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Consultation section: Cataract

November consultation #5

Rosenthal, Kenneth J. MD, FACS

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Journal of Cataract & Refractive Surgery: November 2019 - Volume 45 - Issue 11 - p 1688-1689
doi: 10.1016/j.jcrs.2019.08.028
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This patient clearly has visual impairment attributable to (1) a significantly dislocated IOL, and (2) iris pigment defects probably because of mechanical contact between the poorly secured and anteriorly dislocated IOL. The goal is to reposition or exchange the IOL with a placement such that there is no contact with uveal tissue. This patient is young; therefore, any repair should be undertaken with the idea that it will be durable for 30 to 40 years.

If opting to reposition the IOL, one must avoid many of the commonly used fixation techniques. given the thin sclera, a tunnel approach such as the Yamane1 or Agarwal-Scharioth2,3 “glued IOL,” or its variations, might be ill advised because the partial thickness sclera produced by making a flap or pulling the haptic through partial thickness sclera would likely result in erosion, dislocation, and perforation over time. Similarly, an internal suture fixation can be accomplished, but again, the suture tension necessary to secure the IOL would likely cause scleral compromise over time, especially when placed under a partial thickness scleral flap.

The existence of iris transillumination defects suggests that there is chafing of the iris from the IOL, so that any refixation must set the IOL back from the iris as well as require a reinforcement of the sclera. This would eliminate the option of iris fixation suturing, which, in any case, can be associated with chronic inflammation and cystoid macular edema in susceptible individuals.

These obstacles can be overcome as follows: Because the eye has been vitrectomized, a pars plana infusion trocar should be placed to maintain the globe turgor. Make conjunctival peritomies and ink marks 180 degrees apart 2.0 mm to 2.5 mm posterior to the limbus, preferably at 12 o’clock and 6 o’clock. Mount a 30-gauge thin bore needle on a 1.0 cc syringe and place it perpendicularly through the scleral wall at one of these marks. Feed the haptic into the needle and to externalize it. Then, it can be sutured ab externo to the scleral surface in two places along the haptic arc using a CV8 polytetrafluoroethylene (Gore-Tex) suture. Polytetrafluoroethylene is a soft but nonelastic material that is unlikely to cause erosion or stretching over time. This should be repeated on the opposite scleral mark, securing the IOL. Apply a generously sized (but thinned to one-half thickness) sterilized human tissue allograft (Tutoplast) scleral patch to the arc of externalized haptic, secure it with fibrin glue, and readapt it using an 8-0 polyglactin (Vicryl) suture.

Another approach, which I favor because of the patient’s relatively young age, is the use of the Artisan Aphakia IOL (originally the Worst Claw Lens, OPHTEC BV); this IOL has a use history of over 50 years, and data support its stability over the long term.4,5 This IOL, although widely available, but not approved by the U.S. Food and Drug Administration (FDA) at the time of this writing, is the subject of an FDA clinical trial in the United States, and therefore available at study sites. In the context of a thinned sclera, it can be fixated without any contact with the sclera. Another advantage to using this IOL in this patient is that because it fixates to the anterior iris surface, there is no risk for chafing.

References

1. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology 2017;124:1136-1142.
2. 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.
3. Scharioth GB, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2007;33:1851-1854.
4. Guell JL, Verdaguer P, Elies D, Manero F, Gris O, Morral M. Iris Claw IOL Fixation – Rationale and Results. Chang DF, Agarwal A, Lee BS, editors. Advanced IOL Fixation Techniques. chap 56, Thorofare, NJ: Slack, Inc.; 2019. pp. 429-436.
5. Rosenthal KJ, Venkateswaran N. The Artisan Iris Claw Lens for Anterior Iris Fixation. Chang DF, Agarwal A, Lee BS, editors. Advanced IOL Fixation Techniques. chap 57, Thorofare, NJ: Slack, Inc.; 2019. pp. 437-446.
© 2019 by Lippincott Williams & Wilkins, Inc.