Choices of IOL implantation when there is no capsular

supportJaume Català-Mora, MD

Hospital Sant Joan de Déu. Esplugues de Llobregat

Oftalpilar. Barcelona

No financial relationships to disclose

IOL in the absence of capsular support

• Aetiologies• Ectopia lentis

• Traumatic/surgical aphakia

• Initial approach

• Surgical pearls and videos

• Correction of aphakia

• Meta analysis

• Proposal of a protocol & conclusion

Causes of ectopia lentis

• Secondary ectopia lentis:• Traumatic dislocation:

• Blunt trauma

• Penetrating injury

• Buftalmos

• Aniridia

• Chronic uveitis

• High myopia

• Silicone oil tamponade

• Congenital weakness of zonula/capsula:• Non systemic involvement:

• Isolated ectopia lentis

• Ectopia lentis et pupillae,…

• Systemic involvement:• Marfan disease

• Homocystinuria

• Weil-Marchesiani, sulphite oxidase deficiency, hyperlysinaemia, …

Dureau, P. Pathophysiology of zonular diseases. Current Opinion in Ophthalmology. 2008; 19: 27–30

Ophthalmic examination ectopia lentis

• Age, history of trauma or surgery • BCVA, amblyopia, Strabismus• Retinoscopy and refraction: myopia

& astigmatism• Slit lamp examination

• Corneal diameter (megalocornea)• Iris & Pupillae• Lens position, visual axis & lens edge

• IOP• Fundus examination• Think about systemic involvement

Causes absence of capsular/zonular support

• Penetrating injury

• Complicated cataract surgery

• Previous Lensectomy

Ophthalmic examination: Traumatic or surgical aphakia

• BCVA, amblyopia

• Slit lamp examination• Cornea• Anterior Chamber: Vitreous• Capsular remnants• Iris & pupillae

• IOP

• Fundus examination:• Macula, Optic nerve• Periphery

Indication for surgery

Ectopia Lentis

• VA loss due to lens subluxation with visual axis involvement

• Anterior chamber lens luxation

• Vitreous lens luxation with good potential VA

Traumatic/Surgical aphakia

Good potential VA

• Unable or unwilling to use aphakia spectacles

• Intolerance to contact lens

Endothelial Cell CountEye Biometry

Conservative Aphakia management

• Aphakia spectacle correction• Safe, reliable, easily adjustable

• Optical aberration, non suitable for unilateral cases, poor cosmetics

• Extended-wear contact lens correction + Binocular spectacle• Reliable and easily adjustable

• Difficult management, potential complications, intolerance

• Good temporary option in young children

Intraocular lens implant in the absence of capsular support

Requirements:• Good potential VA• Close life-long follow-up• Postop bifocal correction

Contraindications:• Uncontrolled glaucoma• Active, chronic or recurrent uveitis• Severe anterior segment structural

abnormalities• ECC < 2000 cs; AC depth< 3 mm (prepupillary

Iris claw lens)IOL options:• Scleral fixated IOL• Iris Claw IOL:

• Prepupillary• Retropupillary

• Iris Sutured IOL

Ectopia lentis: surgical management

• Lensectomy in the bag

• Posterior vitrectomy

• Acetylcholine

• Superior iridectomy

• Aphakia/IOL implant

Traumatic o surgical aphakia: surgical management

• Vitreoretinal approach:• Infusion line (pressurize/stabilize

the eye)

• Eliminate any vitreous adherences to the iris or anterior chamber

• Check the capsular remnants. Will they be able to support an IOL?

Condon, G. P. Simplified small-incision peripheral iris fixation of an AcrySof intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003;29:1663–1667.

Scleral fixated IOL

• Scleral flaps at 2/4 & 8/10

• Insertion and suture of the IOL haptics

• Limbal or scleral 7 mm incision

• Implant and center IOL behind the iris

• Removal of viscoelastic Corneal/Scleral suture & IC cefuroxime

Scleral fixated IOLArticle Year Design Eyes Patients Ethiologies

Ageimplantation

Follow-up (years)

Results VA Suture Complications

Zetterström, C 1999 Retrospective 21 13Marfan, idiopathic,

traumatic, spherophakia

5,8 1,8 100% equal or better Prolene 10/0; 9/0 Iris capture IOL

Bardorf CM 2004 Retrospective 43 32Marfan, idiopathic,

traumatic, congenitalcataract

10 3 70 % improve vision Prolene 10/0; 9/0

Intraocularhemorrhage, suture

exposure, iris capture, choroidal

effusion

Asadi, R 2008 Prospective 25 23Marfan, traumatic, congenital cataract

6,5 6,75 48% gain 1 line Prolene 10/0

Intraocularhemorrhage,

choroidal effusion, late endophthalmitis, RD, IOL dislocation in

24 %

Buckley, EG 1999 Retrospective 9 9Trauma, congenital

cataract5,8 2 100% equal or better Prolene 10/0

Anterior Uveitis, Iris capture, glaucoma

Buckley, EG 2008 Retrospective 33 26Trauma, congenitalcataract, Marfan,

idiopathic10 5 81 % improvement Prolene 10/0

Iris capture, glaucoma, dsycoria,

intraocularhemorrhage, suture

breakage, reoperations

GLOBAL 131 103

Trauma, Marfan,

Idiopathic, Congenital

Cataract

7,62 3,71Prolene 10/0Prolene 9/0, Goretex

8/0

Suturebreakage; Intraocular

hemorrhage;Iris capture,

Tilted IOL

Iris Claw IOL

• Biometry. AC constant:• Prepupillary: 115• Retropupillary: 116.9

• Avoid IOL sutures

• Superior Iridectomy

• Limbal or scleral 6 mm incision

• Dispersive viscoelastic

• Implant of the IOL

• Enclavation technique:• Anterior (prepupillary)• Posterior (retropupillary)

• Removal of viscoelastic

• Limbal/scleral suture& IC Cefuroxime

Iris claw IOL (prepupillary)Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Endothelial loss Complications

Sminia ML 2011 Retrospective 20 10 Marfan, Idiopathic 7,50 12,00 N/Acomparable to

mean normal but wider range

N/A

Sminia ML 2007 Retrospective 5 5 Traumatic 7,80 11,00100 % improve

vision40 % mean 1 RD

Cleary C 2012 Prospective 8 5 Marfan, Idiopathic 12,60 2,0062,5 % improve

vision14% loss Endothelial loss

Siddiqui SN 2012 Retrospective 18 11 Marfan, Idiopathic 11,58 1,00 17,1% loss Endothelial loss

Català J 2014 Prospective 27 14 Marfan, Idiopathic 6,80 3,4080 % improve

vision18,4% loss

RD, desinclavation, aseptic uveitis

GLOBAL 78 45Marfan,

Idiopathic, Trauma

9,26 5,88Endothelialcell loss, IOL

luxation

Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Endothelial loss Complications

Gonnermann J 2013 Retrospective 7 4 Marfan, Idiopathic 12 2100% improve

vision6,4% loss

1 traumaticdislocation

Iris claw IOL (retropupillary)

Iris sutured IOL

• Limbal 3.5 mm incision• 3 piece acrylic IOL• Moustache IOL folding & implant• Haptics in posterior chamber &

optic captured above the iris• 10/0 prolene suture the haptics to

the iris (Siepser iris suture)• Placement of the optic posterior to

the iris• Removal of viscoelastic• Corneal suture & IC cefuroxime

Stutzman RD, Stark WJ. Surgical technique for suture fixation of an acrylic intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003; 29:1658-1662Siepser, S. B. The closed chamber slipping suture technique for iris repair. Ann Ophthalmol 1994;26(3):71–72

Iris sutured IOL

Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Suture Complications

Dureau, P 2006 retrospective 17 9Marfan,

idiopathic4,80 1,30

100 % improveVA

Prolene 10/0Hyphema, ectopiapupillae, aseptic

uveitis

Yen KG 2009 retrospective 17 12Marfan,

idiopathic, trauma7,20 1,00

76% improvevision

Prolene 10/0RD, Dislocation,

Iris capture

GLOBAL 34 21Marfan,

idiopathic,trauma

6,00 1,15

IOL dislocation,

Ectopiapupillae,

Hyphema

Discussion

• Scleral fixated IOL:• No iris support

• Combination with iris prosthesis

• Polypropylene 9/0 or Goretex 8/0 sutures are recommended

• Iris Claw IOL:• Easier & quicker technique

• Corneal endothelial risk

• Consider retropupillaryenclavation

• Iris sutured IOL:• Smaller corneal incision

• Difficult management/exchange

• Risk of prolene degradation & IOL dislocation

Hirashima DE, Soriano ES, Meirelles RL, et al. Outcomes of iris-claw anterior chamber versus iris-fixated foldable intraocular lens in subluxated lens secondary to Marfan syndrome. Ophthalmology. 2010;117(8):1479–85Gonnermann J, Torun N, Klamann MKJ, et al. Posterior iris-claw aphakic intraocular lens implantation in children. Am J Ophthalmol. 2013;156(2):382–386.e1Buckley EG. Pediatric sutured intraocular lenses: trouble waiting to happen. Am J Ophthalmol. 2009;147(1):3–4

Protocol for surgical management of ectopia lentis

< 4 yoInability to follow-up

VA< 0.3 due to lens luxationVitreous or AC lens luxation

Contact lenses&/or aphakiaspectacles

> 4 yoECC pre & every 6 monthsAC OCT/BMU yearly

Lensectomy + iridectomy

Lensectomy + Scleral sutured IOL Prolene9/0 +Iris reconstruction

Damaged/absent iris Normal iris

Lensectomy + iridectomyRetropupillary iris claw

ECC pre & every 6 monthsAC OCT/BMU yearly

Protocol for secondary IOL implant in the absence of capsular support

UveitisUncontrolled glaucomaInability to follow-up

Good potential VAInability/Intolerance/Unwilling

Spectacles/Contact lens

Surgery contraindicated

Scleral sutured IOL Prolene 9/0 +Iris reconstruction

Damaged/absent iris Normal iris

Retropupillary iris claw

ECC pre & every 6 monthsAC OCT/BMU yearly

Conclusion

• No evidence of the best option of IOL implant

• Aphakia correction & primary vs secondary IOL implant:• Age• Aetiology• Cornea & Iris status• Surgeon preference

• Traumatic patients require individualized management

• Implanted patients will require a life-long follow-up:• Endothelial Cell Count• AC OCT/BMU• Risk of IOL dislocation• Retinal detachment• Glaucoma

• Bifocal / Multifocal optical correction

Aknowledgements

• Dr. Jesús Díaz-Cascajosa

• Ophthalmology department HSJD

• Optometry team HSJD & Oftalpilar

• Surgical team HSJD