- Email: [email protected]
Fixation of subluxated iris-claw anterior chamber intraocular lens in complex case using a retrievable suture technique
552
CORRESPONDENCE
segments. While this has been reported as a useful technique for repositioning an IOL, we believe this is the first report of the use of this technique with an in-the-bag prosthesis. Indeed, the technique may be more facile in cases such as this since the capsular bag can be more readily OVD dissected in the absence of anterior–posterior capsule fusion. This precludes the need to explant and replace existing intracapsular contents, resulting in the greater safety of smaller wounds.5 Also, the glare reduction in the iris devices is maintained. Although off-label for ophthalmic use, the polytetrafluoroethylene suture does not show signs of the hydrolysis or suture breakage associated with a polypropylene suture6 and has greater tensile strength than polypropylene.7 This case presents the successful management of a subluxated capsular bag containing multiple devices in a manner that avoids the potential complications associated with other techniques. REFERENCES 1. Mavrikakis I, Mavrikakis E, Syam PP, Bell J, Casey JH, Casswell AG, Brittain GP, Liu C. Surgical management of iris defects with prosthetic iris devices. Eye 2005; 19:205–209. Available at: http://www.nature.com/eye/journal/v19/n2/pdf/ 6701448a.pdf Accessed October 5, 2011 2. Burk SE, Da Mata AP, Snyder ME, Cionni RJ, Cohen JS, Osher RH. Prosthetic iris implantation for congenital, traumatic, or functional iris deficiencies. J Cataract Refract Surg 2001; 27:1732–1740 3. Karatza EC, Burk SE, Snyder ME, Osher RH. Outcomes of prosthetic iris implantation in patients with albinism. J Cataract Refract Surg 2007; 33:1763–1769 4. Neuhann IM, Neuhann TF. Cataract surgery and aniridia. Curr Opin Ophthalmol 2010; 21:60–64 5. Gimbel HV, Condon GP, Kohnen T, Olson RJ, Halkiadakis I. Late in-the-bag intraocular lens dislocation: incidence, prevention, and management. J Cataract Refract Surg 2005; 31:2193–2204 6. Price MO, Price FW Jr, Werner L, Berlie C, Mamalis N. Late dislocation of scleral-sutured posterior chamber intraocular lenses. J Cataract Refract Surg 2005; 31:1320–1326 7. von Fraunhofer JA, Storey RJ, Masterson BJ. Tensile properties of suture materials. Biomaterials 1988; 9:324–327
OTHER CITED MATERIAL A. Arbisser L, “Management of Postoperative Residual Refractive Error, ” presented at the annual meeting of the American Academy of Ophthalmology, Orlando, Florida, USA, November 2009
Fixation of subluxated iris-claw anterior chamber intraocular lens in complex case using a retrievable suture technique Francisco Arnalich-Montiel, MD, PhD, Cristina Irigoyen, MD, Constanza Barrancos, MD We present the case of a 27-year-old man with homocystinuria who was sent to our department with a superior iris defect, iris hypoplasia, a temporally
dislocated Artisan anterior chamber intraocular lens (AC IOL) (Ophtec, Inc.), and a corneal decompensation in the left eye. Iris repair and IOL fixation were indicated prior to a Descemet-stripping automated endothelial keratoplasty procedure that was programmed in a second stage. The superior iris defect was corrected using the McCannel/Siepser iris suture technique.1 However, fixating the subluxated haptic with an enclavation needle was difficult because of the thin and hypoplastic iris of the patient and poor visualization of the anterior chamber secondary to corneal edema. It was decided to fixate the AC IOL using a modified McCannel/Siepser iris suture technique1,2 to grip the iris and enclavate it into the IOL claw. A beveled stab incision was made inside the corneolimbal junction at the level where the subluxated IOL claw was to be positioned. Another stab incision, large enough to insert an IOL manipulator instrument, was made inferiorly. Using a double-armed 10-0 polypropylene (Prolene) suture, a long straight needle was passed through the superotemporal limbus to engage the iris just above where the iris claw was to be secured, exiting the iris 2.0 to 3.0 mm below the entry point. The straight needle then exited from the inferotemporal limbus. A microhook was introduced through the original stab incision to engage the intraocular proximal and distal ends of the suture. Both ends of the suture were withdrawn through this incision. Having the iris engaged, the suture was pulled upward with a forceps while the IOL body was simultaneously pressed backward using a manipulator instrument through the inferior incision. The steps of this technique are shown in Figure 1. Once the iris was engaged in the IOL claw, the suture was removed and the self-sealing paracentesis hydrated. The IOL was well centered and stable postoperatively, and no complications were observed in the 4-month follow-up period. The patient is currently waiting for his corneal graft procedure. DISCUSSION We believe that this technique is a useful option to easily fixate a subluxated iris claw AC IOL (such as the Artisan) even in challenging situations such as patients with abnormally thin or hypoplastic irises, as in connective tissue diseases such as Marfan syndrome3,4 or Ehler-Danlos syndrome; after intraocular surgical trauma; and in situations with poor visualization of the iris through a hazy cornea. This procedure can be done with simple instrumentation. It is a very straightforward maneuver that avoids the needle enclavation step, which in some cases can be difficult. It is not necessary to hold the IOL body with a forceps so all
J CATARACT REFRACT SURG - VOL 38, MARCH 2012
CORRESPONDENCE
553
Figure 1. A: The AC IOL is repositioned with the haptics at 3 and 9 o’clock centered on the pupil (left eye). The claw at 3 o’clock is not grabbing any iris tissue. B: Paracenteses are made at 3 o’clock and at 5 o’clock, and the surgeon sits at 3 o’clock. C: The initial pass of the 10-0 polypropylene straight suture through the superotemporal limbus, coming in and out of the iris. D: The needle exits through the inferotemporal limbus. E and F: The superior end of the suture is externalized through the 3 o’clock incision, first retrieving a loop (E) and then the complete suture end (F). F and G: The same steps are followed to externalize the inferior end of the suture after the needle has been cut. H: Simultaneously, the IOL body is gently pushed backward with an IOL manipulator as the ends of the suture are pulled upward in the opposite direction to engage the iris with the claw. I: Finally, the IOL is fixated at both IOL claws.
the surgery is done through small self-sealing incisions and a stable anterior chamber. REFERENCES 1. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976; 7(2):98–103 2. Siepser SB. The closed-chamber slipping suture technique for iris repair. Ann Ophthalmol Glaucoma 1994; 26:71–72
3. Hirashima DE, Soriano ES, Meirelles RL, Alberti GN, W. Outcomes of iris-claw anterior chamber versus Nose iris-fixated foldable intraocular lens in subluxated lens secondary to Marfan syndrome. Ophthalmology 2010; 117: 1479–1485 4. De Paepe A, Devereux RB, Dietz HC, Hennekam RC, Pyeritz RE. Revised diagnostic criteria for the Marfan syndrome. Am J Med Genet 1996; 62:417–426. Available at: http://diagnosticcriteria.net/ marfan/reprints/DePaepe-1996-AJMG-62-p417-426.pdf. Accessed November 12, 2011
J CATARACT REFRACT SURG - VOL 38, MARCH 2012
CORRESPONDENCE
segments. While this has been reported as a useful technique for repositioning an IOL, we believe this is the first report of the use of this technique with an in-the-bag prosthesis. Indeed, the technique may be more facile in cases such as this since the capsular bag can be more readily OVD dissected in the absence of anterior–posterior capsule fusion. This precludes the need to explant and replace existing intracapsular contents, resulting in the greater safety of smaller wounds.5 Also, the glare reduction in the iris devices is maintained. Although off-label for ophthalmic use, the polytetrafluoroethylene suture does not show signs of the hydrolysis or suture breakage associated with a polypropylene suture6 and has greater tensile strength than polypropylene.7 This case presents the successful management of a subluxated capsular bag containing multiple devices in a manner that avoids the potential complications associated with other techniques. REFERENCES 1. Mavrikakis I, Mavrikakis E, Syam PP, Bell J, Casey JH, Casswell AG, Brittain GP, Liu C. Surgical management of iris defects with prosthetic iris devices. Eye 2005; 19:205–209. Available at: http://www.nature.com/eye/journal/v19/n2/pdf/ 6701448a.pdf Accessed October 5, 2011 2. Burk SE, Da Mata AP, Snyder ME, Cionni RJ, Cohen JS, Osher RH. Prosthetic iris implantation for congenital, traumatic, or functional iris deficiencies. J Cataract Refract Surg 2001; 27:1732–1740 3. Karatza EC, Burk SE, Snyder ME, Osher RH. Outcomes of prosthetic iris implantation in patients with albinism. J Cataract Refract Surg 2007; 33:1763–1769 4. Neuhann IM, Neuhann TF. Cataract surgery and aniridia. Curr Opin Ophthalmol 2010; 21:60–64 5. Gimbel HV, Condon GP, Kohnen T, Olson RJ, Halkiadakis I. Late in-the-bag intraocular lens dislocation: incidence, prevention, and management. J Cataract Refract Surg 2005; 31:2193–2204 6. Price MO, Price FW Jr, Werner L, Berlie C, Mamalis N. Late dislocation of scleral-sutured posterior chamber intraocular lenses. J Cataract Refract Surg 2005; 31:1320–1326 7. von Fraunhofer JA, Storey RJ, Masterson BJ. Tensile properties of suture materials. Biomaterials 1988; 9:324–327
OTHER CITED MATERIAL A. Arbisser L, “Management of Postoperative Residual Refractive Error, ” presented at the annual meeting of the American Academy of Ophthalmology, Orlando, Florida, USA, November 2009
Fixation of subluxated iris-claw anterior chamber intraocular lens in complex case using a retrievable suture technique Francisco Arnalich-Montiel, MD, PhD, Cristina Irigoyen, MD, Constanza Barrancos, MD We present the case of a 27-year-old man with homocystinuria who was sent to our department with a superior iris defect, iris hypoplasia, a temporally
dislocated Artisan anterior chamber intraocular lens (AC IOL) (Ophtec, Inc.), and a corneal decompensation in the left eye. Iris repair and IOL fixation were indicated prior to a Descemet-stripping automated endothelial keratoplasty procedure that was programmed in a second stage. The superior iris defect was corrected using the McCannel/Siepser iris suture technique.1 However, fixating the subluxated haptic with an enclavation needle was difficult because of the thin and hypoplastic iris of the patient and poor visualization of the anterior chamber secondary to corneal edema. It was decided to fixate the AC IOL using a modified McCannel/Siepser iris suture technique1,2 to grip the iris and enclavate it into the IOL claw. A beveled stab incision was made inside the corneolimbal junction at the level where the subluxated IOL claw was to be positioned. Another stab incision, large enough to insert an IOL manipulator instrument, was made inferiorly. Using a double-armed 10-0 polypropylene (Prolene) suture, a long straight needle was passed through the superotemporal limbus to engage the iris just above where the iris claw was to be secured, exiting the iris 2.0 to 3.0 mm below the entry point. The straight needle then exited from the inferotemporal limbus. A microhook was introduced through the original stab incision to engage the intraocular proximal and distal ends of the suture. Both ends of the suture were withdrawn through this incision. Having the iris engaged, the suture was pulled upward with a forceps while the IOL body was simultaneously pressed backward using a manipulator instrument through the inferior incision. The steps of this technique are shown in Figure 1. Once the iris was engaged in the IOL claw, the suture was removed and the self-sealing paracentesis hydrated. The IOL was well centered and stable postoperatively, and no complications were observed in the 4-month follow-up period. The patient is currently waiting for his corneal graft procedure. DISCUSSION We believe that this technique is a useful option to easily fixate a subluxated iris claw AC IOL (such as the Artisan) even in challenging situations such as patients with abnormally thin or hypoplastic irises, as in connective tissue diseases such as Marfan syndrome3,4 or Ehler-Danlos syndrome; after intraocular surgical trauma; and in situations with poor visualization of the iris through a hazy cornea. This procedure can be done with simple instrumentation. It is a very straightforward maneuver that avoids the needle enclavation step, which in some cases can be difficult. It is not necessary to hold the IOL body with a forceps so all
J CATARACT REFRACT SURG - VOL 38, MARCH 2012
CORRESPONDENCE
553
Figure 1. A: The AC IOL is repositioned with the haptics at 3 and 9 o’clock centered on the pupil (left eye). The claw at 3 o’clock is not grabbing any iris tissue. B: Paracenteses are made at 3 o’clock and at 5 o’clock, and the surgeon sits at 3 o’clock. C: The initial pass of the 10-0 polypropylene straight suture through the superotemporal limbus, coming in and out of the iris. D: The needle exits through the inferotemporal limbus. E and F: The superior end of the suture is externalized through the 3 o’clock incision, first retrieving a loop (E) and then the complete suture end (F). F and G: The same steps are followed to externalize the inferior end of the suture after the needle has been cut. H: Simultaneously, the IOL body is gently pushed backward with an IOL manipulator as the ends of the suture are pulled upward in the opposite direction to engage the iris with the claw. I: Finally, the IOL is fixated at both IOL claws.
the surgery is done through small self-sealing incisions and a stable anterior chamber. REFERENCES 1. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976; 7(2):98–103 2. Siepser SB. The closed-chamber slipping suture technique for iris repair. Ann Ophthalmol Glaucoma 1994; 26:71–72
3. Hirashima DE, Soriano ES, Meirelles RL, Alberti GN, W. Outcomes of iris-claw anterior chamber versus Nose iris-fixated foldable intraocular lens in subluxated lens secondary to Marfan syndrome. Ophthalmology 2010; 117: 1479–1485 4. De Paepe A, Devereux RB, Dietz HC, Hennekam RC, Pyeritz RE. Revised diagnostic criteria for the Marfan syndrome. Am J Med Genet 1996; 62:417–426. Available at: http://diagnosticcriteria.net/ marfan/reprints/DePaepe-1996-AJMG-62-p417-426.pdf. Accessed November 12, 2011
J CATARACT REFRACT SURG - VOL 38, MARCH 2012