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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 108  |  Issue : 4  |  Page : 157-166

Retropupillary fixation of iris-claw intraocular lens versus trans-scleral suturing fixation for aphakic eyes without capsular support


1 Zagazig University Hospitals; Department of Ophthalmology, Zagazig University, Zagazig, Egypt
2 Department of Ophthalmology, Zagazig University, Zagazig, Egypt

Date of Submission09-Oct-2014
Date of Acceptance08-Jun-2015
Date of Web Publication22-Jan-2016

Correspondence Address:
Dina Mohammad Rashad
3 Abubakr ElSadeek St., Elmoalmeen, Zagazig, 44516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.174638

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  Abstract 

Purpose
The aim of this work was to compare retropupillary fixation of an iris-claw intraocular lens (IOL) (Verisyse) with trans-scleral suturing fixation for aphakic eyes without sufficient capsular support as regards the safety and complications of the procedure.
Design
This study was an interventional comparative prospective one.
Patients and methods
A total of 42 aphakic eyes of 40 patients were divided into two equal groups: 21 eyes were offered iris-claw IOL and 21 eyes were implanted with scleral-fixed IOL. Intraoperative data (mainly surgical time and intraoperative bleeding) and postoperative data [mainly corrected distance visual acuity (CDVA), intraocular pressure, and postoperative complications] were compared between the two groups during the follow-up period (first day,1 week, 2 weeks,1 month, and after 3 months).
Results
The mean surgical time in the iris-claw group was 24.77 ± 4.8 min, whereas the mean surgical time in the scleral fixation group was 67.09 ± 8.1 min, with a statistically significant difference between the two groups. On the first postoperative day, the CDVA ranged from 0.06 to 0.5 in the iris-claw group, with a mean of 0.22 ± 0.116, and it ranged from 0.05 to 0.15 in the scleral fixation group, with a mean of 0.10 ± 0.032; there was a statistically significant difference between the groups (P = 0.00021). However, after the first 3 months postoperatively, the CDVA ranged from 0.25 to 1.0 in the iris-claw group, with a mean of 0.51 ± 0.25, and it ranged from 0.15 to 0.6 in the scleral fixation group, with a mean of 0.42 ± 0.16; there was no statistically significant difference between the two groups (P = 0.152). On the first postoperative day, the mean intraocular pressure in the iris-claw group was 15.62 ± 2.59 mmHg, whereas in the scleral fixation group it was 19.62 ± 3.94 mmHg, with a statistically significant difference between the two groups (P = 0.00038). The iris-claw group showed higher rates of anterior chamber reaction, pupillary distortion, and cystoid macular edema postoperatively. In contrast, the rates of corneal edema, vitreous hemorrhage, and conjunctival erosion were higher in the scleral fixation group.
Conclusion
From our results, it is evident that iris-claw IOLs have now matured to a stage when they can be used with considerable safety and efficacy. The new designs, as well as the evolution of surgical techniques and instrumentation, have made them the best option for primary or secondary implantation in aphakic eyes. The surgical procedure is easier, shorter, and safer than those used for scleral-sutured IOLs.

Keywords: aphakia, retropupillary iris-claw, scleral fixation


How to cite this article:
Rashad DM, Afifi OM, Elmotie GA, Khattab HA. Retropupillary fixation of iris-claw intraocular lens versus trans-scleral suturing fixation for aphakic eyes without capsular support. J Egypt Ophthalmol Soc 2015;108:157-66

How to cite this URL:
Rashad DM, Afifi OM, Elmotie GA, Khattab HA. Retropupillary fixation of iris-claw intraocular lens versus trans-scleral suturing fixation for aphakic eyes without capsular support. J Egypt Ophthalmol Soc [serial online] 2015 [cited 2017 Oct 23];108:157-66. Available from: http://www.jeos.eg.net/text.asp?2015/108/4/157/174638


  Introduction Top


The treatment and correction of aphakia, especially in the absence of capsular support for ciliary sulcus posterior chamber intraocular lens (IOL) implantation, require using special methods. Various IOLs, including angle-supported anterior chamber IOLs, scleral fixation posterior chamber intraocular lenses (SF-PCIOL), and, more recently, retropupillary iris-claw IOLs, have been implanted, during parsplana vitrectomy (PPV) or secondarily, to correct aphakia [1],[2]. Angle-supported lenses entail several long-term complications, including corneal edema, secondary glaucoma, and cystoid macular edema (CME); thus, the use of these lenses has dramatically been reduced [3]. SF-PCIOL implantation is technically difficult; it requires considerable operative time and is associated with complications such as IOL tilt, decentration, displacement into the vitreous cavity, choroidal hemorrhage, retinal detachment, CME, and conjunctival erosion secondary to use of trans-scleral sutures [4],[5]. Iris-claw IOLs were first introduced in 1986 by Fechner and Worst to correct myopia, but were later used to correct aphakia. The new generation of iris-claw IOLs have good visual outcomes and entail few complications in the treatment of aphakia. Despite extensive experience with iris-claw IOL implantation for myopic eyes and during complicated cataract surgery, the use of this lens for aphakia has been less extensively studied [6].

The aim of this work was to compare retropupillary fixation of an iris-claw IOL (Verisyse) with trans-scleral suturing fixation for aphakic eyes without sufficient capsular support as regards the safety and complications of the procedure.


  Patients and methods Top


Before initiating this study, the protocol, the informed consent form, and any other written information to be given to patients was reviewed and approved by the Ethics Committee of the Zagazig University Hospital.

Study sample

A total of 42 aphakic eyes of 40 patients were divided randomly into two equal groups:

Group A included 21 eyes in which the iris-claw lens was used (Verisyse lens), which is an iris-claw, biconvex, polymethylmethacrylate (PMMA) IOL with an 8.5-mm length, 0.95-mm maximum height, and 5.0-mm optical zone. It had an A-constant of 117.

Group B included 21 eyes in which a single piece PMMA IOL (Eye-O-Care, New Delhi, India) was sclerally fixed. The IOL was a 6 mm optic, with 12.75 mm overall diameter, and had one hole for suture fixation in each haptic. It had an A-constant of 118.2.

Preoperative assessment

Complete ophthalmic examinations were performed for all patients, including slit-lamp examination, with emphasis on the position of previous surgical peripheral iridectomy and pupil. Keratometry and A scan were performed. Retinal evaluation with 90 D and indirect ophthalmoscopy was performed. Endothelial cell density was evaluated by means of specular microscopy. Intraocular pressure (IOP) was measured using Goldmann applanation tonometry.

The lens in all cases was implanted as a secondary procedure at least 4 weeks after the first surgery, as the primary surgery was performed in an outreach setup, where all surgeons were not adequately trained to implant the claw lens or the scleral-fixed lens. The lens implantation had to be taken up as a secondary procedure by a single surgeon in all eyes.

Technique of surgery

Group A

Two side ports were made diagonally opposite - that is, at the 3 o'clock and 9 o'clock positions. If the vitreous was noted in the anterior chamber, automated vitrectomy was performed. The conjunctiva was separated from adhesions, exposing the previous temporal scleral section, and the corneal tunnel was opened with the iris repositer. The anterior chamber was formed with viscoelastic substance, and iris-claw IOL was introduced into the anterior chamber such that haptics were in line with the side ports. Holding the optic of the lens with a lens forceps, one haptic was pushed under the iris with gentle manipulation. Simultaneously, a dialer was passed through the paracentesis on the same side and enclaving was performed. Endpoint was noting the dimple at the site of enclavation. Similarly, haptic enclavation in the other side was performed. The section was sutured with one interrupted 10-0 nylon and the conjunctiva with 8-0 vicryl. Postoperatively, topical steroid antibiotics were administered in a tapering schedule over 6 weeks.

Group B

Two partial-thickness scleral flaps were constructed opposite each other. Anterior vitrectomy was performed in all cases before IOL implantation to clear the vitreous from the anterior chamber and around the lens. A long, straight, solid needle of a 10-0 prolene suture was passed through the sclera (under the partial-thickness scleral flaps) ∼1 mm posterior to the limbus, keeping the needle perpendicular to the sclera so that inside the eye the needle emerges in the ciliary sulcus. Similarly, a 27-G hollow needle was passed through the sclera from the other side of the eye underneath the partial-thickness scleral flaps. The solid needle was docked inside the tip of the hollow needle and thus a prolene suture was passed from one side to the other side of the eye. The suture was then pulled out of the eye with the help of a hook or Mcpherson's forceps from the corneal section and cut into two, and each end of the suture was tied to the specially designed haptic of the IOL, which has got eyelet near the tip of the haptic. The corneal section was then opened. This sutured IOL was then placed behind the iris in the posterior chamber, and the sutures were pulled apart and tied to the sclera beneath the half-thickness scleral flaps. Scleral flaps were then replaced. The corneal section was closed, and the conjunctiva was reposited and sutured. Postoperatively, topical steroid antibiotics were administered in a tapering schedule over 6 weeks.


  Results Top


Patients were subdivided into two groups

The iris-claw group (group A)

This group included 21 eyes of 20 patients, of whom 14 were male and 17 patients were female. The mean age was 54.64 ± 11.2 years. The mean preoperative corrected distance visual acuity (CDVA) was 0.36 ± 0.21. A total of 14 eyes had inadequate capsular support after phacoemulsification or ECCE surgery. A total of five eyes were aphakic after intracapsular cataract extraction (ICCE), and two eyes were aphakic after traumatic cataract with posterior capsule rupture.

The scleral fixation group (group B)

This group included 21 eyes of 20 patients, of whom 12 were male and nine patients were female. The mean age was 56.1 ± 12.2 years. The mean preoperative CDVA was 0.37 ± 0.196. A total of 15 eyes had inadequate capsular support after phacoemulsification or ECCE surgery. Three eyes were aphakic after ICCE. Three eyes were aphakic after traumatic cataract with posterior capsule rupture.

Operative data

Duration of surgeries

In group A, the duration ranged from 15 to 35 min, with a mean of 24.77 ± 4.8 min, and in group B it ranged from 43 to 85 min, with a mean of 67.09 ± 8.1 min. The P value was less than 0.00001.

Intraoperative difficulties

Minor intraoperative complications occurred in both groups. In the scleral fixation group, subconjunctival hemorrhage occurred in five cases. Minor ciliary bleeding occurred in one case in the scleral fixation group and small intraoperative hyphema occurred in three iris-claw cases.

Postoperative data

Postoperative corrected distance visual acuity

The postoperative CDVA was measured on the first postoperative day, first week, after 2 weeks, first month, and after 3 months, and the results were as follows [Figure 1].
Figure 1: The mean postoperative corrected distance visual acuity (CDVA) in both groups.

Click here to view


On the first postoperative day, the CDVA ranged from 0.06 to 0.5 in group A, with a mean of 0.22 ± 0.116. It ranged from 0.05 to 0.15 in group B, with a mean of 0.10 ± 0.032. There was a statistically difference between the groups (P = 0.00021).

After the first postoperative week, the CDVA ranged from 0.08 to 0.6 in group A, with a mean of 0.30 ± 0.17. It ranged from 0.15 to 0.3 in group B, with a mean of 0.24 ± 0.09. There was no statistically difference between the groups (P = 0.155).

After the first 2 weeks postoperatively, the CDVA ranged from 0.1 to 1.0 in group A, with a mean of 0.45 ± 0.23. It ranged from 0.1 to 0.6 in group B, with a mean of 0.35 ± 0.17. There was no statistically significant difference between the groups (P = 0.0.109).

After the first postoperative month, the CDVA ranged from 0.15 to 1.0 in group A, with a mean of 0.47 ± 0.25. It ranged from 0.15 to 0.6 in group B, with a mean of 0.38 ± 0.16. There was no statistically significant difference between the groups (P = 0.150).

After the first 3 months postoperatively, the CDVA ranged from 0.25 to 1.0 in group A, with a mean of 0.51 ± 0.25. It ranged from 0.15 to 0.6 in group B, with a mean of 0.42 ± 0.16. There was no statistically significant difference between the groups.

Postoperative intraocular pressure

The IOP was measured on the first postoperative day, first postoperative week, after 1 month, and after 3 months, and the results were as follows [Figure 2].
Figure 2: The mean postoperative intraocular pressure (IOP) in the groups.

Click here to view


On the first postoperative day, the IOP in group A ranged from 12 to 21, with a mean of 15.62 ± 2.59 mmHg, and in group B it ranged from 14 to 28, with a mean of 19.62 ± 3.94 mmHg. There was a statistically significant difference between the groups (P = 0.00038).

This rise in IOP was attributed to postoperative iridocyclitis and residual viscoelastic substance. All cases received topical steroid and topical hypotensive medications.

After the first postoperative week, the IOP in group A ranged from 12 to 18, with a mean of 15.28 ± 2 mmHg, and in group B it ranged from 13 to 20, with a mean of 15.86 ± 2 mmHg, with no statistically significant difference between the groups (P = 0.361).

After the first 2 weeks postoperatively, the IOP in group A ranged from 12 to 18, with a mean of 14.81 ± 1.86 mmHg, and in group B it ranged from 13 to 20, with a mean of 15.43 ± 1.93 mmHg. There was no statistically significant difference between the groups (P = 0.297).

After the first postoperative month, the IOP in group A ranged from 12 to 19, with a mean of 15.1 ± 1.87 mmHg, and in group B it ranged from 12 to 18, with a mean of 14.71 ± 2 mmHg. There was no statistically significant difference between the groups (P = 0.478).

After the first 3 months postoperatively, the IOP in group A ranged from 13 to 20, with a mean of 15.52 ± 2 mmHg, and in group B it ranged from 12 to 18, with a mean of 14.14 ± 1.65 mmHg. There was no statistically significant difference between the groups (P = 0.019).

Postoperative complications

During the early period (within 1 week) [Figure 3]:
Figure 3: Early postoperative complications.

Click here to view


  1. Elevated IOP (>20 mmHg):
    Elevated IOP occurred in two (9.5%) cases in group A and in eight (38.09%) cases in group B. These cases were managed with topical steroid and topical hypotensive medications.
  2. Anterior chamber reaction:
    Six (28.57%) cases in group A and four (19.05%) cases in group B showed anterior chamber reaction. The cases responded to topical steroids.
  3. Corneal edema:
    Three (14.29%) cases in group A and eight (38.09%) cases in group B showed corneal edema; the cases responded to topical antiglaucoma and topical hypertonic agents.
  4. Pupillary distortion:
    Four (19.05%) cases in group A and three (14.29%) cases in group B showed pupillary distortion [Figure 2] and [Figure 3].
  5. Vitreous hemorrhage:
    In group A, no cases of vitreous hemorrhage were detected, but in group B two (9.53%) cases of mild-to-moderate vitreous hemorrhage were detected that were followed up until resolved.


During late period (after 1 week) [Figure 4]:
Figure 4: Late postoperative complications in both groups.

Click here to view


  1. CME was detected on fluorescein angiography in cases with unexplained visual deterioration - in four (19.05%) cases of group A and in two (9.53%) cases of group B.
  2. IOL decentration was observed in two (9.53%) cases in group A and in four (19.05%) cases in group B. IOL decentration could be measured in cases with regular pupils after full mydriasis. This could be performed in 35 cases only (17 in group A and 18 in group B).
  3. Conjunctival erosion of the prolene suture:


No cases of suture erosion were detected in group A, whereas one (4.76%) case was detected in group B, which was treated by means of trimming of the suture with application of cautery to its free ends and recovered by the conjunctiva.


  Discussion Top


Several surgical methods of IOL implantation for eyes without sufficient capsular support have been developed. Angle-fixated anterior chamber IOL implantation is one such therapeutic option and has technical advantages such as ease and minimal invasion during the surgery. However, several complications such as progressive damage of corneal endothelial cells, decompensation, chronic inflammation in the anterior chamber, secondary glaucoma, and CME have been reported. Implantation of an iris-claw-fixated anterior chamber IOL is another method. However, iris-claw IOL implantation in the anterior chamber may cause damage to the corneal endothelial cells, as reported by Güell and colleagues [7],[8].

Furthermore, to maintain the physiological features of an open-angled anterior chamber, it is desirable to implant the IOL in the posterior chamber with adequate distance from the corneal endothelium to avoid progressive corneal endothelial cell loss. For these reasons, the SF-PCIOL suturing technique is favored by many surgeons as a method of posterior chamber IOL fixation at the ciliary sulcus for eyes without sufficient capsular support. In contrast, there have been various reports on the complications associated with scleral-fixed IOL, such as ciliary and choroidal body hemorrhage, vitreous prolapse into the anterior chamber, retinal detachment, IOL dislocation, uveitis, and CME. Retropupillary fixation of iris-claw IOL in the posterior chamber is expected to be a less invasive and safer method of posterior chamber IOL implantation for aphakic eyes without sufficient capsular support.

In this study, 42 eyes were included. Verisyse iris-claw lenses were implanted retropupillary in 21 eyes (group A), whereas single piece PMMA IOLs with one hole in each haptic (for scleral fixation) were used in 21 eyes (group B).

In our series, 69.04% were aphakic after ECCE or phacoemulsification with accidental rupture of posterior capsule during operation, with inadequate capsular support for IOL implantation. An overall 19.04% were aphakic after ICCE (which is performed due to lens subluxation). An overall 11.9% were having traumatic cataract with posterior capsule tears that hindered primary implantation.

Gonnermann and Coworkers reported that eight (50%) cases had undergone complicated cataract surgery with extensive capsule rupture and vitreous loss. Three (18.7%) cases had undergone congenital cataract extraction through a manual dissection - aspiration technique. Two (12.5%) cases had penetrating ocular trauma. Two (12.5%) cases had undergone combined surgery, penetrating keratoplasty, and angle-supported anterior chamber IOL exchange, and one (6.25%) case had undergone anterior vitrectomy and IOL exchange after a nontraumatic posterior chamber lens subluxation. Johannes and colleagues reported that six (60%) cases had Marfan syndrome and ectopia lentis, three (30%) cases had pseudoexofoliation syndrome, and one (10%) case had complicated phaco for senile cataract [9].

The mean surgical time in the Verisyse IOL group (24.77 ± 4.8 min) was significantly shorter than that in the scleral fixation group (67.09 ± 8.1 min). This difference can be attributed to the fact that, in the scleral fixation group, surgeons often struggle when searching for adequate fixation positions for the haptics. Scleral flaps are constructed to hide the knots, and proper vitrectomy is performed to avoid undesirable retinal detachment and ciliary choroidal hemorrhage. Because surgeons can omit these procedures in the retropupillary fixation of the Verisyse IOL, surgical time could be shortened in comparison with scleral fixation.

Hara et al. (2011) [10] stated similar results. They stated that the mean surgical time in the Verisyse IOL group (20.0 ± 8.9 min) was significantly shorter than that in the scleral fixation group (49.7 ± 18.9 min) (P < 0.0001).

In this study, the mean CDVA significantly deteriorated 1 day after surgery in the scleral fixation group compared with preoperative CDVA. This presumably occurred due to hyphema and ciliary choroidal body hemorrhage that resulted from invasive manipulation around the ciliary choroidal body. Perforation of the ciliary choroidal body, even by needles, can cause considerable stress to the eye. Eyes undergoing retropupillary fixation of the Verisyse IOL showed no decrease in CDVA 1 day postoperatively. In eyes undergoing implantation of the scleral-fixed IOL, the mean postoperative CDVA recovered to the preoperative level in 1 week. The retropupillary fixation of the Verisyse IOL showed earlier visual recovery and fewer complications compared with SF-PCIOL.

In group A, the final CDVA was better than that preoperatively in 14 eyes (66.6%), was unchanged in five eyes (23.9%), and was worse in two eyes (9.5%). On average, the group had a significant improvement in postoperative CDVA over the preoperative CDVA. However, in group B, the final CDVA was better than that preoperatively in 10 eyes (47.6%), was unchanged in six eyes (28.6%), and was worse in five eyes (23.8%). On average, group B had a significant improvement in postoperative CDVA over the preoperative CDVA. In our series, the mean difference between the preoperative CDVA and the 3-month follow-up CDVA was 0.15. Improvements in group A showed statistically significant results (P = 0.01). In contrast, the mean difference between the preoperative CDVA and the 3-month follow-up CDVA was 0.08 in group B, which was statistically insignificant (P = 0.11).

Hara and colleagues (2011) performed retropupillary iris-claw IOL and trans-scleral suturing fixation in aphakic cases without capsular support. They reported that no statistically significant changes in CDVA (logMAR) were noted in the Verisyse IOL group at each examination point before and after surgery: preoperative, 0.49 ± 0.46 (decimal 0.32 ± 0.34); 1 day, 0.61 ± 0.39 (decimal 0.24 ± 0.40); 1 week, 0.41 ± 0.21 (decimal 0.38 ± 0.62); 2 weeks, 0.32 ± 0.21 (decimal 0.48 ± 0.62); 1 month, 0.35 ± 0.26 (decimal 0.45 ± 0.55); and 6 months, 0.28 ± 0.28 (decimal 0.52 ± 0.52). In the trans-scleral suturing fixation group, CDVA at postoperative day 1 (0.97 ± 0.84; decimal 0.11 ± 0.14) was statistically significantly worse compared with preoperative CDVA (0.41 ± 0.41; decimal 0.39 ± 0.39) (P < 0.05) and recovered at postoperative week 1 (0.59 ± 0.33; decimal 0.26 ± 0.47) compared with the preoperative level [10].

Rao and colleagues (2013) [11],[12] performed posterior iris-claw lenses for aphakic cases. They reported visual outcome at 6 months. The majority of patients (80%) had visual acuity of 20/40 (decimal 0.5) or better.

Johannes and colleagues (2012) performed their study on retropupillary iris-claw IOL in aphakia. They reported that the mean postoperative CDVA (0.38 ± 0.31 logMAR) (decimal 0.42 ± 0.49) was statistically significantly better at the last follow-up than that at 1 day preoperatively (0.65 ± 0.58 logMAR) (decimal 0.22 ± 0.26) (P < 0.05). The final logMAR CDVA was better than that preoperatively in 80 eyes (58.4%), was unchanged in 53 eyes (38.7%), and was worse in four eyes (2.9%). On average, all subgroups had a significant improvement in postoperative CDVA over the preoperative CDVA [9].

Lett and Chaudhuri (2011) performed their study on retropupillary iris-claw IOL in aphakia. They reported that 12 eyes (30.8%) achieved a final acuity equal to that measured preoperatively, and only one eye (2.6%) ended up with a poorer final acuity. This patient had Marfan's syndrome and was diagnosed with nonarteritic anterior ischemic neuropathy shortly after Artisan implantation [13],[14].

Farrahi and colleagues (2012) performed their study on anterior iris-claw IOL and scleral-fixed IOL. They found that the iris claw anterior chamber IOL (IC-ACIOL) group showed better results compared with the SF-PCIOL group in terms of postoperative BCVA at final follow-up, which was logMAR 0.24 ± 0.17 (decimal 0.58 ± 0.68) versus 0.41 ± 0.22 (decimal 0.39 ± 0.60), respectively (P = 0.041); BCVA of 20/40 or greater was present in nine (75%) IC-ACIOL patients versus five (38%) SF-PCIOL patients (P = 0.027) [15].

Luk and colleagues (2013) reported that after scleral fixation 72.1% of patients had unchanged or improved final postoperative visual acuity, whereas 27.9% had reduced visual acuity compared with preoperative measurement. The mean difference between final postoperative and preoperative visual acuity was 0.3 ± 0.6 logMAR units (95% confidence interval 0.15-0.39; P < 0.01), which was statistically significant [16].

On the first postoperative day, the IOP in group A ranged from 12 to 21, with a mean of 15.62 ± 2.59 mmHg, and in group B it ranged from 14 to 28, with a mean of 19.62 ± 3.94 mmHg. There was a statistically significant difference between the groups (P = 0.00038). This rise in IOP was attributed to postoperative iridocyclitis and residual viscoelastic substance. All cases received topical steroid and topical hypotensive medications.

Hara and colleagues (2011) stated that the mean preoperative IOP showed no significant differences between groups (Verisyse IOL 14.8 ± 2.2 mmHg and scleral fixation group 13.9 ± 3.5 mmHg). IOP at postoperative day 1 in the scleral fixation group (20.2 ± 7.4 mmHg) was statistically significantly higher than that in the Verisyse IOL group at the same time period (13.3 ± 3.9 mmHg) (P = 0.0126). No significant differences were noted in the mean IOP between the Verisyse IOL and the scleral fixation group at 1 week (15.2 ± 5.8 and 14.7 ± 7.7 mmHg, respectively), 2 weeks (14.3 ± 4.9 and 13.5 ± 3.7 mmHg, respectively), 1 month (16.0 ± 2.8 and 12.4 ± 3.4 mmHg, respectively), and 6 months (15.5 ± 2.1 and 13.7 ± 1.9 mmHg, respectively) [10].

Hazar and colleagues (2013) stated that the mean IOP was not significantly different at baseline between the two groups. Although the mean IOP was significantly higher in the SF-PCIOL group than in the RP-IFIOL group (P = 0.042) at postoperative 1 week, there was no difference in IOP between the groups at other follow-up visits. The rate of patients who had an IOP of 22 mmHg or more postoperatively was statistically higher in the SF-PCIOL group than in the other group at postoperative 1 week, whereas no differences were seen between the groups at the other follow-up visits [17].

Johannes and colleagues (2012) reported six (4.3%) cases of IOP elevation (more than 20 mmHg) with posterior iris-claw IOL [9].

Fass and Herman (2010) [18] reported one (11.1%) case of IOP elevation with scleral-fixed IOL.

Jose΄ and colleagues (2005) stated that an elevated intraoperative pressure, probably steroid induced, was found in three eyes (18.75%) after secondary Artisan lens implantation during the first 6 weeks after surgery. Once the steroids were discontinued, IOP decreased to normal values. However, Farrahi and colleagues (2012) reported elevated IOP (>20 mmHg) in two (16.6%) patients with iris-claw, which was controlled with one or two topical medications. They reported elevated IOP in two (15.3%) patients with scleral fixation [15].

Postoperative complications

In this work, anterior chamber reaction occurred in six (28.5%) eyes in the iris-claw group and in four (19.1%) eyes in the scleral fixation group. Anterior chamber reaction has been associated with extensive anterior vitrectomy and iris manipulation by a previous study. Visual acuity was markedly affected and deteriorated, but with the application of intensive course of postoperative systemic and topical steroids and anti-inflammatory drugs, a dramatic improvement was achieved in all of the cases without a long-lasting effect on the visual acuity.

These results are comparable to the results obtained by Hazar and colleagues (2013),who reported five (20.8%) cases after retropupillary iris-fixed IOL and three (9.6%) cases after scleral-fixed IOL implantation. No significant difference was found between the groups in terms of incidence of anterior chamber reaction [17].

In this work, corneal edema occurred into three (14.3%) cases in group A and in eight (38.1%) cases in group B.

Hazar and colleagues (2013) reported a lower rate of corneal edema, one (4.1%) in the retropupillary iris-claw group and three (9.6%) in the scleral fixation group [17].

Fass and Herman (2010) [18] reported one eye (11.1%) with corneal edema during scleral fixation.

In this work, persistent pupillary distortion occurred in four (19.1%) cases in the retropupillary iris-claw group and in three (14.3%) cases in the scleral fixation group at last follow-up. Temporary pupil ovalization occurred at a higher rate in the early postoperative period (nine; 42.8%) cases in group A. Pupil ovalization can occur if the fixation of the haptics is performed asymmetrically or too tightly. It is unclear whether this difference was due to a lack of objective photodocumentation of all eyes sequentially after surgery or if pupil ovalization tends to normalize over time. Pérez-Torregrosa et al. (1995) [19] found no serious visual impairment caused by slight IOL decentration with a standard 4.0 mm entrance pupil but that larger pupils could cause visual impairment.

Johannes and colleagues (2012) recorded persistent pupil ovalization in 19 eyes (13.9%) in the retropupillary iris-claw group [9].

Baykara and colleagues (2007) found persistent pupil ovalization after posterior iris-claw IOL implantation in 12.7% of eyes [24].

Luk et al. (2013) [16] reported two (1.9%) cases of drawn-up pupil during their study on scleral-fixed IOL.

Hazar et al. (2013) [17] reported four (12.9%) cases of pupillary distortion in the scleral fixation group, whereas zero (0%) cases in the retropupillary iris-claw group.

In the present study, no postoperative hemorrhage occurred in the iris-claw group, whereas ciliary choroidal body hemorrhage was seen in two (9.5%) eyes in the scleral fixation group. Bleeding typically occurred during needle passage.

These results are comparable to the results obtained by Hara et al. (2011) [10], who recorded no cases of hemorrhage in the Verisyse IOL group, whereas ciliary choroidal body hemorrhage was seen in 20% of eyes in the SuperFlex620H scleral fixation group and in 33% of eyes in the CP60NS scleral fixation group.

Samantha and colleagues (2011) reported three (2.6%) cases of vitreous hemorrhage from peripheral iridectomy in the retropupillary iris-claw group [21].

Fass and Herman (2010) [18] reported vitreous hemorrhage, which occurred in four eyes (44.4%) during scleral fixation.

Hazar et al. (2013) [17] reported one (4.1%) case of hemorrhage in retropupillary iris-claw cases, whereas they reported two (6.4%) eyes with vitreous hemorrhage in scleral fixation cases.

Ohta and colleagues (2014) reported three (6%) cases of vitreous hemorrhage with IOL intrascleral fixation, whereas they reported two (6.4%) eyes with vitreous hemorrhage with IOL sutured fixation [22].

Almashad et al. (2009) [23] reported three (20%) cases of vitreous hemorrhage with scleral-fixed IOL.

CME has been the leading cause of poor visual outcome in all series of PC lenses. This is always attributed to the initial pathology, which is present in the eye before fixation. In our work, CME was found in four patients (19.1%) of the retropupillary iris-claw group and into two patients (9.5%) of the scleral fixation group. These patients underwent extensive anterior vitrectomy during the operation. They developed gradual deterioration of vision after initial improvement and the condition was diagnosed by means of fluorescein angiography. It was managed with topical treatment - sub-Tenons triamcinolone and intravitreal triamcinolone.

Hazar et al. (2013) [17] reported two (8.3%) cases of CME in the retropupillary iris-claw group, whereas they reported one (3.2%) eyes with CME in the scleral fixation group.

Samantha and colleagues (2011) reported nine (7.7%) cases of CME in the retropupillary iris-claw group [21].

Johannes and colleagues (2012) reported 12 (8.7%) cases of CME in the retropupillary iris-claw group [9].

Hara et al. (2011) [10] recorded no cases of CME in the Verisyse IOL group, whereas it was recorded in one (3.2%) case in the scleral fixation group.

Farrahi et al. (2012) [15] reported one case (8.3%) of CME in the scleral fixation group, whereas they reported no cases of CME in the anterior iris-claw IOL group.

Luk et al. (2013) [16] reported one (1.0%) case of CME after scleral-fixed IOLs implantation.

Almashad et al. (2009) [23] reported no cases of CME in scleral-fixed IOL cases.

In this work, decentration was observed in two (9.5%) cases of the retropupillary iris-claw group and in four (19%) cases of the scleral fixation group. Comparable results were achieved by Menezo and colleagues (1996), who reported two (4.8%) cases of IOL decentration in the iris fixated Worst claw group, whereas they reported two (15.3%) cases in the sutured sulcus-fixated PC lens group [20].

Almashad et al. (2010) [23] reported IOLs decentration in two eyes (22.2%) in scleral fixation cases.

Ahmed and colleagues (2009) used ultrasound biomicroscopy to compare ab-interno and ab-externo SF-PCIOLs. They stated that ultrasound biomicroscopy showed that, in the ab-interno group, five haptics (31%) were in the sulcus, four (35%) were anterior to the sulcus, and seven (44%) were posterior to the sulcus. Ultrasound biomicroscopy also showed that six optics (75%) were central, one (12.5%) was displaced posteriorly, and one (12.5%) was displaced laterally. Ultrasound biomicroscopy showed that, in the ab-externo group, four haptics (29%) were in the sulcus, four (29%) were anterior to the sulcus, and four (29%) were posterior to the sulcus; two haptics (14%) were not seen because the patient was young and uncooperative. In addition, five optics (71%) were central, one (14%) was displaced posteriorly, and one (14%) was displaced laterally [25].

Kumar et al. (2010) [26] reported a lower rate of decentration, four eyes (1.9%) with glued PC IOL during 1-year follow-up period.

Hazar et al. (2013) [17] reported one (4.1%) case of decentration in the retropupillary iris-claw group, whereas two (6.4%) cases of decentration in the scleral-fixed IOL group.

Durak et al. (2001) [27] reported decentration greater than 1.0 mm in seven eyes (16.7%) after secondary implantation and in one eye (7.1%) after primary implantation of scleral-fixed IOL.

In our series, no suture erosion through the conjunctiva was found in group A as there were no sutures under the conjunctiva. These results are similar to those of Johannes (2012) [9], Hara et al. (2012) [10], and Rao et al. (2013) [28].

There was one (4.7%) case of knot erosion in group B despite covering the suture with scleral flaps. A similar result occurred with Donaldson and Colleagues (2005) [29], who reported three (3%) cases of suture erosion. Hazar et al. (2013) [17] reported one (3.2%) case of scleral suture fixation of IOL implantation.

A higher rate of erosion was encountered by Farrahi et al. (2012) [15], who stated that suture erosion occurred in 14.3% of cases.

In contrast, Almashad et al. (2010) [23] reported no case of erosion as they had performed four-point scleral fixation of posterior chamber IOL.

The cases of erosion were treated with trimming of the suture with application of cautery to its free ends and recovered by the conjunctiva in two cases. Cauterization can be risky as the integrity of the suture can be jeopardized by excessive melting.

No cases of IOL dislocation were recorded in either group in this study.

These results are consistent with the results obtained by Hara et al. (2011) [10], who reported zero (0%) case of dislocation after retropupillary iris-claw IOL implantation and only one (5.8%) after scleral-fixed IOL implantation. Rao et al. (2013) [28] reported no cases of dislocation after retropupillary iris-claw IOL. Almashad et al. (2010) [23] reported no case of IOL dislocation after scleral-fixed IOL.

Samantha and colleagues (2011) [21] reported two (1.7%) cases and Johannes and colleagues (2012) reported 12 (8.7%) of haptic disenclavation after iris-claw IOL implantation [9].

Toshihiko and colleagues (2014) reported two (5%) cases of IOL dislocation after intrascleral fixation of the IOL, and seven (18%) cases of IOL dislocation after IOL suture fixation [22].


  Conclusion Top


This study shows that Verisyse IOL implantation is capable of delivering good visual outcomes with a low complication rate in patients who are unable to undergo intracapsular or sulcus IOL positioning. The retropupillary iris-claw lens has the advantages of a true posterior chamber IOL with low intraoperative and postoperative complications. The implantation process with this technique is simple. We believe that it is a better option than a scleral-fixated IOL. Secondary iris-claw IOL implantation is a viable option to correct monocular surgical aphakia in eyes without capsular support.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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