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Cataract surgery combined with implantation of an artificial iris
case reports
Cataract surgery combined with implantation of an artificial iris Robert H. Osher, MD, Scott E. Burk, MD, PhD ABSTRACT We describe 6 patients who presented with cataract or aphakia and absent or nonfunctional irides. The etiologies included congenital aniridia, traumatic iris loss, and chronic mydriasis secondary to recurrent herpetic uveitis. In 5 eyes, a prosthetic iris was successfully implanted in combination with small incision cataract surgery. In 2 eyes, a single-piece iris diaphragm and optical lens was implanted. Artificial irides offer a safe alternative for patients who previously had no viable options for iris reconstruction. J Cataract Refract Surg 1999; 25:1540 –1547 © 1999 ASCRS and ESCRS
T
he artificial iris implant was introduced in Europe in 1994 by Reinhard and coauthors,1 who reported using the black diaphragm intraocular lens (IOL) in traumatic aniridia (Figure 1). Subsequently, Rosenthal reported the first use of a smaller incision artificial iris implant in the United States in 1996 in a case of iris dysgenesis (Figure 2) (K. Rosenthal, MD, “Iris Diaphragm Ring Insertion,” presented at the Welsh Cataract Congress, Houston, Texas, USA, September 1996). We report 7 eyes of 6 patients with congenital aniridia, traumatic iris loss, or chronic mydriasis. All patients noted a marked reduction of glare symptoms and qualitative improvement in their vision after implantation of these prosthetic devices. Case 1
A 25-year-old woman was diagnosed with congenital cataract, aniridia, high myopia, and 25 prism diopters of alter-
Accepted for publication June 10, 1999. From the Cincinnati Eye Institute, Cincinnati, Ohio, USA. Neither author has a proprietary or financial interest in any product mentioned. Reprint requests to Robert H. Osher, MD, Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, Ohio 45242, USA. © 1999 ASCRS and ESCRS Published by Elsevier Science Inc.
nating exotropia for which strabismus surgery had been performed. A review of her ocular history disclosed a best corrected visual acuity (BCVA) (Snellen) of 20/60 in each eye before maturation of the cataracts. Maternal history was positive for aniridia and cataracts. Examination revealed a Snellen visual acuity of hand motions in the right eye and 20/400 in the left with a ⫺10.50 diopter (D) sphere. Biomicroscopy disclosed a tiny remnant of iris tissue in each anterior segment, and both lenses were opaque with anterior polar elevations (Figure 3). Intraocular pressure (IOP) was normal in both eyes. Fundus examination was difficult because of the dense cataract. After informed consent was obtained from the patient and approval of the Institutional Review Committee at the Cincinnati Eye Institute was received, surgery was performed in the right eye on September 22, 1997. The capsulorhexis was completed, and the nucleus was removed using slow motion phacoemulsification.2 After cortical removal and posterior capsule vacuuming, 2 endocapsular rings with multiple fins (Type 50C) were sequentially inserted and rotated into the capsular bag (Figure 4). The surgeon was unaware that during the rotation of the more anterior ring, the edge of the anterior capsule was nicked by a microhook. When a ⫹17.0 D AcrySof威 IOL (Alcon Surgical Products, Inc.) was inserted in the capsular bag, the anterior capsule tear extended around the equator and totally transected the posterior capsule. This sequence was captured on videotape; otherwise, the cause of the tear would not have been identified. Despite the capsule tear, the rings remained stable and supported the IOL, 0886-3350/99/$–see front matter PII S0886-3350(99)00246-1
CASE REPORTS: OSHER
Figure 1. (Osher) Morcher single-piece iris-diaphragm IOL type
Figure 2. (Osher) Morcher iris diaphragm ring type 50C.
67G.
which was well centered in the capsular bag perpendicular to the orientation of the tear (Figure 5). The postoperative course was uneventful. The patient attained a visual acuity of 20/30 and expressed satisfaction that her lifelong glare was no longer present. The IOL remained well centered and did not shift during the 18 month follow-up. In August 1998, the cataract in the fellow eye was removed by phacoemulsification. The same artificial iris rings (Type 50C) and a ⫹17.0 D AcrySof IOL were placed in the intact capsular bag uneventfully. The patient attained a successful result similar to that in the first eye, with a final BCVA of 20/50 (Figure 6).
Case 2
Figure 3. (Osher) Opaque cataract with anterior polar elevation in
Figure 4. (Osher) Insertion of 2 Morcher iris diaphragm ring type
an aniridic eye.
50C rings.
A 28-year-old woman was referred, having sustained a penetrating injury to her right eye when she was struck by a nail 2 years previously. She immediately lost her vision, which did not improve after a surgical procedure whose details were unknown. She reported blurred vision and bothersome glare. Examination revealed a Snellen visual acuity of 20/200 in the right eye. Biomicroscopy disclosed a nasal conjunctival scar with complete loss of nasal iris, exposing an abnormal lens with posterior subcapsular opacification and capsular striae converging on a fibrotic equatorial scar (Figure 7). Intraocular pressure was normal. The posterior segment revealed a pig-
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Figure 5. (Osher) Horizontal tear in posterior capsule noticed as
Figure 6. (Osher) Slitlamp appearance of iris rings in second eye.
AcrySof IOL inserted.
mented chorioretinal scar associated with retinal striae located just above the papillomacular bundle. Having given informed consent for cataract surgery and prosthetic iris implantation according to the protocol developed by the Institutional Review Board at the Cincinnati Eye Institute, the patient had slow motion phacoemulsification in June 1998. No complications occurred despite the previous rupture of the equatorial lens capsule. Fortified by a fibrotic scar, the capsular bag remained intact, allowing endocapsular implantation of a single-piece IOL. A sector iris device (Type 96G) with a single fin (Figure 8) was placed in the capsular bag and rotated until it occupied the location of the nasal iris defect (Figure 9). On the first postoperative day, uncorrected visual acuity was 20/40, improving to 20/20 with a ⫺0.75 D spherical refractive error at 1 week postoperatively. The pupil was slightly nasal, measuring 3.0 mm; both the IOL and artificial iris were in excellent position (Figure 10). The patient was followed for 8 months, during which she experienced no glare
or IOL-edge-related symptoms. The anterior segment remained stable and quiet, and the optic’s nasal edge remained covered by the prosthetic iris device.
Figure 7. (Osher) Cataractous lens with traumatic loss of nasal iris
Figure 8. (Osher) Sector iris prosthesis (Morcher iris-diaphragm ring type 96G).
and equatorial capsular rupture.
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Case 3 A 68-year-old woman was referred for a mature cataract, elevated IOP, and recurrent granulomatous anterior uveitis in the right eye, resulting in severe iris damage and a fixed dilated pupil. She had been examined at the Massachusetts Eye and Ear Infirmary, where a presumed diagnosis of herpetic uveitis was made and long-term systemic antiviral therapy recommended. Her ocular medications included prednisolone acetate and dorzolamide hydrochloride with timolol maleate (Cosopt威) twice a day in the right eye. Ocular history was positive for biopsy-proven Sjo¨gren’s syndrome. Examination revealed a Snellen visual acuity of 20/200, which was consistent with mature brunescent nuclear sclerosis and complete cortical opacification. The anterior chamber was deep with mild flare but no cells. The right pupil was
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Figure 9. (Osher) Nasal iris defect occupied by sector iris prosthesis (surgeon’s view).
Figure 10. (Osher) Slitlamp appearance of sector iris device.
8.5 mm in diameter and immobile (Figure 11). Widespread posterior synechiae were present and the iris was diaphanous with numerous transillumination defects. Intraocular pressure was 15 mm Hg, and the fundus could not be viewed through the cataract. After appropriate informed consent was obtained, the right cataract was removed by slow motion phacoemulsification in August 1998. An Alcon AcrySof IOL was implanted in the capsular bag, and additional sodium hyaluronate 1.4% (Healon GV威) was injected behind the IOL. The first iris ring (Type 50C) was inserted in the capsular bag posterior to the IOL. The Healon GV was removed from the posterior capsular bag with a 27 gauge cannula and reinjected in front of the IOL, displacing the optic posteriorly. The second iris ring was inserted in the bag in front of the IOL (Figure 12). The anterior ring was rotated with a Sinskey hook until the interdigitating plates appeared contiguous, forming a solid iris diaphragm (Figure 13). The Healon GV was removed and the watertight incision left sutureless.
On the first postoperative day, IOP was 43 mm Hg. The patient was given topical dorzolamide hydrochloride (Trusopt威), pilocarpine, timolol maleate (Timoptic威), and brimonidine (Alphagan威) as well as oral acetazolamide (Diamox威). Intraocular pressure decreased to 12 mm Hg within several hours. The postoperative course was otherwise uneventful, and the visual acuity improved to 20/20. The new pupil was 6.0 mm in diameter with no iris transillumination defects (Figure 14). The persistent glare the patient experienced before maturation of her cataract resolved.
Figure 11. (Osher) Fixed dilated pupil, cataract, and posterior synechiae secondary to chronic uveitis.
Case 4 A 49-year-old woman was referred with congenital aniridia, nystagmus, glaucoma, and cataract in the left eye. She had had extracapsular surgery with implantation of a sulcus-fixated IOL in the right eye elsewhere. Although she reported poor vision, her chief complaint was intolerable glare. Her family history was positive for aniridia.
Figure 12. (Osher) Insertion of second iris ring.
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Figure 13. (Osher) Surgical appearance of artificial iris and IOL.
Figure 14. (Osher) Slitlamp appearance of IOL and artificial iris rings 1 day postoperatively.
Examination revealed a visual acuity of 20/200 in the pseudophakic right eye and 20/250 in the phakic left eye. There was no visible iris in either eye. A single-piece IOL was present in the right eye, and the posterior capsule was thickened and opacified. The left lens showed cortical and axial posterior subcapsular opacities (Figure 15). Gonioscopy disclosed a tiny iris remnant for 360 degrees. Other positive findings included borderline IOPs on timolol (Betimol威), congenital nystagmus, and hypoplasia of the maculae. After the patient gave appropriate informed consent, the left cataract was removed by phacoemulsification in January 1999. The anterior capsule was abnormally thin and behaved like wet tissue paper during the attempted capsulorhexis. After the nucleus and cortex were removed and the posterior capsule vacuumed, several peripheral tears in the anterior capsule were observed (Figure 16). Because of aberrant capsule fragility, a single-piece lens–iris diaphragm was implanted in the ciliary sulcus. The incision was enlarged to 10.0 mm to accommodate a 20.5 D lens–iris device (Type 67F, Morcher) compris-
Figure 15. (Osher) Preoperative slitlamp photograph shows the apparent absence of iris and the cortical and axial posterior subcapsular opacities. 1544
ing a biconvex optic 5.0 mm in diameter and surrounded by a 2.5 mm wide, full-iris diaphragm. The implant was inserted (Figure 17), and intraoperative gonioscopy confirmed the placement in the ciliary sulcus behind the residual stump of the peripheral iris. Postoperatively, visual acuity improved to 20/100, which was consistent with the patient’s nystagmus and macular hypoplasia. The aniridia IOL was in excellent position, and the anterior segment was quiet with normal IOP (Figure 18). The patient was very satisfied with the improvement in her sight and the disappearance of her glare symptoms in the operative eye.
Case 5 A 56-year-old man was referred with a history of trauma to the right eye 5 months earlier. He had suffered an extensive penetrating corneal injury from a metal punch, which had avulsed the entire iris and ruptured the lens capsule. The corneal laceration had been repaired, but the lens had become
Figure 16. (Osher) Intraoperative photograph shows peripheral capsular tears highlighting the extreme friability of the anterior capsule.
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Figure 17. (Osher) Insertion of Morcher type 67F device.
hypermature and the patient developed lens particle glaucoma. Ocular medications included prednisolone acetate, atropine, Timoptic, and Trusopt. On examination, visual acuity was reduced to light perception, and the anterior chamber was filled with fluffy white lens material. Positive findings included a transcorneal curvilinear scar, diffuse epithelial edema, zonular dialysis between 6 and 8 o’clock, and complete absence of visible iris tissue (Figure 19). Intraocular pressure was 26 mm Hg on the medications mentioned previously. There was no view of the retina because of the opaque cataract, and B-scan ultrasonography demonstrated vitreous hemorrhage without evidence of retinal detachment. After the patient gave appropriate informed consent, surgery was performed in January 1999. The anterior chamber was cleared of lens material, exposing a large laceration in the anterior lens capsule. A small capsulorhexis was made far from the rupture site to accommodate phacoemulsification and removal of the remaining cortex. Inspection of the capsular bag demonstrated visible accordion-like folds in the peripheral bag, suggesting a pre-existing equatorial rupture in the cap-
Figure 18. (Osher) Postoperative retroillumination photograph highlighting the artificial iris.
sule. Because of experience with endocapsular ring stability in the presence of capsular defects, the surgeon (R.H.O.) elected to place 2 artificial iris rings (Type 50C) in the capsular bag through the remote capsulorhexis site (Figure 20). The iris diaphragm appeared stable and centered; thus, an acrylic IOL was placed over the rings within the torn capsular bag (Figure 21). Last, the bridge of anterior capsule between the preexisting tear and the capsulorhexis was excised. Intraoperative ophthalmoscopy revealed an attached retina with resolving vitreous hemorrhage. During the first postoperative week, elevated IOP was managed with medical therapy. Visual acuity improved to 20/70 consistent with the resolving corneal edema, irregular astigmatism, and old vitreous hemorrhage. The IOL and iris rings appeared in excellent position, and the patient’s light sensitivity was markedly improved. At the 1 month postoperative visit, visual acuity was reduced to 20/100, and the anterior segment was more inflamed than expected despite topical steroidal and nonsteroidal medications. Intraocular pressure measured 28 mm Hg with the use of prednisolone acetate (Pred Forte威), Timoptic, Trusopt, and Alphagan. The IOL and iris rings were well positioned, but corrugations of the nasal posterior capsule were visible as evidence of the suspected equatorial capsular tear. Cystoid macular edema was identified through the vitreous hemorrhage, and the patient had a pars plana vitrectomy to attempt to clear the vitreous hemorrhage and inflammatory debris. At the time of the vitrectomy, 2 atrophic holes were discovered in the inferior retinal periphery and were treated with endolaser photocoagulation. The patient returned 1 month later with a small, localized, inferior retinal detachment. This was managed by additional vitrectomy, membrane peeling, fluid–air exchange, and endolaser treatment. After this procedure, the IOL was decentered nasally through the equatorial capsular tear. The lens was then recentered and captured within the aniridia rings.
Figure 19. (Osher) Preoperative photograph shows the healed corneal scar and extensive lens material spilled into the anterior chamber (surgeon’s view).
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Postoperatively, the lens and rings remained stable in excellent position, and visual acuity improved to 20/60. The patient was pleased with his visual improvement; however, his prognosis after extensive penetrating trauma remains guarded.
by the corneal surface disease, nystagmus, and macular hypoplasia, the patient noticed a significant improvement in quality of vision as well as a marked reduction in glare. The aniridia lens has remained in excellent position, and the fellow eye has been scheduled for surgery (Figure 22).
Case 6 A 61-year-old man presented with congenital aniridia, corneal pannus, macular hypoplasia, nystagmus, and medically controlled glaucoma. He had had bilateral extracapsular cataract extraction in 1980 and was intolerant of his aphakic contact lenses and extremely sensitive to light. Examination revealed visual acuity of 20/160 in the right eye and 20/125 in the left with aphakic gas-permeable contact lenses. Biomicroscopy disclosed an irregular corneal epithelium with peripheral subepithelial scarring and neovascularization. A torn posterior capsule with vitreous prolapse was present in the right eye, while the posterior capsule in the left eye was intact. Gonioscopy showed a remnant of peripheral iris present for 360 degrees in each eye. The IOP measured 18 mm Hg and 15 mm Hg in the right and left eyes, respectively, on Timoptic and Alphagan. The cup-to-disc ratio was approximately 0.5 in each eye. In March 1999, the patient had an anterior vitrectomy followed by implantation of a ⫹20.0 D Morcher Type 67F lens–iris device. The implant has a haptic diameter of 13.5 mm and an eyelet on each haptic, allowing the device to be sutured to the sclera at the level of the ciliary sulcus. Intraoperative gonioscopy confirmed proper positioning of the device behind the iris remnant. The 10.0 mm incision was closed with 7 interrupted 10-0 nylon sutures. Because of the history of glaucoma and because a small amount of viscoelastic material would be retained behind the implant, a small area of the wound was intentionally left loose to allow a slight fluid leak under the sutured conjunctival flap, avoiding a postoperative IOP spike. The postoperative course was uneventful except for transient hypotony. Although visual acuity was limited to 20/160
Figure 20. (Osher) Intraoperative photograph shows insertion of the first of 2 artificial iris rings (Type 50C). 1546
Discussion Use of an IOL with an artificial iris is not new. An anterior chamber lens with an optic surrounded by a colored diaphragm was designed by Choyce in 1959.3 We are also aware of a similar posterior chamber lens– iris diaphragm designed by John Pearce of England nearly 20 years ago. Various Morcher IOLs consisting of opaque diaphragms surrounding an optical lens have been described.4 One drawback of placing the optic within an iris diaphragm is that a relatively large incision is required to obtain a full iris diaphragm. To avoid the drawbacks of large incisions, Heino Hermeking, MD, of Germany, designed a system in which the optic portion and the iris diaphragm are inserted separately and then assembled in the eye. The Type 50C Morcher endocapsular ring with iris diaphragm, developed by Volker Rasch, MD, of Potsdam, Germany, provides a method for combining iris diaphragm implantation with modern small incision surgery. The 50C aniridia ring does not have an optical portion and therefore can be inserted through the same small incision as the foldable IOL. This approach offers the advantages of a full iris diaphragm and separate optical system, both of which may be inserted through a sutureless small incision. The iris diaphragm produces a pupil size of approxi-
Figure 21. (Osher) Intraoperative photograph demonstrating the appearance of the eye after foldable IOL implantation.
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Figure 22. (Osher) Retroillumination photograph highlights the postoperative appearance of a well-centered Type 67F sutured IOL.
mately 6.0 mm, which is compatible with excellent fundus viewing. The disadvantage of the 50C is that the device is brittle and susceptible to fracture. Moreover, the insertion technique is not fully refined, and we have implanted the rings behind, in front of, and even straddling the IOL with some technical difficulty. Finally, the capsular bag can become somewhat crowded after 3 devices have been inserted. With respect to safety, the pigment used for dyeing the poly(methyl methacrylate) (PMMA) black is nontoxic, and it is polymerized into the clear PMMA. Morcher has tested this material since 1991, and it was certified with the communaute´ europe´enne mark in 1994, satisfying the European requirements for an implanted medical product. Another important safety issue can be examined in patients with a torn posterior capsule (Cases 1 and 5). Although the centrifugal forces of an expansile device could theoretically result in posterior subluxation into the vitreous cavity, the stability of the ring was confirmed even in the presence of a large tear through the capsular bag. However, when the integrity of the capsular bag is compromised, we recommend implantation of a single-piece lens–iris device, as described in Cases 4 and 6. To date, the indications for an artificial iris have been congenital and traumatic aniridia as well as iris
atrophy. An artificial iris diaphragm has also been useful in preventing silicone– endothelial contact after vitreoretinal surgery.5–7 In this series, we have presented our approach to the management of cataract or aphakia with visually disabling glare secondary to iris loss or absence. These 6 challenging cases had various problems, including aniridia, trauma, and iris atrophy. We have evaluated the surgical techniques for implantation of a variety of artificial iris diaphragms in combination with cataract surgery. Our approach permits insertion of the Morcher Type 50C and Type 96G iris devices through the same small incision as the foldable IOL, while offering an adequate pupil diameter through which to view fundus detail. If endocapsular fixation is not possible, the Type 67F is ideal for ciliary sulcus fixation or haptic suturing to the sclera. As we move forward with the development of artificial irides, the design, availability, and flexibility, as well as insertion techniques, will likely continue to improve.
References 1. Reinhard T, Sundmacher R, Althaus C. Irisblenden-IOL bei Traumatischer Aniridie. Klin Monatsbl Augenheilkd 1994; 205:196 –200 2. Osher RH. Slow motion phacoemulsification approach (letter). J Cataract Refract Surg 1993; 19:667 3. Choyce P. Intra-ocular Lenses and Implants. London, England, HK Lewis, 1964; 21 4. Variations of the Aniridia IOL. Stuttgart, Germany, Morcher, April 1997 5. Marullo M, Scupola A, Pasqua R, et al. Iris diaphragm implantation in post-traumatic aniridia and tractional retinal detachment. Eur J Opthalmol 1997; 7:171–173 6. Heimann K, Konen W. Ku¨nstliches Irisdiaphragma fu¨r die Silikono¨ chirurgie. Fortschr Ophthalmol 1990; 87: 329 –330 7. Thurmann G, Kirchhof B, Bartz-Schmidt KU, et al. The artificial iris diaphragm for vitreoretinal silicone oil surgery. Retina 1997; 17:330 –337
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Cataract surgery combined with implantation of an artificial iris Robert H. Osher, MD, Scott E. Burk, MD, PhD ABSTRACT We describe 6 patients who presented with cataract or aphakia and absent or nonfunctional irides. The etiologies included congenital aniridia, traumatic iris loss, and chronic mydriasis secondary to recurrent herpetic uveitis. In 5 eyes, a prosthetic iris was successfully implanted in combination with small incision cataract surgery. In 2 eyes, a single-piece iris diaphragm and optical lens was implanted. Artificial irides offer a safe alternative for patients who previously had no viable options for iris reconstruction. J Cataract Refract Surg 1999; 25:1540 –1547 © 1999 ASCRS and ESCRS
T
he artificial iris implant was introduced in Europe in 1994 by Reinhard and coauthors,1 who reported using the black diaphragm intraocular lens (IOL) in traumatic aniridia (Figure 1). Subsequently, Rosenthal reported the first use of a smaller incision artificial iris implant in the United States in 1996 in a case of iris dysgenesis (Figure 2) (K. Rosenthal, MD, “Iris Diaphragm Ring Insertion,” presented at the Welsh Cataract Congress, Houston, Texas, USA, September 1996). We report 7 eyes of 6 patients with congenital aniridia, traumatic iris loss, or chronic mydriasis. All patients noted a marked reduction of glare symptoms and qualitative improvement in their vision after implantation of these prosthetic devices. Case 1
A 25-year-old woman was diagnosed with congenital cataract, aniridia, high myopia, and 25 prism diopters of alter-
Accepted for publication June 10, 1999. From the Cincinnati Eye Institute, Cincinnati, Ohio, USA. Neither author has a proprietary or financial interest in any product mentioned. Reprint requests to Robert H. Osher, MD, Cincinnati Eye Institute, 10494 Montgomery Road, Cincinnati, Ohio 45242, USA. © 1999 ASCRS and ESCRS Published by Elsevier Science Inc.
nating exotropia for which strabismus surgery had been performed. A review of her ocular history disclosed a best corrected visual acuity (BCVA) (Snellen) of 20/60 in each eye before maturation of the cataracts. Maternal history was positive for aniridia and cataracts. Examination revealed a Snellen visual acuity of hand motions in the right eye and 20/400 in the left with a ⫺10.50 diopter (D) sphere. Biomicroscopy disclosed a tiny remnant of iris tissue in each anterior segment, and both lenses were opaque with anterior polar elevations (Figure 3). Intraocular pressure (IOP) was normal in both eyes. Fundus examination was difficult because of the dense cataract. After informed consent was obtained from the patient and approval of the Institutional Review Committee at the Cincinnati Eye Institute was received, surgery was performed in the right eye on September 22, 1997. The capsulorhexis was completed, and the nucleus was removed using slow motion phacoemulsification.2 After cortical removal and posterior capsule vacuuming, 2 endocapsular rings with multiple fins (Type 50C) were sequentially inserted and rotated into the capsular bag (Figure 4). The surgeon was unaware that during the rotation of the more anterior ring, the edge of the anterior capsule was nicked by a microhook. When a ⫹17.0 D AcrySof威 IOL (Alcon Surgical Products, Inc.) was inserted in the capsular bag, the anterior capsule tear extended around the equator and totally transected the posterior capsule. This sequence was captured on videotape; otherwise, the cause of the tear would not have been identified. Despite the capsule tear, the rings remained stable and supported the IOL, 0886-3350/99/$–see front matter PII S0886-3350(99)00246-1
CASE REPORTS: OSHER
Figure 1. (Osher) Morcher single-piece iris-diaphragm IOL type
Figure 2. (Osher) Morcher iris diaphragm ring type 50C.
67G.
which was well centered in the capsular bag perpendicular to the orientation of the tear (Figure 5). The postoperative course was uneventful. The patient attained a visual acuity of 20/30 and expressed satisfaction that her lifelong glare was no longer present. The IOL remained well centered and did not shift during the 18 month follow-up. In August 1998, the cataract in the fellow eye was removed by phacoemulsification. The same artificial iris rings (Type 50C) and a ⫹17.0 D AcrySof IOL were placed in the intact capsular bag uneventfully. The patient attained a successful result similar to that in the first eye, with a final BCVA of 20/50 (Figure 6).
Case 2
Figure 3. (Osher) Opaque cataract with anterior polar elevation in
Figure 4. (Osher) Insertion of 2 Morcher iris diaphragm ring type
an aniridic eye.
50C rings.
A 28-year-old woman was referred, having sustained a penetrating injury to her right eye when she was struck by a nail 2 years previously. She immediately lost her vision, which did not improve after a surgical procedure whose details were unknown. She reported blurred vision and bothersome glare. Examination revealed a Snellen visual acuity of 20/200 in the right eye. Biomicroscopy disclosed a nasal conjunctival scar with complete loss of nasal iris, exposing an abnormal lens with posterior subcapsular opacification and capsular striae converging on a fibrotic equatorial scar (Figure 7). Intraocular pressure was normal. The posterior segment revealed a pig-
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Figure 5. (Osher) Horizontal tear in posterior capsule noticed as
Figure 6. (Osher) Slitlamp appearance of iris rings in second eye.
AcrySof IOL inserted.
mented chorioretinal scar associated with retinal striae located just above the papillomacular bundle. Having given informed consent for cataract surgery and prosthetic iris implantation according to the protocol developed by the Institutional Review Board at the Cincinnati Eye Institute, the patient had slow motion phacoemulsification in June 1998. No complications occurred despite the previous rupture of the equatorial lens capsule. Fortified by a fibrotic scar, the capsular bag remained intact, allowing endocapsular implantation of a single-piece IOL. A sector iris device (Type 96G) with a single fin (Figure 8) was placed in the capsular bag and rotated until it occupied the location of the nasal iris defect (Figure 9). On the first postoperative day, uncorrected visual acuity was 20/40, improving to 20/20 with a ⫺0.75 D spherical refractive error at 1 week postoperatively. The pupil was slightly nasal, measuring 3.0 mm; both the IOL and artificial iris were in excellent position (Figure 10). The patient was followed for 8 months, during which she experienced no glare
or IOL-edge-related symptoms. The anterior segment remained stable and quiet, and the optic’s nasal edge remained covered by the prosthetic iris device.
Figure 7. (Osher) Cataractous lens with traumatic loss of nasal iris
Figure 8. (Osher) Sector iris prosthesis (Morcher iris-diaphragm ring type 96G).
and equatorial capsular rupture.
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Case 3 A 68-year-old woman was referred for a mature cataract, elevated IOP, and recurrent granulomatous anterior uveitis in the right eye, resulting in severe iris damage and a fixed dilated pupil. She had been examined at the Massachusetts Eye and Ear Infirmary, where a presumed diagnosis of herpetic uveitis was made and long-term systemic antiviral therapy recommended. Her ocular medications included prednisolone acetate and dorzolamide hydrochloride with timolol maleate (Cosopt威) twice a day in the right eye. Ocular history was positive for biopsy-proven Sjo¨gren’s syndrome. Examination revealed a Snellen visual acuity of 20/200, which was consistent with mature brunescent nuclear sclerosis and complete cortical opacification. The anterior chamber was deep with mild flare but no cells. The right pupil was
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Figure 9. (Osher) Nasal iris defect occupied by sector iris prosthesis (surgeon’s view).
Figure 10. (Osher) Slitlamp appearance of sector iris device.
8.5 mm in diameter and immobile (Figure 11). Widespread posterior synechiae were present and the iris was diaphanous with numerous transillumination defects. Intraocular pressure was 15 mm Hg, and the fundus could not be viewed through the cataract. After appropriate informed consent was obtained, the right cataract was removed by slow motion phacoemulsification in August 1998. An Alcon AcrySof IOL was implanted in the capsular bag, and additional sodium hyaluronate 1.4% (Healon GV威) was injected behind the IOL. The first iris ring (Type 50C) was inserted in the capsular bag posterior to the IOL. The Healon GV was removed from the posterior capsular bag with a 27 gauge cannula and reinjected in front of the IOL, displacing the optic posteriorly. The second iris ring was inserted in the bag in front of the IOL (Figure 12). The anterior ring was rotated with a Sinskey hook until the interdigitating plates appeared contiguous, forming a solid iris diaphragm (Figure 13). The Healon GV was removed and the watertight incision left sutureless.
On the first postoperative day, IOP was 43 mm Hg. The patient was given topical dorzolamide hydrochloride (Trusopt威), pilocarpine, timolol maleate (Timoptic威), and brimonidine (Alphagan威) as well as oral acetazolamide (Diamox威). Intraocular pressure decreased to 12 mm Hg within several hours. The postoperative course was otherwise uneventful, and the visual acuity improved to 20/20. The new pupil was 6.0 mm in diameter with no iris transillumination defects (Figure 14). The persistent glare the patient experienced before maturation of her cataract resolved.
Figure 11. (Osher) Fixed dilated pupil, cataract, and posterior synechiae secondary to chronic uveitis.
Case 4 A 49-year-old woman was referred with congenital aniridia, nystagmus, glaucoma, and cataract in the left eye. She had had extracapsular surgery with implantation of a sulcus-fixated IOL in the right eye elsewhere. Although she reported poor vision, her chief complaint was intolerable glare. Her family history was positive for aniridia.
Figure 12. (Osher) Insertion of second iris ring.
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Figure 13. (Osher) Surgical appearance of artificial iris and IOL.
Figure 14. (Osher) Slitlamp appearance of IOL and artificial iris rings 1 day postoperatively.
Examination revealed a visual acuity of 20/200 in the pseudophakic right eye and 20/250 in the phakic left eye. There was no visible iris in either eye. A single-piece IOL was present in the right eye, and the posterior capsule was thickened and opacified. The left lens showed cortical and axial posterior subcapsular opacities (Figure 15). Gonioscopy disclosed a tiny iris remnant for 360 degrees. Other positive findings included borderline IOPs on timolol (Betimol威), congenital nystagmus, and hypoplasia of the maculae. After the patient gave appropriate informed consent, the left cataract was removed by phacoemulsification in January 1999. The anterior capsule was abnormally thin and behaved like wet tissue paper during the attempted capsulorhexis. After the nucleus and cortex were removed and the posterior capsule vacuumed, several peripheral tears in the anterior capsule were observed (Figure 16). Because of aberrant capsule fragility, a single-piece lens–iris diaphragm was implanted in the ciliary sulcus. The incision was enlarged to 10.0 mm to accommodate a 20.5 D lens–iris device (Type 67F, Morcher) compris-
Figure 15. (Osher) Preoperative slitlamp photograph shows the apparent absence of iris and the cortical and axial posterior subcapsular opacities. 1544
ing a biconvex optic 5.0 mm in diameter and surrounded by a 2.5 mm wide, full-iris diaphragm. The implant was inserted (Figure 17), and intraoperative gonioscopy confirmed the placement in the ciliary sulcus behind the residual stump of the peripheral iris. Postoperatively, visual acuity improved to 20/100, which was consistent with the patient’s nystagmus and macular hypoplasia. The aniridia IOL was in excellent position, and the anterior segment was quiet with normal IOP (Figure 18). The patient was very satisfied with the improvement in her sight and the disappearance of her glare symptoms in the operative eye.
Case 5 A 56-year-old man was referred with a history of trauma to the right eye 5 months earlier. He had suffered an extensive penetrating corneal injury from a metal punch, which had avulsed the entire iris and ruptured the lens capsule. The corneal laceration had been repaired, but the lens had become
Figure 16. (Osher) Intraoperative photograph shows peripheral capsular tears highlighting the extreme friability of the anterior capsule.
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Figure 17. (Osher) Insertion of Morcher type 67F device.
hypermature and the patient developed lens particle glaucoma. Ocular medications included prednisolone acetate, atropine, Timoptic, and Trusopt. On examination, visual acuity was reduced to light perception, and the anterior chamber was filled with fluffy white lens material. Positive findings included a transcorneal curvilinear scar, diffuse epithelial edema, zonular dialysis between 6 and 8 o’clock, and complete absence of visible iris tissue (Figure 19). Intraocular pressure was 26 mm Hg on the medications mentioned previously. There was no view of the retina because of the opaque cataract, and B-scan ultrasonography demonstrated vitreous hemorrhage without evidence of retinal detachment. After the patient gave appropriate informed consent, surgery was performed in January 1999. The anterior chamber was cleared of lens material, exposing a large laceration in the anterior lens capsule. A small capsulorhexis was made far from the rupture site to accommodate phacoemulsification and removal of the remaining cortex. Inspection of the capsular bag demonstrated visible accordion-like folds in the peripheral bag, suggesting a pre-existing equatorial rupture in the cap-
Figure 18. (Osher) Postoperative retroillumination photograph highlighting the artificial iris.
sule. Because of experience with endocapsular ring stability in the presence of capsular defects, the surgeon (R.H.O.) elected to place 2 artificial iris rings (Type 50C) in the capsular bag through the remote capsulorhexis site (Figure 20). The iris diaphragm appeared stable and centered; thus, an acrylic IOL was placed over the rings within the torn capsular bag (Figure 21). Last, the bridge of anterior capsule between the preexisting tear and the capsulorhexis was excised. Intraoperative ophthalmoscopy revealed an attached retina with resolving vitreous hemorrhage. During the first postoperative week, elevated IOP was managed with medical therapy. Visual acuity improved to 20/70 consistent with the resolving corneal edema, irregular astigmatism, and old vitreous hemorrhage. The IOL and iris rings appeared in excellent position, and the patient’s light sensitivity was markedly improved. At the 1 month postoperative visit, visual acuity was reduced to 20/100, and the anterior segment was more inflamed than expected despite topical steroidal and nonsteroidal medications. Intraocular pressure measured 28 mm Hg with the use of prednisolone acetate (Pred Forte威), Timoptic, Trusopt, and Alphagan. The IOL and iris rings were well positioned, but corrugations of the nasal posterior capsule were visible as evidence of the suspected equatorial capsular tear. Cystoid macular edema was identified through the vitreous hemorrhage, and the patient had a pars plana vitrectomy to attempt to clear the vitreous hemorrhage and inflammatory debris. At the time of the vitrectomy, 2 atrophic holes were discovered in the inferior retinal periphery and were treated with endolaser photocoagulation. The patient returned 1 month later with a small, localized, inferior retinal detachment. This was managed by additional vitrectomy, membrane peeling, fluid–air exchange, and endolaser treatment. After this procedure, the IOL was decentered nasally through the equatorial capsular tear. The lens was then recentered and captured within the aniridia rings.
Figure 19. (Osher) Preoperative photograph shows the healed corneal scar and extensive lens material spilled into the anterior chamber (surgeon’s view).
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Postoperatively, the lens and rings remained stable in excellent position, and visual acuity improved to 20/60. The patient was pleased with his visual improvement; however, his prognosis after extensive penetrating trauma remains guarded.
by the corneal surface disease, nystagmus, and macular hypoplasia, the patient noticed a significant improvement in quality of vision as well as a marked reduction in glare. The aniridia lens has remained in excellent position, and the fellow eye has been scheduled for surgery (Figure 22).
Case 6 A 61-year-old man presented with congenital aniridia, corneal pannus, macular hypoplasia, nystagmus, and medically controlled glaucoma. He had had bilateral extracapsular cataract extraction in 1980 and was intolerant of his aphakic contact lenses and extremely sensitive to light. Examination revealed visual acuity of 20/160 in the right eye and 20/125 in the left with aphakic gas-permeable contact lenses. Biomicroscopy disclosed an irregular corneal epithelium with peripheral subepithelial scarring and neovascularization. A torn posterior capsule with vitreous prolapse was present in the right eye, while the posterior capsule in the left eye was intact. Gonioscopy showed a remnant of peripheral iris present for 360 degrees in each eye. The IOP measured 18 mm Hg and 15 mm Hg in the right and left eyes, respectively, on Timoptic and Alphagan. The cup-to-disc ratio was approximately 0.5 in each eye. In March 1999, the patient had an anterior vitrectomy followed by implantation of a ⫹20.0 D Morcher Type 67F lens–iris device. The implant has a haptic diameter of 13.5 mm and an eyelet on each haptic, allowing the device to be sutured to the sclera at the level of the ciliary sulcus. Intraoperative gonioscopy confirmed proper positioning of the device behind the iris remnant. The 10.0 mm incision was closed with 7 interrupted 10-0 nylon sutures. Because of the history of glaucoma and because a small amount of viscoelastic material would be retained behind the implant, a small area of the wound was intentionally left loose to allow a slight fluid leak under the sutured conjunctival flap, avoiding a postoperative IOP spike. The postoperative course was uneventful except for transient hypotony. Although visual acuity was limited to 20/160
Figure 20. (Osher) Intraoperative photograph shows insertion of the first of 2 artificial iris rings (Type 50C). 1546
Discussion Use of an IOL with an artificial iris is not new. An anterior chamber lens with an optic surrounded by a colored diaphragm was designed by Choyce in 1959.3 We are also aware of a similar posterior chamber lens– iris diaphragm designed by John Pearce of England nearly 20 years ago. Various Morcher IOLs consisting of opaque diaphragms surrounding an optical lens have been described.4 One drawback of placing the optic within an iris diaphragm is that a relatively large incision is required to obtain a full iris diaphragm. To avoid the drawbacks of large incisions, Heino Hermeking, MD, of Germany, designed a system in which the optic portion and the iris diaphragm are inserted separately and then assembled in the eye. The Type 50C Morcher endocapsular ring with iris diaphragm, developed by Volker Rasch, MD, of Potsdam, Germany, provides a method for combining iris diaphragm implantation with modern small incision surgery. The 50C aniridia ring does not have an optical portion and therefore can be inserted through the same small incision as the foldable IOL. This approach offers the advantages of a full iris diaphragm and separate optical system, both of which may be inserted through a sutureless small incision. The iris diaphragm produces a pupil size of approxi-
Figure 21. (Osher) Intraoperative photograph demonstrating the appearance of the eye after foldable IOL implantation.
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Figure 22. (Osher) Retroillumination photograph highlights the postoperative appearance of a well-centered Type 67F sutured IOL.
mately 6.0 mm, which is compatible with excellent fundus viewing. The disadvantage of the 50C is that the device is brittle and susceptible to fracture. Moreover, the insertion technique is not fully refined, and we have implanted the rings behind, in front of, and even straddling the IOL with some technical difficulty. Finally, the capsular bag can become somewhat crowded after 3 devices have been inserted. With respect to safety, the pigment used for dyeing the poly(methyl methacrylate) (PMMA) black is nontoxic, and it is polymerized into the clear PMMA. Morcher has tested this material since 1991, and it was certified with the communaute´ europe´enne mark in 1994, satisfying the European requirements for an implanted medical product. Another important safety issue can be examined in patients with a torn posterior capsule (Cases 1 and 5). Although the centrifugal forces of an expansile device could theoretically result in posterior subluxation into the vitreous cavity, the stability of the ring was confirmed even in the presence of a large tear through the capsular bag. However, when the integrity of the capsular bag is compromised, we recommend implantation of a single-piece lens–iris device, as described in Cases 4 and 6. To date, the indications for an artificial iris have been congenital and traumatic aniridia as well as iris
atrophy. An artificial iris diaphragm has also been useful in preventing silicone– endothelial contact after vitreoretinal surgery.5–7 In this series, we have presented our approach to the management of cataract or aphakia with visually disabling glare secondary to iris loss or absence. These 6 challenging cases had various problems, including aniridia, trauma, and iris atrophy. We have evaluated the surgical techniques for implantation of a variety of artificial iris diaphragms in combination with cataract surgery. Our approach permits insertion of the Morcher Type 50C and Type 96G iris devices through the same small incision as the foldable IOL, while offering an adequate pupil diameter through which to view fundus detail. If endocapsular fixation is not possible, the Type 67F is ideal for ciliary sulcus fixation or haptic suturing to the sclera. As we move forward with the development of artificial irides, the design, availability, and flexibility, as well as insertion techniques, will likely continue to improve.
References 1. Reinhard T, Sundmacher R, Althaus C. Irisblenden-IOL bei Traumatischer Aniridie. Klin Monatsbl Augenheilkd 1994; 205:196 –200 2. Osher RH. Slow motion phacoemulsification approach (letter). J Cataract Refract Surg 1993; 19:667 3. Choyce P. Intra-ocular Lenses and Implants. London, England, HK Lewis, 1964; 21 4. Variations of the Aniridia IOL. Stuttgart, Germany, Morcher, April 1997 5. Marullo M, Scupola A, Pasqua R, et al. Iris diaphragm implantation in post-traumatic aniridia and tractional retinal detachment. Eur J Opthalmol 1997; 7:171–173 6. Heimann K, Konen W. Ku¨nstliches Irisdiaphragma fu¨r die Silikono¨ chirurgie. Fortschr Ophthalmol 1990; 87: 329 –330 7. Thurmann G, Kirchhof B, Bartz-Schmidt KU, et al. The artificial iris diaphragm for vitreoretinal silicone oil surgery. Retina 1997; 17:330 –337
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