Download Anterior chamber iris-fixated intraocular lens placement

ARTICLE
Anterior chamber iris-fixated intraocular
lens placement in vitreoretinal surgery
Elizabeth McElnea, MD1; Deirdre Townley1; Susan Fitzsimon2; Michael O’Keefe1,2; David Keegan1, 3
PURPOSE: To report the clinical presentation of retinal detachment (RD) in patients with
iris-fixated anterior chamber (AC) intraocular lenses (IOLs), describe their management,
and review the outcome of RD repair in these patients.
SETTING: Mater Misericordiae University Hospital, Dublin, Ireland.
METHODS: The medical records of patients undergoing iris-fixated ACIOL implantation
and subsequent RD repair over the three-year period from 2008 to 2011 were reviewed.
The best corrected visual acuity (BCVA), manifest refraction spherical equivalent and axial
length of these patients prior to their refractive surgery was noted. The time between IOL
placement and presentation with RD was recorded. The fundal findings at presentation
with RD were documented. The outcome of vitreoretinal (VR) surgery for RD repair and
BCVA following this was recorded.
RESULTS: RD occurred in 5 eyes of 4 patients with a mean time between IOL implantation
and detachment of 11.3 months. U-tears and atrophic holes were found in 1 and 4 eyes,
respectively. Three eyes underwent scleral buckling surgery, 2 underwent pars plana
vitrectomy surgery. Anatomical retinal reattachment was achieved after a single surgery in
all eyes. Mean BCVA after RD repair was 0.15 logMAR.
CONCLUSION: Conventional VR surgical intervention after ACIOL implantation
is possible and can achieve an excellent visual outcome in patients with these lenses that
develop RD. The presence of an iris-fixated ACIOL does not hinder such surgery.
J Emmetropia 2014; 5: 127-131
The incidence of retinal detachment (RD) is higher
in myopic eyes than in emmetropic eyes1. RD in the
former is thought to be influenced by four factors
associated with myopia: longer axial length, premature
Submitted: 02/01/2014
Revised: 05/25/2014
Accepted: 06/27/2014
Ophthalmology Department, Mater Misericordiae University
Hospital, Dublin, Ireland.
1
The Laser Suite, Mater Private Hospital, Dublin, Ireland.
2
The Mater Vision Institute, Dublin, Ireland.
3
Financial disclosure: None of the authors listed above have any
financial relationships or conflicts of interest to report.
Corresponding Author: Elizabeth McElnea
Ophthalmology Department, Mater Misericordiae University
Hospital, Eccles Street, Dublin 7, Ireland.
E-mail: [email protected]
© 2014 SECOIR
Sociedad Española de Cirugía Ocular Implanto-Refractiva
vitreous liquefaction, posterior vitreous detachment and
increased prevalence of peripheral retinal degenerations
including lattice degeneration.
Pseudophakia also increases the risk of RD2. The
incidence of RD after phacoemulsification cataract
surgery is estimated to range from 0% to 3.6%3,4. Up to
40% of patients referred to vitreoretinal (VR) surgeons
for retinal reattachment surgery have had prior cataract
extraction5. It is estimated that the risk of pseudophakic
RD in myopic eyes with an axial length > 25 mm is
6 times higher than in those with shorter axial length6,7.
Concern exists that intraocular lens (IOL) implantation,
rather than simply the myopia it often corrects, could
be a cause, or at least a contributing factor, of RD after
iris-fixated anterior chamber (AC) IOL implantation.
The presence of an iris-fixated ACIOL may present a
new challenge to the VR surgeon confronted with RD
repair in a patient in whom such a lens has been placed.
Little information is currently available on RD repair in
patients with iris-fixated ACIOLs5.
ISSN: 2171-4703
127
128
IRIS-FIXATED IOL IN VITREORETINAL SURGERY
We report the clinical presentation of RD in
patients with iris-fixated ACIOLs, describe their
management, and review the outcome of RD repair
in these patients.
All patients gave their informed consent for the
inclusion of their details in this study.
PATIENTS AND METHODS
Five eyes of 4 patients with iris-fixated ACIOL
implantation developed RD. Iris-fixated ACIOL
implantation was performed in around 420 consecutive
eyes over the course of the study period. The overall
incidence of RD in this cohort is thus estimated to
be 1.2%. Mean patient age at the time of RD was
48.4 ± 13.0 years (range 33.1 to 64.3). One female and
three male patients developed RD. Three right eyes and
4 left eyes were affected.
One patient had received Artiflex® IOLs (Ophthec,
Groningen, The Netherlands) as phakic IOLs (PIOLs)
to correct myopia. Another patient had received
Artiflex® Toric IOLs, also as PIOLs to correct myopic
astigmatism. One patient had received Artisan®
IOLs (Ophthec) to correct aphakia following
sequential bilateral vitrectomy and lensectomy for
familial ectopia lentis. One patient with Marfan
Syndrome had received Artisan® IOLs at the time of
sequential vitrectomy and lensectomy for bilateral
lens subluxation, and developed left and subsequently
right RD. Table 1 describes the clinical characteristics
of our patients.
Mean MRSE before IOL implantation was
−10.13 ± 1.04 D (range −7.00 to −12.00 D). Mean
axial length of these patients that developed RD was
26.6 ± 2.6 mm (range 23.9 to 31.0). Mean time
between IOL implantation and RD detection was
11.3 ± 10.6 months (range 0.5 to 29 months). In one
case, RD was subsequent to blunt trauma.
Table 2 summarizes the individual clinical course of
each of our patients. RD was associated with a U-tear
in one case and atrophic holes in 4 cases. Four eyes had
a single causative retinal break. One eye had multiple
retinal breaks.
An SB procedure was performed in three eyes: in one,
100% SF6 gas was used as tamponade; air was used as
tamponade in another; and no tamponade was used in
the third. PPV was performed in two eyes, with 20%
SF6 and 16% C2F6 used as tamponade in these cases.
Retinal reattachment was achieved in all eyes after
a single reparative surgical procedure. No patients
required explantation of ACIOL for RD repair. All
iris-fixated ACIOLs remained well enclavated after VR
surgery.
Before RD, mean BCVA in these patients was
0.09 ± 0.09 logMAR. At presentation with RD mean
BCVA was 0.29 ± 0.09 logMAR, and at last follow-up
mean BCVA was 0.15 ± 0.08 logMAR. The duration of
follow-up after RD was, on average, 10.8 ± 5.8 months
(range 3-17 months). At last follow up, the retina had
remained attached in all cases.
Before refractive surgery each patient underwent
a complete ocular examination which included an
assessment of best corrected visual acuity (BCVA)
and manifest refraction spherical equivalent (MRSE),
measurement of intraocular pressure (IOP) using a
Goldmann applanation tonometer and axial length
using the IOL Master® (Carl Zeiss Meditec AG, Jena,
Germany), and slit-lamp microscopy including dilated
fundoscopy.
Anterior chamber intraocular lens implantation
All ACIOLs were implanted in eyes with stable
myopia of between −3.00 and −12.00 dioptres (D),
an endothelial cell count (Cellchek, Konan Medical,
Irvine, California, USA) greater than 2,500 cells/mm2
and a normal anterior segment with an AC depth of
greater than 3 mm measured using the IOL Master®.
ACIOL implantation was performed by two surgeons.
In all eyes, the IOL was introduced via a 6 mm superior
corneal incision and the iris enclavated in each of the
haptics of the IOL using an enclavation needle via a
nasal and temporal corneal paracentesis.
Retinal detachment surgery
Patients had presented with a subjective reduction in
visual acuity, floaters, or the observation of a shadow
in their visual field when RD was noted. The number,
location and morphological features of the causative
retinal break or breaks were recorded in addition to
the extension of the RD and the presence or absence of
proliferative vitreoretinopathy.
RD repair was performed by a single surgeon. Surgical
technique, gas tamponade used, if any, BCVA, and
duration of follow-up after VR surgery were noted.
Scleral buckling (SB) surgery was performed under
general anaesthesia. Cryotherapy was used to treat
retinal breaks and a silicone sponge placed (5 mm
sponge [Type 506] or a grooved 3.5 × 7.5 mm sponge
[Type 509G]; FCI Ophthalmics, Massachusetts, USA).
Pars plana vitrectomy (PPV) surgery was performed
under sub-Tenon’s local anaesthesia using standard
3 × port 23-gauge sclerostomies. Eyes underwent full
vitrectomy. Scleral compression was used to assist
removal of the peripheral vitreous. Cryotherapy or
endophotocoagulation was used to treat retinal breaks.
Patients were instructed to assume an appropriate head
position postoperatively.
RESULTS
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Table 1. Characteristics of patients with iris-fixated anterior chamber intraocular lenses and retinal detachment.
Patient
Gender
Age (years)
Affected eye
Diagnosis
Axial length (mm)
IOL type
1
Male
31
Right
High myopia
31.04
Artiflex® PIOL
2
Female
59
Left
Myopic astigmatism
25.95
Artisan® Toric
PIOL
3
Male
43
Right/Left
Marfan syndrome
26.24 / 26.12
Artisan®/Artisan®
4
Female
65
Right
Ectopia lentis
23.87
Artisan®
IOL = Intraocular lens; PIOL = Phakic intraocular lens.
Table 2. Clinical course of patients with retinal detachment after iris-fixated anterior chamber intraocular lens
implantation.
Patient
Time from IOL
History of
implantation to
trauma
RD (months)
BCVA
BCVA
after RD
with RD
repair
Retinal
break/s
BCVA
with IOL
6 / 7.5
6 / 15
1
29
Yes
Multiple
superior
and inferior
breaks
2
10
No
ST U-tear
6 / 9
6 / 12
6 / 9
3 OD
9
No
Inferior hole
6 / 5
6 / 6
6 / 5
6 / 9
3 OS
0.5
No
Superior
hole
4
8
No
Superior
hole
RD surgery
6 / 9 post
C / B / 20% SF6
LASEK
Duration of
follow up
(months)
18
C / B / Air
12
6 / 9.5
C / B
12
6 / 12
6 / 7.5
PPV / C / 18%
C2F6
21
6 / 9
6 / 6
PPV / C / 20%
SF6
10
RD = Retinal detachment; IOL = Intraocular lens; BCVA = Best corrected visual acuity;
C = Cryotherapy; B = Buckle; OD = right eye; OS = left eye; PPV = Pars plana vitrectomy;
ST = Superotemporal; LASEK = Laser assisted subepithelial keratoplasty.
DISCUSSION
Several surgical treatments for myopia are available,
including corneal refractive procedures, laser
assisted stromal in situ keratomileusis (LASIK), laser
assisted subepithelial keratoplasty (LASEK), clear
lens extraction with IOL implantation, and PIOL
implantation8. The last of these is currently one
of the more preferred methods of correcting high
myopic refractions.
Ectopia lentis can occur as an ocular manifestation of
systemic disorders such as Marfans disease, homocystinuria
and Weil Marchesani syndrome. Idiopathic ectopia
lentis has also been described9. In any of these cases,
lens subluxation causes myopic astigmatism10. PPV and
lensectomy which renders the affected eye aphakic is
the surgical treatment of choice in the majority of these
patients. The implantation of iris-fixated ACIOLs has
become a popular management strategy for patients with
ectopia lentis following this type of surgery.
The popular Artisan® and Artiflex® IOLs are anchored
only to the mid periphery of the iris. Elsewhere they are
slightly raised above the iris plane, preventing them from
interfering with the usual constriction and dilation of the
iris and the structures of the AC angle.
Cases of unilateral and even bilateral giant retinal tear
(GRT) associated RD after Artisan® PIOL implantation
have been reported11,12. In the second of these cases,
bilateral GRT associated RD occurred soon (2 months)
after Artisan® IOL implantation in highly myopic
(OD –6.00 D and OS –7.50 D) eyes with an axial length
of OD 25.00 mm and OS 25.83 mm in an individual
without Stickler or Marfan Syndrome who had had
an unremarkable preoperative fundus examination.
Perioperative fluctuations in IOP and/or surgically
induced inflammatory response were thought to have
produced changes in the vitreous which promoted
retinal traction and predisposed the affected patient to
RD12, suggesting an aetiological association between
Artisan® IOL implantation and the development of RD.
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IRIS-FIXATED IOL IN VITREORETINAL SURGERY
ACIOL implantation may be a contributing factor in
the development of RD. RD develops in 0.7%-2.3%
of myopic eyes13, and has been found to develop in
2.9%- 7.1% of eyes with an iris-fixated PIOL, occurring
on average 24.4 ± 24.4 months (range 1-92) after IOL
implantation13.
However, the incidence of RD after cataract surgery
complicated by posterior capsular tear and vitreous
loss (a patient group that, like those with a myopic
refractive error, are at increased risk of RD14-16) has
been found to be similar for patients receiving either
an anterior or a posterior chamber IOL. This suggests
that neither the placement nor the presence of an
ACIOL greatly increases the risk of RD, if at all17.
In the cases described here, given the temporal
relationship between ACIOL placement and the
development of RD, it is reasonable to assume that
high myopia and/or the presence of other already well
defined risk factors for RD such as Marfan Syndrome
or blunt trauma were the major contributing factors
to RD development. Pre-ACIOL implantation
counselling should, therefore, include a discussion
of the possible risk of RD in patients planning such
surgery to correct myopia13. Longer axial length
(> 30.24 mm) has been identified as a particular risk
factor for RD development in myopic eyes following
this type of refractive surgery13.
Little information on RD repair in patients with irisfixated ACIOLs is currently available18. RD repair
has a worse prognosis when only an incomplete view
of the ora serrata can be obtained19-21. This problem
was frequently encountered with the older iris claw
lenses which significantly limited pupil dilatation20-22,
but does not appear to occur with Artisan® or
Artiflex® IOLs which, as already mentioned, do
not affect normal iris function. Indentation can
improve visualization of the peripheral retina18, and
this is often further improved by the absence of a
lenticular capsular bag and its associated peripheral
aberrations23. Given the current tendency for cataract
surgeons to opt for smaller anterior capsulorrhexis
openings and smaller diameter lenses, visualization
in the presence of an Artisan IOL may be the same
if not better than that obtained with a standard
posterior capsule IOL18. In the cases described here,
intra-operative manipulations during SB or PPV
were performed without difficulty.
SB and PPV surgery were effective in the treatment
of RD in these patients. SB has the disadvantage of
causing postoperative refractive error24,25, while such
refractive changes can be avoided with PPV, although
the major disadvantage of this technique is frequently
subsequent development of nuclear sclerosis. Anterior
movement of the crystalline lens after vitrectomy
might result in close contact with the PIOL, which
may contribute to cataract formation.
Precautions are necessary when performing VR surgery
in patients with Artisan® lenses. Gas in the vitreous
cavity can push the lens against the endothelium.
Injecting viscodispersive into the superior portion of
the AC will prevent contact between the endothelium
and IOL. IOP usually remains in a reasonable range
if acetazolamide is given postoperatively. With short
term gas tamponade, for instance, a bubble that is
expected to disappear completely in 7 to 10 days,
reinjection of Healon® (Abbott Medical Optics) is not
often required18.
The prognosis for RD repair in patients with ACIOLs
appears to be excellent. Our small series demonstrates
that good reattachment rates can be achieved in
patients with iris-fixated ACIOLs, i.e. successful
retinal reattachment was achieved after a single
procedure in all of our cases. The reattachment rate
of detached retina in eyes with iris-fixated IOLs after
one operation has previously been shown to be less
than the post-conventional posterior chamber IOL
implantation detachment rate18. Overall however, the
rate of reattachment between these two groups was
comparable.
In this paper we present our experience in repairing
RD in a small cohort of patients in whom iris-fixated
ACIOLs were implanted. Nonetheless, our study
correlates with the opinion of others, namely, that
the presence of the current generation of ACIOLs
does not hinder VR surgery to any great extent, and
excellent visual outcomes can be achieved.
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JOURNAL OF EMMETROPIA - VOL 5, JULY-SEPTEMBER
First author:
Elizabeth McElnea, MD
Mater Misericordiae University Hospital,
Dublin , Ireland