With higher rates of cataract surgery and posterior chamber intraocular lens (IOL) implantation being performed for uveitis patients, very late subluxation and dislocation of the IOL is now well-recognized.1 Capsular contraction and secondary traction on the zonular fibers and subsequent shear injury from IOL donesis are recognized causes of dislocated IOLs in uveitis. There remains no consensus on the best approach to managing these patients, in particular, aphakic patients who have either quiescent uveitis or medically controlled uveitis.1
There are several strategies for secondary IOL implantation in any patient who does not have adequate capsular support: iris-fixated (iris-claw), scleral-fixated/scleral-sutured, or anterior chamber IOL (AC IOL) surgery. AC IOLs have been reported to have good long-term outcomes in uveitis patients.2 Several relatively large studies3,4 have demonstrated the efficacy and safety of iris-claw Artisan IOL insertion, and this is a recognized intervention performed by surgeons. However, these studies have excluded patients who have a history of uveitis; therefore, there are no current benchmarks in these patients. One case report5 described the safe and effective use of an iris-claw IOL in a patient with Fuchs heterochromic cyclitis; however, to our knowledge, no other evidence exists in the literature for their use in uveitis patients because there is concern that Artisan IOL-iris touch will trigger inadvertent inflammation in patients, leading to long-term uveitic complications.
We present a case series of patients with uveitis who have undergone anterior-fixated Artisan IOL implantation at Moorfields Eye Hospital, London, England.
Patients and Methods
This was a single-center retrospective case series study. All uveitis patients who had an iris-claw IOL (Artisan, Ophtec BV) inserted over a 5-year period between January 2014 and July 2019 at Moorfields Eye Hospital were included. Cases were identified using the hospital’s electronic patient record system with external validation using medical records. Patients who had less than 2 months of follow-up were excluded from the analysis. The study was approved by the Institutional Review Board at Moorfields Eye Hospital (CA18/VR/114). The study adhered to the tenets of the Declaration of Helsinki.
Statistical analysis was conducted using IBM SPSS Statistics for Windows software (version 24.0, IBM Corp.) for descriptive and numerical statistical comparisons. The visual acuity was converted from Snellen to logarithm of the minimum angle of resolution (logMAR) for analysis. Snellen counting fingers at 1 m vision was converted to 1.87 logMAR. The means were compared with Student t tests. All cases identified were included in the analysis, there were no cases excluded. A P value less than 0.05 was considered statistically significant.
Eleven uveitis patients underwent anterior-fixated Artisan IOL insertion, with a mean follow up of 1.7 years. Nine of 11 patients had more than 1 year of follow-up. The mean age of the 7 women and 4 men was 61 years ± 14 (SD).
All the patients were under the care of the vitreoretinal (M.M.) and uveitis (C.P.) services at Moorfields Eye Hospital. Seven patients had already undergone pars plana vitrectomy before Artisan IOL insertion, the reasons for which are shown in Table 1, with a mean time between initial vitrectomy and Artisan IOL insertion of 6 years (range 1 month to 17 years). Four patients underwent pars plana vitrectomy at the time of Artisan IOL insertion to assist with the removal of IOLs dislocated or subluxated within the posterior vitreous. The surgery involved a 5.5 mm clear corneal incision with closure of the wound with 10/0 nylon in 9 patients. A scleral tunnel approach was used in 2 patients. An intracameral acetylcholine chloride (Miochol-E) injection was used to maintain a constricted pupil, and a custom Artisan implantation forceps was used to stabilize the Artisan IOL in the anterior chamber. Two 20-gauge paracenteses were made in line with the two iris enclavation locations, and a vacuum enclavation system (VacuFix, Ophtec BV) was used to enclavate the peripheral iris, in a controlled vacuum-assisted step, to the Artisan IOL haptics. The Artisan IOL was enclaved anterior to the iris in all patients, and a peripheral surgical iridotomy (if not already present) was created at the time (Figure 1).
Table 1 shows the patient characteristics, including type of uveitis. The mean corrected distance visual acuity (CDVA) pre-Artisan insertion was 20/200 (1.0 ± 0.73 logMAR). The mean uncorrected distance visual acuity at the 2-week follow-up was 20/125 (0.8 ± 0.8 logMAR). The mean CDVA at the final follow-up was 20/50 (0.4 ± 0.7 logMAR). This was a significant improvement in visual acuity (P = .02, paired t test) at the final follow-up. Table 2 shows the preoperative and postoperative uveitis medication regimens. Six patients were on preoperative topical steroids, and 5 patients stopped treatment. Two patients were on oral steroids and remained on this treatment postoperatively. There were no surgical complications intraoperatively.
The mean intraocular pressure (IOP) before the Artisan IOL insertion was 16 ± 11 mm Hg. The mean IOP at the final follow-up was 13 ± 5 mm Hg. Only one patient was using IOP-lowering therapy at the final follow-up; that patient was also using IOP-lowering therapy preoperatively. One patient underwent elective Baerveldt tube insertion postoperatively; this procedure was preplanned before the Artisan IOL insertion.
One patient required an anterior chamber washout because of retained lens capsular fragments after subluxated IOL and fibrotic capsule removal surgery. One patient developed a proliferative vitreoretinopathy-related retinal detachment 1 month after the IOL insertion. The Artisan IOL was explanted during the vitreoretinal surgery to repair the detachment and the patient remains aphakic with silicone oil in situ. There were no complications of Artisan IOL disenclavation, dislocation, subluxation, or decentration. Two patients developed deposits of giant cells on the Artisan IOL that resolved with short courses of topical steroids. In our series, careful preoperative and postoperative management of the uveitis was required to minimize significant flare-ups. One (9.1%) of the 11 patients developed cystoid macular edema (CME) after the surgery, which was treated with orbital-floor triamcinolone 40 mg injections. The edema has resolved, and the patient remains off treatment.
This case series is unique in demonstrating efficacy and safety of anterior-fixated Artisan IOLs in patients with a history of anterior uveitis, intermediate uveitis, and panuveitis. Artisan IOL insertion produced a significant improvement in visual acuity in these patients and the side-effects were minimal.
Traditionally, surgeons have been concerned that Artisan-style IOLs in these patients might lead to flare-ups and severe uveitis complications. These opinions arise from previous reports of inflammation secondary to Artisan IOLs in eyes without a history of uveitis.6,7 None of our patients had a significant flare-up of their uveitis. CME is also a theoretical concern given the rate is around 3% in patients without a history of uveitis.4 We found a 9.1% CME rate. One of our patients underwent combined vitrectomy and Artisan IOL implantation, and later developed a retinal detachment. Retinal detachment is a recognized complication of vitrectomy,8 and it is unlikely that the presence of uveitis contributed to the rhegmatogenous cause of the retinal detachment.
Our results compare favorably with those obtained with AC IOL insertion in uveitis patients. One recent study, with an average follow-up of 35 months,2 found uveitis flare-ups attributable to the AC IOL in 29% of patients, worsening or new CME in 41%, and anterior IOL deposits in 47%. However, late onset CME, corneal endothelial loss, and uveitis in the presence of iridodonesis might only manifest over 3 to 5 years postoperatively; therefore, we will continue to monitor our patient group to obtain longer-term data.
Relevant to this series is the higher incidence of IOL dislocations post vitrectomy. There are also several postoperative observations and iris-related changes that were not studied. In particular, in cases of previous vitrectomy, there is frequently a good deal of iridodonesis and even possible fluctuations in refraction.9
Our recommendations to minimize postoperative inflammatory complications in Artisan-style IOL surgery include (1) preoperative topical antiinflammatory medications with advice from the uveitis service; (2) Use of custom Artisan instrumentation and the vacuum enclavation system that can minimize iris trauma during IOL implantation; (3) An intensive postoperative steroid eyedrop regimen with initial twice hourly steroids for a minimum of 2 weeks, then a tapering course over 8 to 10 weeks; and (4) multidisciplinary follow-up monitoring in uveitis and vitreoretinal services after surgery.
To our knowledge, we report for the first time, the outcomes of patients with uveitis who had anterior-fixated Artisan IOLs implanted. Further, larger studies with longer follow-ups are required to evaluate this secondary IOL; however, this is a promising first step.
What Was Known
- To date, surgeons have been reluctant to use iris-claw Artisan-style intraocular lenses (IOLs) in patients with uveitis because of theoretical concerns about increased intraocular inflammation.
What This Paper Adds
- Patients with uveitis had improved visual acuity with minimal adverse effects after having iris-claw Artisan-style IOLs inserted.
- Anterior-fixated Artisan IOL implantation was found to be safe and effective for patients with a history of anterior uveitis, intermediate uveitis, and panuveitis.
- Recommendations to minimize postoperative inflammatory complications in Artisan-style IOL surgery were developed.
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2. Suelves AM, Siddique SS, Schurko B, Foster CS. Anterior chamber intraocular lens implantation in patients with a history of chronic uveitis: five-year follow-up. J Cataract Refract Surg 2014;40:77-81.
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7. Kleinmann G, Apple DJ, Mackool RJ. Recurrent iritis after implantation of an iris-fixated phakic intraocular lens for the correction of myopia. Case report and clinicopathologic correlation. J Cataract Refract Surg 2006;32:1385-1387.
8. Marie-Louise J, Philippakis E, Darugar A, Tadayoni R, Dupas B. Occurrence rate of retinal detachment after small gauge vitrectomy for idiopathic epiretinal membrane. Eye (Lond) 2017;31:1259-1265.
9. Linke JB, Miller M, Ebneter A, Zinkernagel MS. Gravitational pseudoaccommodation in patients with aphakic iris-claw intraocular lenses. J Cataract Refract Surg 2016;42:1456-1460.
None of the authors has a financial or proprietary interest in any material or method mentioned.