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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 17  |  Issue : 1  |  Page : 9-13

Secondary Artisan iris-fixated intraocular lens implantation for correction of aphakia


Department of Ophthalmology, Qena Faculty of Medicine, South Valley University, Qena, Egypt

Date of Submission01-Apr-2015
Date of Acceptance12-Aug-2015
Date of Web Publication16-Mar-2016

Correspondence Address:
Ahmed H Mohamed
Department of Ophthalmology, Qena Faculty of Medicine, South Valley University, Qena 83511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9173.178761

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  Abstract 

Purpose
The aim of this study was to assess the visual and refractive outcome after Artisan lens secondary implantation for correction of aphakia and to report the incidence of complications.
Patients and methods
A total of 24 eyes of 24 patients rendered aphakic after complicated phacoemulsification and extracapsular cataract extraction were implanted with Artisan aphakia lens in Qena University Hospital. All patients underwent complete ophthalmic examination including uncorrected visual acuity, best-corrected visual acuity (BCVA), and manifest refraction both preoperatively and at 1 day, 1 week, 1 month, 2 months, and 6 months after surgery. Any intraoperative or postoperative complications were recorded.
Results
A total of 24 eyes of 24 patients were included, 16 of whom were men and eight were women. The mean follow-up was 7.2 ± 1.1 months (range = 6-9 months). The cause of aphakia was a complicated phacoemulsification (13 cases) and extracapsular cataract extraction (11 cases). At the final follow-up, the mean postoperative BCVA improved from 0.55 ± 0.19 preoperatively to 0.68 ± 0.20 postoperatively. Analysis of the final BCVA compared with that measured preoperatively demonstrated that 13 eyes (54%) improved, 12 eyes (50%) matched preoperative BCVA, and one eye (4%) decreased due to the occurrence of cystoid macular edema. The mean postoperative spherical equivalent was 1.00 ± 0.67 D, whereas it was 9.50 ± 1.7 D preoperatively. Of the 24 eyes, two developed high intraocular pressure in the early postoperative period.
Conclusion
Secondary implantation of Artisan iris-claw fixated lens is an effective and safe modality for correction of aphakia in eyes lacking sufficient capsular support.

Keywords: aphakia, Artisan, complicated phacoemulsification, iris-claw intraocular lens


How to cite this article:
Mohamed AH. Secondary Artisan iris-fixated intraocular lens implantation for correction of aphakia. Delta J Ophthalmol 2016;17:9-13

How to cite this URL:
Mohamed AH. Secondary Artisan iris-fixated intraocular lens implantation for correction of aphakia. Delta J Ophthalmol [serial online] 2016 [cited 2017 Dec 12];17:9-13. Available from: http://www.djo.eg.net/text.asp?2016/17/1/9/178761


  Introduction Top


Correction of aphakia involves implantation of intraocular lens (IOL), which is the benchmark for correction of aphakia. Implantation of an IOL provides superior visual rehabilitation over glasses and contact lenses [1].

In the presence of adequate capsular support, implantation of a posterior chamber (PC) IOL in the capsular bag remains the state-of-the-art choice [2]. However, if there is posterior capsule rupture with good anterior capsulorhexis, the surgeon has to implant PC IOL in the sulcus to be supported by anterior capsule. In the absence of adequate capsular support, the choices for IOL implantation are angle supported in the anterior chamber (AC) [3] or PC [4],[5], or scleral supported in the PC through suture fixation [6],[7].

It seems that, at least currently, there is no sufficient evidence to demonstrate the superiority of the lens type or fixation site [8].

Advantages of AC IOL include ease of insertion and decreased intraoperative time [9], but its insertion is associated with iritis, hyphema, glaucoma, corneal decompensation, and cystoid macular edema (CME) [10],[11].

Trans-scleral fixated IOL has the advantages of preserving the anatomy of the eye and causing less corneal endothelial and AC angle damage [12], but its insertion has complications such as retinal detachment, hemorrhagic choroidal detachment, persistent CME, and late lens dislocation [13].

There is no definitive consensus with regard to the position of the iris-claw in the AC in aphakic patient. For some authors, the ideal position of an aphakic iris-claw IOL, to minimize the risks for endothelial cell loss, is behind the iris. This would give it the advantages of a true PC IOL. In this case, the power of IOL has to be calculated using the SRK/T formula with adjusted A-constant (116 instead of 115, the manufacturer's recommendation).

The Artisan aphakia IOL (Ophtec BV, Netherlands), one of the latest versions of this type of iris-fixated IOL, is a single-piece polymethyl methacrylate IOL with haptics that are attached to the iris with clips on both sides of the optic. The haptics are enclavated to the midperiphery of the iris [14],[15].

Many studies have evaluated the safety and efficacy of implantation of Artisan aphakic lens and reported that it has a convincing and refractive outcome. In addition, they demonstrated its easy insertion and the possibility of its replacement or removal (if necessary) postoperatively [16],[17],[18].


  Patients and methods Top


This was a prospective interventional study that included 24 eyes of 24 patients, 16 of whom were men and eight were women. All eyes were implanted with Artisan iris-claw lens (Ophtec BV) for correction of aphakia between July 2008 and June 2010 at the Department of Ophthalmology, Qena University Hospital, South Valley University, Qena, Egypt.

Secondary Artisan lens implantation was performed in aphakic eyes because of lack of capsular support after complicated phacoemulsification (n = 13) and complicated extracapsular cataract extraction (n = 11).

Preoperatively, all patients received complete ophthalmic examination. The following data were recorded: uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), refraction, slit-lamp biomicroscopy, intraocular pressure (IOP) measurement, and AC depth, which was measured using the ultrasound biomicroscope (UBM). In addition, using UBM, we measured central corneal thickness to ensure that corneal thickness is less than 600 μm to avoid postoperative corneal compensation.

Follow-up visits were scheduled at 1 day, 1 week, 1 month, 2 months, and 6 months after surgery.

Determination of central corneal thickness using the UBM was performed preoperatively and at 6 months after surgery. The IOL power was calculated using the SRK-II formula.

Surgical technique

All surgeries were performed under general anesthesia by the same surgeon (A.H.A.). A two-plane posterior corneal incision, 5.5 mm in diameter, was centered over 12 o'clock position and two paracentesis were created at 3 and 9 o'clock.

Anterior vitrectomy was performed in nine cases and one eye underwent complete vitrectomy to remove a posteriorly dislocated IOL. Thereafter, acetyl choline 1% was injected into the AC to constrict the pupil, followed by injection of dispersive and cohesive ophthalmic viscosurgical device (OVD) to help protect the cornea and facilitate the positioning of the Artisan IOL.

The IOL was inserted (Artisan aphakia lens has 5 mm optic and a total diameter of 8.5 mm and available in powers from +2.00 to +30.0 D) in the AC, rotated, and centered over the pupil. The IOL was enclavated into the iris using the enclavation forceps. Thereafter, a peripheral iridectomy was performed at 12 o'clock position using scissors to avoid pupillary block. Finally, after removing the OVD using the irrigation/aspiration technique, the wound was closed with three interrupted 10-0 nylon sutures.


  Results Top


Twenty-four patients (24 eyes) with aphakia were included in this study. The mean age of patients was 58.7 (range = 46-74) years; 16 were men and eight were women. The cause of aphakia was following a complicated phacoemulsification (13 eyes) and a complicated extracapsular cataract extraction (11 eyes). The mean follow-up was 7.1 ± 1.1 months (range = 6-9 months).

The mean preoperative BCVA was 0.55 and mean preoperative spherical equivalent (SE) was 9.5 ± 1.69 D [Table 1].
Table 1: Baseline characteristics

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At the final follow-up, the mean BCVA was 0.68, which was better than that measured preoperatively.

Analysis of the final BCVA compared with that measured preoperatively demonstrated that 13 eyes (54%) improved, 10 eyes (42%) matched preoperative BCVA, and one eye (4%) showed decreased BCVA. This eye developed CME, which persisted to the end of follow-up.

The mean postoperative SE at the end of the follow-up was 1 ± 0.67 D. Analysis of the postoperative SE demonstrated that 91% were within 2 D of emmetropia.

Two eyes showed pigment dispersion on the surface of the IOL. Two eyes developed transient IOP elevation.

No eyes showed IOL displacement or dislocation, and no other severe adverse events such as postoperative retinal detachment or endophthalmitis occurred [Table 2], [Table 3] and [Table 4] and [Figure 1].
Figure 1: The mean preoperative best-corrected visual acuity (BCVA) and the mean postoperative uncorrected visual acuity (UCVA) and BCVA.

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Table 2: The visual and refractive outcome

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Table 3: Paired sample test for preoperative best-corrected visual acuity and postoperative uncorrected visual acuity

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Table 4: Paired sample test for preoperative best-corrected visual acuity and postoperative best-corrected visual acuity

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Postoperative central corneal thickness was 527.4 mm at the final follow-up in the current study when compared with its value preoperatively (534.5 mm), indicating that Artisan aphakia lens implantation is far from inducing a significant loss of endothelial cell count. [Table 5] shows the preoperative and postoperative values of central corneal thickness.
Table 5: Preoperative and postoperative values of central corneal thickness

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  Discussion Top


The correction of aphakia in the absence of sufficient capsular support with secondary IOL implantation was studied by various researchers. The demonstration of the superiority of one lens type or fixation site over the other is not yet evidenced [8].

In this study we corrected our aphakia with the implantation of Artisan iris-claw fixated lenses. The Artisan IOL for correction of aphakia (introduced by J. Worst in 1978) showed good results as regards efficacy and safety [4],[15].

In the present study, at the end of the follow-up period, UCVA improved in all patients and 78% of them achieved UCVA of 6/12 or better. The BCVA was unchanged or improved in 96% of cases, where 54% showed improvement of BCVA.

These results are comparable to the results of previously published series [16] that reported stability or improvement of BCVA in 88% of cases.

In another study [15], BCVA improved in 15 of 16 patients.

In this study, the mean postoperative SE was 1 ± 0.67 D, whereas it was 9.5 ± 1.7 D preoperatively, and in 78% of these cases the postoperative SE was within 2 D of emmetropia. Our results are consistent with other published series [4],[15].

The present study showed no major complications except persistent macular edema. Even when complications occurred, they were mild and transient. In two cases, the IOP was higher than 21 mmHg in the early postoperative period that was controlled with topical antiglaucoma drugs. The postoperative rise of IOP may be attributed to incomplete removal of the OVD. CME developed in one case and persisted to the end of the follow-up period. The occurrence of CME may be due to vitreous prolapse in the AC, which is a major risk factor for the development of CME.

CME has been reported after secondary Artisan IOL implantation [4]. The development of CME may be avoided by performing complete pars plana vitrectomy [16], or by performing surgery in a relatively short time with undilated pupil [15].

Two eyes in our study developed mild iritis and dispersed pigmentation was noted over the surface of the IOL, but without disturbing the patients' vision, and relieved with topical corticosteroid eye drops. Pigment dispersion over the surface of the IOL may be due to multiple factors such as inflammatory reactions, IOL design, surgical manipulation of the iris, hypotony, and medication (intracameral acetyl choline) [18].

These two cases with pigment dispersion were associated with difficulty in fixation of the IOL where the enclavation process was repeated more than one time.

Pigmentation over the surface of the IOL was reported in one study and this was due to the concomitant silicone oil removal and thus there was more iris trauma and more prolonged surgery [16].

In the present study, we achieved good centration of the IOL, with no displacement or dislocation, and this was maintained until the end of the follow-up. No pupil ovalization was noted in our cases.

Sobottka Venture et al. [19] demonstrated that endothelial cell density within the physiological range was not correlated with central corneal thickness. Furthermore, they revealed that central corneal thickness returned to the preoperative values after 3 or 12 months irrespective of the severity of endothelial cell loss. These findings were similar to other published series [20],[21]. In addition, central endothelial cell loss was attributed to surgical trauma rather than the Artisan lens itself [22].


  Conclusion Top


During the learning curve while performing conventional extracapsular cataract extraction (ECCE) and phacoemulsification, we encountered more cases of aphakia lacking insufficient capsular support, and so secondary Artisan iris-claw fixated lens is an efficient and safe modality for correction of aphakia in eyes lacking sufficient capsular support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Young AL, Leung GY, Cheng LL, Lam DS A modified technique of scleral fixated intraocular lenses for aphakic correction. Eye (Lond) 2005; 19:19-22.  Back to cited text no. 1
    
2.
Lett KS, Chaudhuri PR. Visual outcomes following Artisan aphakia iris claw lens implantation. Eye (Lond) 2011; 25:73-76.  Back to cited text no. 2
    
3.
Drolsum L. Long-term follow-up of secondary flexible, open-loop, anterior chamber intraocular lenses. J Cataract Refract Surg 2003; 29:498-503.  Back to cited text no. 3
    
4.
Güell JL, Velasco F, Malecaze F, Vázquez M, Gris O, Manero F. Secondary Artisan-Verysise aphakic lens implantation. J Cataract Refract Surg 2005; 31:2266-2271.  Back to cited text no. 4
    
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Baykara M, Ozcetin H, Yilmaz S, Timuçin OB. Posterior iris fixation of the iris-claw intraocular lens implantation through a scleral tunnel incision. Am J Ophthalmol 2007; 144:586-591.  Back to cited text no. 5
    
6.
Fass ON, Herman WK. Four-point suture scleral fixation of a hydrophilic acrylic IOL in aphakic eyes with insufficient capsule support. J Cataract Refract Surg 2010; 36:991-996.  Back to cited text no. 6
    
7.
Kjeka O, Bohnstedt J, Meberg K, Seland JH. Implantation of scleral-fixated posterior chamber intraocular lenses in adults. Acta Ophthalmol 2008; 86:537-542.  Back to cited text no. 7
    
8.
Wagoner MD, Cox TA, Ariyasu RG, Jacobs DS, Karp CL, American Academy of Ophthalmology Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology. Ophthalmology 2003; 110:840-859.  Back to cited text no. 8
    
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Evereklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2003; 29:301-308.  Back to cited text no. 9
    
10.
Koenig SB, McDermott ML, Hyndiuk RA. Penetrating keratoplasty and intraocular lens exchange for pseudophakic bullous keratopathy associated with a closed-loop anterior chamber intraocular lens. Am J Ophthalmol 1989; 108:43-48.  Back to cited text no. 10
    
11.
Apple DJ, Mamalis N, Loftfield K, Googe JM, Novak LC, Kavka-Van Norman D, et al. Complications of intraocular lenses. A historical and histopathological review. Surv Ophthalmol 1984; 29:1-54.  Back to cited text no. 11
[PUBMED]    
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Smiddy WE, Sawusch MR, O'Brien TP, Scott DR, Huang SS. Implantation of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 1990; 16:691-696.  Back to cited text no. 12
    
13.
Bellucci R, Pucci V, Morselli S, Bonomi L. Secondary implantation of angle-supported anterior chamber and scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 1996; 22:247-252.  Back to cited text no. 13
    
14.
Karimian F, Sadoughi MM. Air-assisted Descemet-stripping automated endothelial keratoplasty with posterior chamber iris-fixation of aphakic iris-claw intraocular lens. J Cataract Refract Surg 2011; 37:224-228.  Back to cited text no. 14
    
15.
Koss MJ, Kohnen T. Intraocular architecture of secondary implanted anterior chamber iris-claw lenses in aphakic eyes evaluated with anterior segment optical coherence tomography. Br J Ophthalmol 2009; 93:1301-1306.  Back to cited text no. 15
    
16.
Riazi M, Moghimi S, Najmi Z, Ghaffari R. Secondary Artisan-Verysise intraocular lens implantation for aphakic correction in post-traumatic vitrectomized eye. Eye (Lond) 2008; 22:1419-1424.  Back to cited text no. 16
    
17.
Menezo JL, Martinez MC, Cisneros AL. Iris-fixated Worst claw versus sulcus-fixated posterior chamber lenses in the absence of capsular support. J Cataract Refract Surg 1996; 22:1476-1484.  Back to cited text no. 17
    
18.
Chen Y, Liu Q, Xue C, et al. Three-year follow-up of secondary anterior iris fixation of an aphakic intraocular lens to correct aphakia. J Cataract Refract Surg 2012; 38:1595-1601.  Back to cited text no. 18
    
19.
Ventura AC, Wälti R, Böhnke M. Corneal thickness and endothelial density before and after cataract surgery. Br J Ophthalmol 2001; 85:18-20.  Back to cited text no. 19
    
20.
Cheng H, Bates AK, Wood L, McPherson K. Positive correlation of corneal thickness and endothelial cell loss. Serial measurements after cataract surgery. Arch Ophthalmol 1988:106:920-922.  Back to cited text no. 20
    
21.
Amon M, Menapace R, Radax U, et al. Endothelial cell density and corneal pachymetry after no-stitch small-incision cataract surgery. Doc Ophthalmol 1992; 81:301-307.  Back to cited text no. 21
    
22.
Koss MJ, Kohnen T. Intraocular architecture of secondary implanted anterior chamber iris-claw lenses in aphakic eyes evaluated with anterior segment optical coherence tomography. Br J Ophthalmol 2009; 93:1301-1306.  Back to cited text no. 22
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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