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Correspondence

Managing total aniridia with aphakia using a glued iris prosthesis

Kumar, Dhivya Ashok MD; Agarwal, Amar MS, FRCS, FRCOphth; Prakash, Gaurav MD; Jacob, Soosan MS, FRCS

Journal of Cataract & Refractive Surgery: May 2010 - Volume 36 - Issue 5 - p 864-865
doi: 10.1016/j.jcrs.2010.03.009
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Traumatic aniridia with combined lens injuries leading to aphakia is one of the sequelae of severe blunt trauma. Congenital aniridia with badly subluxated cataract is also not uncommon. With iris and lens abnormalities, these conditions lead to cosmetic and optical defects. An intact iris diaphragm is essential as it reduces the optical aberrations arising from the crystalline lens and thereby increases the depth of focus.1,2 Thus, total aniridia is known to cause incapacitating glare and photophobia. Moreover, associated aphakia adds induced refractive problems to the existing defect. Managing both (aniridia and aphakia) is challenging for a cataract surgeon. Iris reconstructive implants have been inserted intracapsularly in some cases of aniridia with a capsular bag.3 In eyes with partial aniridia, iris enclavation has been tried.4 However, in eyes with total aniridia and aphakia, transscleral fixation has been the option.3,5 We would like to share our experience in managing total aniridia and aphakia with an aniridia intraocular lens (IOL) implanted with the glued IOL technique.6–8

The glued iris prosthesis we use is a poly(methyl methacrylate) (PMMA) aniridia IOL of ocular vision lens style ANI5 (Intra Ocular Care Pvt. Ltd.) (Figure 1). The optic has a clear central zone (clear optic zone) with an opaque or pigmented peripheral annulus and an A-constant of 118.2. The haptics, also made of PMMA, have acute angulation and an eyelet for polypropylene (Prolene) suture placement during transscleral fixation.

Figure 1
Figure 1:
The PMMA aniridia IOL with a clear central optic and peripheral pigmented annulus.

The glued IOL technique6–8 was used to implant the iris prosthesis (Figure 2). Two scleral flaps were made 180 degrees apart, and the haptics were externalized under the scleral flaps and tucked in the intralamellar scleral tunnel, followed by fibrin glue application on the scleral flap bed.

Figure 2
Figure 2:
Glued iris prosthesis technique. A: Lensectomy is performed. B: The PMMA aniridia IOL haptic (arrow) is externalized under the scleral flaps (sf). C: The IOL haptic (arrow) is tucked in the intralamellar scleral tunnel (t). D: The IOL is well centered at the end of surgery.

This technique was used in 2 patients: Case 1 had congenital aniridia with a subluxated cataract; Case 2 had traumatic aniridia with aphakia. Both patients showed good symptomatic improvement. The postoperative corrected distance visual acuity (CDVA) was 20/80 in Case 1 and 20/40 in Case 2. Anterior segment optical coherence tomography examination of the IOL showed good centration. There was no loss of CDVA in either eye. The intraocular pressure was 10 mm Hg in Case 1 and 8 mm Hg in Case 2. The postoperative refraction was 0.0 −1.5 × 180 and −0.5 −1.0 × 156, respectively, and the induced astigmatism, −0.25 D and −0.50 D, respectively. No postoperative uveitis or corneal decompensation was noted during the 6-months follow-up.

This method of implantation removes the suture-related complications of transscleral fixation of the IOL. A glued iris prosthesis can be used in cases of total aniridia with aphakia in which there is no residual iris for fixation.4 This effectively improves postoperative outcomes by correcting aphakia, reducing glare disability, and addressing cosmetic issues faced by a deficient iris and aphakia. However, a large series study is required to analyze the long-term functional and anatomical outcome in eyes with aniridia.

REFERENCES

1. Thompson CG, Fawzy K, Bryce IG, Noble BA. Implantation of a black diaphragm intraocular lens for traumatic aniridia. J Cataract Refract Surg. 1999;25:808-813.
2. Shaw MW, Falls HF, Neel JV. Congenital aniridia. Am J Hum Genet. 12. 1960. 389-415. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1932171/pdf/ajhg00566-0002.pdf. Accessed January 27, 2010.
3. Pozdeyeva NA, Pashtayev NP, Lukin VP, Batkov YN. Artificial iris-lens diaphragm in reconstructive surgery for aniridia and aphakia. J Cataract Refract Surg. 2005;31:1750-1759.
4. Hanumanthu S, Webb LA. Management of traumatic aniridia and aphakia with an iris reconstruction implant. J Cataract Refract Surg. 2003;29:1236-1238.
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6. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34:1433-1438.
7. Prakash G, Ashokumar D, Jacob S, Kumara KS, Agarwal A, Agarwal A. Anterior segment optical coherence tomography–aided diagnosis and primary posterior chamber intraocular lens implantation with fibrin glue in traumatic phacocele with scleral perforation. J Cataract Refract Surg. 2009;35:782-784.
8. Agarwal A, Kumar DA, Jacob S, Prakash G, Agarwal A. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules [reply to letter by Falavarjani KG, Modarres M, Foroutan A, Bakhtiari P]. J Cataract Refract Surg. 2009;35:795-796.
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