes of 187 patients who underwent iris-claw lens implantation, with minimum 1 month follow-up, were included in the study. Analysis of records was done for preoperative, intraoperative findings and was recorded and postoperative best corrected visual acuity (BCVA) and IOP were noted in each follow-up. Results: Mean preoperative BCVA of 187 eyes was 1.78 logMAR (SD 0.68), which increased to 0.61 ± 0.50, 0.36 ± 0.26, 0.21 ± 0.16 logMAR at postoperative day 1, day 7, and 1 month, respectively. Most common indications included phacodonesis (17.65%), small dilating and nondilating pupil (11.22%), zonular dialysis (6.41%), and pseudoexfoliation in (4.81%). Few patients (6.94%) had preexisting corneal pathologies which lend up in intraoperative complications that lead to iris-claw implantation. Mean IOP in vitrectomized eye after 1 month was 15.53 (SD 2.16) mm Hg and those of nonvitrectomized was 16 (SD 1.90) mm Hg. Posterior capsular rent and whole capsular bag loss were the most common intraoperative indications. Incidence of secondary glaucoma was 2.13%. Irregular pupil was the most common anterior segment finding at 1 month postoperatively. Conclusion: Retropupillary iris-claw implantation is one of the safe and least complicated methods of managing intraoperative complications which gives good visual acuity and prevent patient from the trauma of multiple surgeries.
Keywords: Retropupillary iris claw lens, cataract, secondary glaucoma
|How to cite this article:|
Singh R, Ramraika D, Kapadia S, Agrawal S, Ramraika M. Retropupillary iris-claw lens: Helpful or not?. MAMC J Med Sci 2023;9:7-12
|How to cite this URL:|
Singh R, Ramraika D, Kapadia S, Agrawal S, Ramraika M. Retropupillary iris-claw lens: Helpful or not?. MAMC J Med Sci [serial online] 2023 [cited 2023 Jun 4];9:7-12. Available from: https://www.mamcjms.in/text.asp?2023/9/1/7/375329
| Introduction|| |
Management of various intraoperative complications is a daunting task during cataract surgery and when it comes to complex cataracts which have higher chances of aphakia, it becomes more difficult to manage the complications and implant an appropriate intraocular lens (IOL) to avoid multiple surgeries and provide best visual rehabilitation to the patient.
The basic protocol of cataract surgery is implantation of IOL in the capsular bag. When IOL is placed in capsular bag, it is likely to be in physiological state which is closest to the nodal point of the eye. But for the eye which has congenital or acquired zonular weakness, zonular dehiscence more than 180 degree or traumatic dislocation or subluxation of lens, aphakia following congenital cataract surgery, and in complex cataract which has inadequate posterior capsular support, implantation of IOL in the bag is not possible.
Surgical options available are anterior chamber IOLs (ACIOLs), iris-claw IOLs (anterior- & posterior-fixated), and scleral-fixed IOLs (SFIOLs).
ACIOL implantation is an easy surgical procedure but has the risk of increased corneal endothelial loss, corneal decompensation, cystoid macular edema (CME), retinal detachment (RD), uveitis, secondary glaucoma, iris chafing, and poor pupillary dilatation.
SFIOLs are placed at the anatomical position of the lens but it’s a long and tedious surgical procedure and requires a skilled surgeon trained for it. Sutures degenerate in long term leading to tilting, decentration, or dislocation of the IOL into the vitreous cavity,,, choroidal hemorrhage, RD, and CME. Sutures can also cause irritation and granuloma formation.
In glued SFIOLs, flaps made in sclera and haptics of IOL are tucked in those flaps. It is associated with complications like IOL decentration, haptic extrusion, and subconjunctival haptic in long term.
In 1972, Prof. Jan Worst developed the iris-claw lens fixating to the anterior iris. Corneal endothelium damage was a major complication associated with it especially in patients with shallow anterior chamber and in patients with corneal transplantation. To avoid corneal endothelial damage, Brasse and Neuhann modified the technique by clipping the lens to the posterior iris. Iris-claw implantation is a preferred technique where iris support is feasible. Posterior iris-claw IOLs have lesser risk of corneal endothelial damage and secondary glaucoma than ACIOLs, being clipped to the immobile midperipheral portion of iris can achieve good pupillary dilation, less risk of tilting of IOL leading to astigmatism, they do not interfere with the physiological vascular dynamics of iris and lesser chance of distortion of pupil.
In our study, the safety, effectivity, and complications related to posterior iris-claw implantation are evaluated. The aim of our study is to evaluate the preoperative and intraoperative indications, postoperative complications, incidence of secondary glaucoma, and visual outcome in patient who underwent iris-claw implantation during cataract surgery and effect of vitrectomy and peripheral iridectomy at 12 o’clock position on postoperative intraocular pressure (IOP).
| Materials and Methods|| |
We conducted a retrospective study on 187 eyes of 187 patients who underwent iris-claw lens implantation at tertiary care center from January 2016 to February 2020, with a minimum 1 month of follow-up. Data including demographics, preoperative best corrected visual acuity (BCVA), lens status, detailed anterior and posterior segment findings, associated comorbidities, and intraoperative findings were noted. Vitrectomy and peripheral iridectomy status, postoperative complications, and IOP recorded with noncontact tonometer (NCT) on postoperative day 1, 7, and 30 were noted. A‑scan biometry (A constant used for IOL power calculation is 117.0 and SRK/T formula was used) and power of iris-claw lens implanted were also noted.
All surgeries were performed by experienced and skilled surgeons. All the patients underwent manual small incision cataract surgery in a community set up. Surgical procedures differed and were individually modified due to wide variety of cases and preexisting pathologies too. All patients had iris-claw IOL fixed to the posterior surface of iris and underwent peripheral iridectomy at 12 o’clock position. Anterior vitrectomy was performed where it was found necessary. The IOL was implanted through the anterior chamber and moved with special iris-claw IOL holding forceps, through the iris to posterior chamber and with a help of a second instrument (spatula), haptics were clipped to the iris at 3 and 9 or 12 and 6 ’o clock position. Moxifloxacin 0.5% with prednisolone acetate 1% combination eye drops were used in a tapering dose over a period of 6 weeks after surgery in all the cases.
Statistical analysis was done using parametric method of univariate analysis. Percentage, proportions, and frequency were analyzed for important parameters using Microsoft Excel Sheet (Version 6.0, Microsoft, USA).
| Results|| |
This study included 187 patients with 91 (48.66%) males and 96 (51.34%) females [Table 1], of which 105 (56.14%) were operated on right eye and 82 (43.85%) on left. The mean age of patients was 65.5 years (SD of 7.92 years, range 40–90 years).
|Table 1 Preoperative and Intraoperative Indications for Iris-Claw IOL Implantation|
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Most common indications included phacodonesis (17.65%), small dilating and nondilating pupil (11.22%), zonular dialysis (6.41%), and pseudoexfoliation in (4.81%). Few patients (6.94%) had preexisting corneal pathologies which lend up in intraoperative complications that lead to iris-claw implantation [Table 2].
|Table 2 Showing Percentage Distribution of Various Cataract Forms with Iris-Claw Implantation|
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Ninety eyes (48.12%) had immature senile cataract including nuclear sclerosis ranging from grade I to IV, of which 2 had posterior polar component. Out of 63 mature cataracts, 3 had intumescent cataract and 18 had hypermature cataracts. Three patients had a morgagnian cataract with weak zonules and eight had absorbed cataracts. Five patients presented with a hard black cataract and 2 eyes had a traumatic mature cataract. One patient presented with aphakia, wherein an iris-claw lens implantation was preplanned [Table 3].
Intraoperative indications included posterior capsular rent in 53 eyes (28.34%), loss of capsular bag in 73 eyes (39.04%), and zonular dialysis in 34 eyes (18.18%). Of all the patients, 169 (90.37%) eyes underwent anterior vitrectomy and all the patients underwent peripheral iridectomy.
Postoperatively on day 1, 83 (44.38%) patients had nil complications, 45 (24.06%) had corneal edema ranging from mild to severe, and 29 (15.51%) had striate keratopathy (SKs), which resolved in all the patients except for 2 who had persistent edema on the 30th postoperative day. Anterior chamber reaction was noted in 19 (10.16%) patients and reactionary membrane in 18 (9.62%) on postoperative day 1, of which only 1 had persistent uveitis at 1-month follow-up rest all resolved. Iridodonesis was observed in 2 (1.06%) patients and in 5 (2.67%) patients irregular pupil persisted even after 1-month follow-up. Shallow A/C and hypotony on postoperative day 1 were present in 2 (1.07%) patients, which resolved after pressure patch. Hyphema was seen in 7 (3.74%) patients, which cleared till 1-month follow-up. One (0.53%) patient had vitreous strand on post op day 1, which resolved at postoperative day 30. None of the patients had IOL decentration, dislocation, haptic disenclavation, and endophthalmitis.
Mean IOP on postoperative day 1 was 17.24 ± 7.95 mm Hg, which became 15.65 ± 3.02 mm Hg on postoperative day 7 and mean IOP at 1 month postoperatively was 15.06 ± 2.35 mm Hg. On the 1st postoperative day, 33 (17.64%) patients had raised IOP >20 mm Hg for which oral and topical antiglaucoma medication was started. On postoperative day 30, 4 eyes (2.14%) had IOP in range of 20 to 30 mm Hg. None had IOP more than 30 on postoperative day 30. On the first postoperative day, IOP of 30 out of 169 (17.7%) vitrectomized eyes was higher than 21 mm Hg (range 21–60 mm Hg) and mean IOP was 17.24 ± 7.95 mm Hg and 4 out of 18 (22.2%) nonvitrectomized eyes had higher pressure value of >21 mm Hg and mean IOP was 18.94 ± 7.8 mm Hg. Incidence of glaucoma was 0.21 [Table 4].
Mean preoperative BCVA of 187 eyes was 1.78 logarithm of minimum angle of resolution (logMAR) with (SD 0.68 logMAR). The mean BCVA of postoperative day 1, day 7, and 1 month was 0.61 ± 0.50, 0.36 ± 0.26, 0.21 ± 0.16 logMAR, respectively.
In the study, 156 eyes (83.42%) had BCVA ranging from 6/12 to 6/6, of which 24.06% had 6/6, 41.71% had 6/9, and 17.64% had 6/12 Snellen’s acuity as BCVA. Twenty-seven eyes (14.44%) had BCVA 6/18 on postoperative day 30. One eye each (0.53%) had BCVA 6/24 and 6/36, respectively.
| Discussion|| |
Surgical management of eyes with complex cataract having capsule-related complications is very challenging. ACIOLs and SFIOLs are commonly preferred surgical options for management of aphakia in the absence of adequate capsular support, and for last 20 years many studies have been focused on different secondary IOL implantation like SFIOLs, ACIOLs, and Iris-Fixated IOLs.,
With the advent of iris-fixated IOL, many short comings of ACIOLs and SFIOLs like angle structure involvement and transscleral fixation were overcome. Iris-claw IOL has midperipheral retropupillary iris stromal fixation which is advantageous as the midperipheral iris stroma is immobile, less vascularized, has lesser risk of corneal decompensation, and has no effect on mydriasis., Our study emphasizes on the effectivity and safety of posterior iris-claw IOL implantation. Fast learning curve is one of the few advantages.
As compared to Upadhyay et al. in which, trauma was the most common etiologic factor which resulted in aphakia, Labeille et al. considered complex cataract and trauma as etiology. In our study, majority of patients had complex cataract with phacodonesis, corneal pathology, small and nondilating pupil, zonular dialysis, iridodonesis, posterior synechiae, capsule calcification and rupture and shallow A/C, pseudoexfoliation, traumatic cataract, and aphakia.
De Silva et al. and Sumitha C et al. had postoperative BCVA improved in 88.7% and 88.9%, respectively which is less as compared to our study where 97.86% cases showed visual acuity more than 6/18.
Upadhyay et al. showed there was no significant rise in IOP. Sumitha C et al. showed only a single patient with raised IOP with mean postoperative IOP on day 1 and end of 3rd month within normal range. Schallenberg et al. had raised IOP in a single patient and Jare et al. noted raised IOP in 3 of 108 eyes at first week follow-up. In our study, 33 patients had raised IOP at 1st postoperative day, of which only 4 had raised IOP on postoperative day 30 as seen in a study done by Mario Damiano Toro et al. In our study, incidence of secondary glaucoma was much lower as compared to Sri Ganesh et al. and by Pattanaik et al. The reason behind lower incidence might be prophylactic peripheral iridectomy and anterior vitrectomy in most of the patients and a short period of follow-up.
Helvaci et al. suggested performing an efficient anterior vitrectomy to prevent a permanent IOP increase. Upadhyay et al. recommended performing intraoperative peripheral iridectomy and anterior vitrectomy if vitreous is present in A/C. In our study, the pressure was controlled in all the eyes except 4 vitrectomized eyes at postoperative day 30. According to our study, role of vitrectomy stays controversial and further study needs to be done to find association between raised IOP and vitrectomy. It seems intact vitreous interface and peripheral iridectomy are more important in controlling postoperative IOP spike. [Figure 2]
|Figure 2 Showing percentage distribution of postoperative visual outcome at 1 month.|
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In our study, anterior chamber reaction and fibrin membrane were noted in 10.16% and 9.62% patients, respectively on postoperative day 1, of which only one had persistent uveitis on 1-month follow-up, rest all resolved which is comparable to the results in the studies done by Patil A et al. and Periyanayagi M et al. Anterior chamber inflammation post iris-claw implantation is frequent may be due to iris tissue handling but is not an issue to worry about as it resolves with conventional treatment.
Sri Ganesh et al. showed corneal decompensation and haptic disenclavation, whereas Sumitha C et al. showed corneal decompensation, horizontal oval pupil, and irregular pupil postoperatively. Helvaci et al. had few cases of pupil distortion, whereas Upadhyay et al. had no IOL disenclavation or dislocation; however, pupillary distortion was seen in few. Patil A et al. had hyphema, haptic disenclavation, and vitreous in anterior chamber postoperatively in few cases.
In our study, nearly quarter of the patients had corneal edema ranging from mild to severe and few had SKs and hyphema which resolved in all the patients except for two who had persistent edema on the 30th postoperative day. Iridodonesis and irregular pupil were seen in seven cases, which persisted even after 1-month follow-ups. None of the patient had IOL decentration, dislocation, or haptic disenclavation. We did not have any case of endophthalmitis or toxic anterior segment syndrome as observed in Gonnermann J et al.
Our study being retrospective has its own inherent limitations. Longer follow-up should be considered to label a patient as secondary glaucoma, but as our study was performed in community setup it was really hard to get longer follow-ups. One of the finding in our study, raised IOP was observed only in vitrectomized eyes at 30 days follow-up, which is controversial and requires further study.
| Conclusion|| |
Retropupillary iris-claw implantation is one of the safest and least complicated methods of managing intraoperative complications which gives good visual acuity and prevent patient from the trauma of multiple surgeries. It could be done at primary center by ophthalmologist, the technique has very fast learning curve and easy to acquire expertise in it. It has very minimum and medically manageable postoperative complications and has predictable results. To be more affirmative and conclusive about the postoperative complications, long-term follow-up is required.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]