Combined aphakia and aniridia eyes are among the most challenging surgical cases to manage yet may benefit the most from a definitive surgical intervention. The reduced visual acuity, glare, and photophobia are debilitating, and there is a psychological burden due to the cosmetic discrepancy between the eyes. Although cosmetic contact lenses can address both issues, there can be tolerability challenges and finding a proper fit is often problematic because of traumatic corneal scars.
Numerous surgical techniques have been described to implant intraocular lenses (IOLs) in eyes with inadequate capsule or zonule support, including anterior chamber IOLs, iris-sutured posterior chamber IOLs (PC IOLs), scleral-sutured PC IOLs, and iris-claw IOLs.1 Gabor and Pavilidis2 described a method for sutureless intrascleral fixation of a 3-piece IOL, and Agarwal et al.3 modified the technique to include fibrin glue for wound closure. However, these techniques alone may not be possible in eyes with deficient iris tissue and would not address glare and photophobia from aniridia. Combination iris prosthesis and IOLs are available, but the iris prosthesis component is only available in black, leaving a suboptimal cosmetic result. Furthermore, these implants require suture fixation in the absence of an intact capsular bag.
Recently, a customized contralateral eye-matched artificial iris made of silicone was produced for implantation in patients with aniridia, with favorable cosmetic outcomes.4 It can be implanted in the capsular bag or inserted into the ciliary sulcus and sutured to the sclera. Spitzer et al.4 described a technique for haptic fixation of a 3-piece IOL onto a silicone iris prosthesis and the resulting IOL–iris prosthesis complex is sutured to the sclera and fixated within the ciliary sulcus.
We present a combination approach of implanting a custom color-matched iris prosthesis attached to a 3-piece IOL using a belt-loop technique and anchored using sutureless intrascleral fixation to optimally address the visual symptoms as well as to provide an excellent cosmetic result.
Using a preoperative color photo, a custom iris prosthesis (Artificial Iris, Dr. Schmidt Intraocularlinsen GmbH, Humanoptics AG) is prepared. This foldable silicone implant is designed with a 3.35 mm open pupillary aperture, has a diameter of 12.8 mm, and is 0.4 mm thick centrally and 0.25 mm thick in the periphery. The implant is available with a polymer fiber meshwork, which provides stiffness for fixation with sutures or haptics and without polymer fiber for in-the-bag placement without suture fixation. For this technique, the “with fiber” version was selected.
After a localized conjunctival peritomy is performed, two 2.0 mm by 2.0 mm, 50% thickness scleral flaps are fashioned 180 degrees from each other, obliquely from the surgeon (Figure 1, A; Video 1, available at: http://jcrsjournal.org). Following this, a 7.0 mm corneal limbal groove is made in preparation for the main incision to insert the IOL–iris prosthesis complex. The horizontal and vertical white-to-white (WTW) measurements are made for sizing the artificial iris. A corneal trephine is chosen to match the oblique corneal WTW diameter (Figure 1, B). Downsizing the artificial iris is intended to reduce the risk for the implant to chafe ciliary body structures, potentially causing a uveitis-glaucoma-hyphema syndrome, and also provide sufficient haptic clearance from the edge of the iris prosthesis (most 3-piece PC IOLs are 13.0 mm in length).
A 3-piece acrylic PC IOL is used to fixate on the iris prosthesis. An IOL with a diameter of 13.0 mm that is vaulted 10 degrees posteriorly is preferred. Using a disposable 30-degree slit blade and working on the posterior unprinted surface of the iris implant, a belt loop is fashioned in the midperiphery of the artificial iris by creating 2 parallel slits (Figure 1, C). A similar belt loop is created 180 degrees away. The IOL is placed upside down in an S-shaped configuration on the posterior surface of the iris implant. A 23-gauge micro-tying forceps (Microsurgical Technology) is threaded through the belt loop to grasp the tip of the haptic to pull the haptic through the belt loop (Figure 1, D). The second haptic is threaded through the second belt loop in a similar fashion. Centration of the optic on the iris prosthesis is achieved by adjusting both haptics within the belt loops.
Sclerotomies are created with a 23-gauge microvitreoretinal blade within the bed of the scleral flaps and 1.0 mm posterior to the scleral spur. The sclerotomies are biased toward the site of the future intrascleral tunnel for the haptic (Figure 1, E). This maximizes the length of the haptic in the scleral tunnel to improve stability of the implant. The sclerotomies are also used to externalize the haptics. An anterior chamber maintainer pressurizes the globe during vitrectomy as well as during the implant insertion. A localized vitrectomy is performed through the sclerotomies to clear the areas of vitreous (Figure 1, F). The intrascleral tunnels for the haptics are created with a bent 26-gauge hypodermic needle inserted in a trajectory parallel to the limbus and made 2.5 to 3.0 mm in length (Figure 2, A). The orientation of the tunnels must be a Z-shaped configuration to match the final position of the IOL.
A 7.0 mm wound is created for insertion of the IOL–iris prosthesis complex. Alternatively, a folding forceps can be used to fold the IOL–iris prosthesis complex and place it through a 4.5 mm wound. The implant is grasped with a pair of curved micro-tying forceps. Prior to insertion of the complex, a 23-gauge micro-tying forceps is placed through the nasal sclerotomy. After one third of the implant is inserted, the micro-tying forceps grasps the tip of the leading haptic (Figure 2, B). The remainder of the complex is inserted into the eye, leaving the trailing haptic external to the globe through the main wound. The micro-tying forceps then pulls the leading haptic through the sclerotomy to externalize the haptic (Figure 2, C). A straight micro-tying forceps held by the assistant stabilizes the nasal haptic to prevent posterior migration of the implant. The micro-tying forceps is inserted through the temporal sclerostomy to grasp the trailing haptic, which is brought into the eye through the main incision with a second micro-tying forceps (Figure 2, D and E). The main wound is closed with 10-0 nylon with a temporary knot to restore a closed system.
Both externalized haptics are placed using curved micro-tying forceps into the previously created scleral tunnels. Centration of the implant is achieved by slight adjustments to either haptic. Optionally, fibrin glue (Tisseel, Baxter Healthcare Corp.) is sequentially applied to close the scleral flaps and then, the conjunctiva.
A 61-year-old man with right traumatic aphakia and a 7 clock hour iris defect was referred to our service for anterior segment reconstruction (Figure 3, A). Previously, he had a ruptured globe in an industrial accident and had multiple prior operations at another center, including the primary globe rupture repair, iridectomy, intraocular foreign-body removal, vitrectomy, and lensectomy. The uncorrected distance visual acuity (UDVA) in the affected eye was 20/40. The patient was extremely photosensitive, in both photopic and scotopic conditions. Intraocular pressure (IOP) was 20 mm Hg without glaucoma medications.
The patient consented to have a secondary sutureless scleral-fixated IOL–iris prosthesis complex using the aforementioned technique (Figure 3, B). Three months postoperatively, the UDVA in the right eye was 20/30, the IOP was 11 mm Hg, and there was no evidence of inflammation. A postoperative ultrasonic biomicroscopic study showed the implant was well centered, not tilted, and there was no contact with uveal structures. The photophobia had resolved completely. The patient was very pleased with his vision, reduction in symptoms, and the cosmetic appearance of his eyes.
In correcting aniridia, nonsurgical techniques such as colored contact lenses are a temporary solution and carry the inherent risks of contact lens use, including infectious keratitis. Both corneal tattooing and IOLs with a peripheral colored ring are surgical options to correct aniridia.5,6 Although both can be used with good success for small iris defects, for complete aniridia, the cosmetic results may be conspicuous. Furthermore, all techniques described previously require suture fixation of the iris prosthesis to the sclera. The Artificial Iris is a device designed to correct the subjective symptoms of aniridia, including photophobia and glare, and to provide an excellent cosmetic result.4 It is a highly versatile tool in anterior segment reconstruction as it can be folded and injected into the capsular bag or sutured to the sclera.
Our modified sutureless technique yields theoretical advantages over scleral suturing. Scleral suturing risks suture breakage, externalized sutures, IOL tilt, and persistent full-thickness tracts with their risk of endophthalmitis.7 In scleral-sutured IOLs with polypropylene, suture breakage has been found to occur at rates of 6.0% to 27.9% a mean of 50 months postoperatively,8,9 although some cases have occurred as late as 14 years later.10 The use of larger sutures or polytetrafluoroethylene (Gore-Tex) has been purported to decrease the rate of suture breakage, and partial-thickness scleral flaps, created traditionally or through clear cornea, have been used to decrease other risks.10–12
More recently, sutureless intrascleral haptic fixation has been shown to be a safe and effective technique of securing a PC IOL in the absence of capsule support. A recent large review of sutureless scleral-fixated IOLs found a 2% rate of haptic displacement.13 Sutureless scleral fixation was found to have lower rates of postoperative inflammation than suturing an IOL.14 For implanting an IOL–iris prosthesis complex, which given its size would be difficult to reposition in the event of a dislocation, we believe the intrascleral fixation of the haptics will have better longevity than scleral suturing and reduce the risk for late implant dislocation. Kumar et al.15 described a technique for managing combined aphakia and aniridia with an aniridia IOL containing a black poly(methyl methacrylate) (PMMA) iris prosthesis. Because of the rigid black PMMA construction of the implant, their technique requires a larger corneal incision (10.0 to 12.0 mm) without improvement in cosmesis compared with a customized iris prosthesis.
Our technique for sutureless intrascleral fixation of a custom iris prosthesis–IOL complex is a novel approach to anterior segment reconstruction for patients with aniridia and aphakia that we believe provides excellent visual and cosmetic rehabilitation with improved stability and reduced risk for postoperative inflammation.
What Was Known
- Patients with both traumatic aniridia and aphakia have serious visual and psychological challenges.
- A new custom cosmetic iris prosthesis has had excellent cosmetic results.
- Sutureless intrascleral haptic fixation is a more recent method to address aphakia without capsular support.
What This Paper Adds
- Combining haptic fixation of a 3-piece IOL onto a custom iris prosthesis with intrascleral haptic fixation provides a sutureless method to treat patients with both aphakia and aniridia.
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Video 1 Sutureless intrascleral fixation of a custom-tailored iris prosthesis with a belt loop-anchored 3-piece IOL.