Implantation and fixation of intraocular lenses (IOLs) in eyes without capsule support is performed using several procedures including sutured scleral fixation, anterior chamber angle fixation, and iris fixation. These methods, however, have potential disadvantages.1–10
Sutured scleral fixation is associated with lens tilting, decentration, and subluxation,11–13 mainly as a result of fixation at 2 opposite points and the difficulty penetrating the sulcus with the needle without causing ovalization. In addition, suture erosion, vitreous hemorrhage, retinal detachment, and macular edema can occur intraoperatively and postoperatively.14,15
Anterior chamber IOLs were the most common lenses used worldwide to correct aphakic eyes without capsule support.16,17 They are currently making a comeback as phakic IOLs.18 They are also the most extensively researched lens. Most studies, however, show that anterior chamber IOLs can cause serious complications; endothelial cell loss, secondary glaucoma, and pupil ovalization are the most common.
Iris fixation using iris-claw lenses also has several drawbacks, especially in aphakic eyes as the lack of compartmentalization allows greater movement of the iris–IOL diaphragm. In addition to iris fixation being difficult to perform, an insufficient amount of iris tissue may incarcerate in the lens claws, resulting in lens decentration and potentially injuring the endothelium. Conversely, too much incarcerated lens tissue can cause pupil ovalization and iris atrophy.19 Visual impairments such as glare and halos caused by the optic's limited size have also been reported. A technique of iris fixation of a posterior chamber IOL was recently reported.20
We describe a technique using an IOL designed for implantation in the ciliary sulcus without fixating sutures. The IOL was implanted in 3 eyes of 2 patients. The surgeries were the first using this lens design and surgical technique.
The IOL was designed by Helmut Binder, MD, for implantation in the posterior chamber. The lens, the Binder IOL, is manufactured by Physiol and distributed by Eyegenica. It has the approval of the European CE (Conformité Européen). The sulcus-fixated posterior chamber IOL has peripheral iris anchors. The haptics are designed to be lodged in the ciliary sulcus over a long surface area. They have small cuff-link-like ends going through and buttoning in peripheral iridotomies (Figure 1). The haptics consist of 3 functional regions. The first secures the IOL in the sulcus. The second passes through the iridectomies (most favorably at 3 o'clock and 9 o'clock). The third, or anchor region, hinders the IOL from sliding backward toward the posterior segment.
The IOL is stable in every spatial axis and secured against rotation for 4 reasons. First, there is no displacement along the long axis of the globe. Backward sliding through the iris into the posterior segment is prevented by the anchor at the haptic end, while forward sliding is impossible because of the long, C-shaped region lying in the sulcus. The haptic regions on either side of the iris provide reciprocal support, with 1 side preventing displacement of the haptic region on the other side. This prevents damage to the corneal endothelium and anterior chamber angle and keeps the optic in place.
Second, there is no rotation around the long axis of the globe. The regions passing through the iridectomies prevent IOL rotation.
Third, the IOL is prevented from tilting by 4 opposite points of fixation: the 2 iris anchors at 3 o'clock and 9 o'clock and the 2 sulcus regions at 6 o'clock and 12 o'clock. The lens cannot tilt in any direction out of its plane, lying exactly parallel to the plane of the iris.
Fourth, radial displacement is prevented by the sulcus regions.
Implantation of the IOL
The implantation of this IOL is essentially the same as that of conventional sulcus-fixated IOLs except for the addition of 2 peripheral iridotomies at 3 o'clock and 9 o'clock. It is best to perform the iridotomies preoperatively using a neodymium:YAG laser. They should be placed approximately 0.5 mm from the anterior chamber angle, not extending beyond 0.5 mm in diameter. During implantation, the leading haptic is inserted through a 6.0 mm scleral tunnel or limbal incision. The anchor of the leading haptic is folded under the optic to prevent it from being caught at the edge of the scleral tunnel. The leading haptic is placed in the sulcus at 6 o'clock, making sure the iris anchor is temporarily hooked onto the pupil. The second haptic is placed in the sulcus at 12 o'clock; its anchor is tentatively hooked onto the pupil at 9 o'clock. The IOL is then rotated 90 degrees clockwise. Through the corneal paracentesis at 3 o'clock and 9 o'clock, the iris anchors are inserted through the iridotomies from behind the iris using a Guerin-type forceps. Before IOL insertion, extensive anterior vitrectomy is performed to avoid vitreous incarceration or prolapse.
The IOL implantation technique was performed in 3 eyes of 2 patients. They both gave informed consent.
A 35-year-old man with an aphakic left eye was treated in 1985 in Poland after an occupational incident with perforating trauma (Figure 2). The eye also had vitreous incarceration in the previous sclerocorneal incision at the base of the iris and a pigment dot on the endothelium, both at 1 o'clock. Peripheral anterior synechias and iris trauma were present.
Iridotomies were performed preoperatively (Figure 3). One week after surgery, visual acuity was 20/20. Three months postoperatively, the 3 o'clock iris anchor of 1 haptic subluxated; however, the lens was still in position because of the haptic fixation in the sulcus region and the stable fixation of the opposite haptic. The haptic's iris anchor remained in place in the iridotomy. Six months later, the lens was completely luxated at 3 o'clock and was removed.
A 67-year-old, bilaterally aphakic woman had intracapsular cataract extraction in both eyes in 1980. The diameters of the preoperative laser iridotomies were smaller than in Case 1. No complications were noted after implantation of Binder IOLs in both eyes, and visual acuity was 20/20 in the immediate postoperative period (Figure 4).
At 1 year, there were no signs of IOL dislocation. The corneas were clear, and the endothelium was unchanged. Visual acuity was 20/20 in both eyes, and the fundus was normal.
The precise placement and size of the 2 basal iridectomies and the careful buttoning of the 2 haptic anchors into the iridectomies are crucial to successful implantation of the Binder IOL. The iridotomy size presumably accounted for anchor subluxation in Case 1, with the additional disadvantage of iris pathology. The smaller iridotomies in Case 2 held the haptic anchors in place, with subsequent examinations showing no complications. The anchors not only protect the lens from rotation and dislocation, they also enable surgeons to know the exact position of the part of the haptic lying in the sulcus.
Technically, the most difficult part of the procedure is the introduction of the haptic anchors into the basal iris openings. A slight modification of a Guerin-type forceps, however, could facilitate this maneuver.
In conclusion, the Binder IOL is an alternative in the treatment of eyes without capsule support such as in secondary implantation and trauma with lens luxation. Thus, sulcus-fixated posterior chamber IOLs might reduce the complications associated with anterior chamber and iris-fixated lenses such as endothelial cell loss, secondary glaucoma, and pupil ovalization and are an alternative to suture-fixated posterior chamber IOLs.
Compared to implantation of sutured lenses, our technique is less difficult and traumatic and provides more precise IOL positioning. Long-term results are better because of the stable and precise 4-region fixation and the lack of damage to post-iridal structures. We report the first 3 implantations using this lens and technique. Improvements in lens design, implantation technique, and instrumentation promise to lead to better results. Foldable IOLs of this type should reach the market for implantation through small, sutureless incisions. Further clinical studies with longer follow-up are needed before this IOL is considered an option for routine implantation in aphakic eyes without capsule support. The IOL is also a possible alternative to existing toric IOLs as it is a posterior chamber lens that does not rotate.
1. Apple DJ, Price FW, Gwin T, et al. Sutured retropupillary posterior chamber intraocular lenses for exchange of secondary implantation. Ophthalmology 1989; 96:1241-1247
2. Bleckmann H, Kaczmarek U. Functional results of posterior chamber lens implantation with scleral fixation. J Cataract Refract Surg 1994; 20:321-326
3. Holland EJ, Djalilian AR, Pederson J. Gonioscopic evaluation of haptic position in transsclerally sutured posterior chamber lenses. Am J Ophthalmol 1997; 123:411-413
4. Küchle M, Seitz B, Hofmann-Rummelt C, Naumann GOH. Histopathologic findings in a transsclerally sutured posterior chamber intraocular lens. J Cataract Refract Surg 2001; 27:1884-1888
5. Lubniewski AJ, Holland EJ, Van Meter WS, et al. Histologic study of eyes with transsclerally sutured posterior chamber intraocular lenses. Am J Ophthalmol 1990; 110:237-243
6. Pavlin CJ, Rootman D, Arshinoff S, et al. Determination of haptic position of transsclerally fixated posterior chamber intraocular lenses by ultrasound biomicroscopy. J Cataract Refract Surg 1993; 19:573-577
7. Smiddy WE, Sawusch MR, O'Brien TP, et al. Implantation of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 1990; 16:691-696
8. Steiner A, Steinhorst UH, Steiner M, et al. Ultraschallbiomikroskopie (UBM) zur Lokalisation der Kunstlinsenhaptik nach transskleraler Nahtfixation. Ophthalmologe 1997; 94:41-44
9. Teichmann KD, Teichmann IAM. Haptic design for continuous-loop, scleral fixation of posterior chamber lens. J Cataract Refract Surg 1998; 24:889-892
10. Uthoff D, Teichmann KD. Secondary implantation of scleral-fixated intraocular lenses. J Cataract Refract Surg 1998; 24:945-950
11. Durak I, Öner HF, Kocak N, Kaynak S. Tilt and decentration after primary and secondary transsclerally sutured posterior chamber intraocular lens implantation. J Cataract Refract Surg 2001; 27:227-232
12. Hayashi K, Hayashi H, Nakao F, Hayashi F. Intraocular lens tilt and decentration, anterior chamber depth, and refractive error after trans-scleral suture fixation surgery. Ophthalmology 1999; 106:878-882
13. Lee J-G, Lee J-H, Chung H. Factors contributing to retinal detachment after transscleral fixation of posterior chamber intraocular lenses. J Cataract Refract Surg 1998; 24:697-702
14. Lee S-C, Chen FK, Tseng S-H, Cheng S-C. Repositioning a subluxated sutured intraocular lens in a vitrectomized eye. J Cataract Refract Surg 2000; 26:1577-1580
15. Solomon K, Gussler JP, Gussler C, Van Meter WS. Incidence and management of complications of transsclerally sutured posterior chamber lenses. J Cataract Refract Surg 1993; 19:488-493
16. de Souza RF, Forseto A, Nosé R, et al. Anterior chamber intraocular lens for high myopia; five year results. J Cataract Refract Surg 2001; 27:1248-1253
17. Hahn TW, Kim MS, Kim JH. Secondary intraocular lens implantation in aphakia. J Cataract Refract Surg 1992; 18:174-179
18. Lyle WA, Jin J-C. Secondary intraocular lens implantation: anterior chamber vs posterior chamber lenses. Ophthalmic Surg 1993; 24:375-381
19. Budo C, Hessloehl JC, Izak M, et al. Multicenter study of the Artisan phakic intraocular lens. J Cataract Refract Surg 2000; 26:1163-1171
20. Zeh WG, Price FW Jr. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg 2000; 26:1028-1034