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Transscleral sulcus fixation of a small-diameter iris-diaphragm intraocular lens in combined penetrating keratoplasty and cataract extraction for correction of traumatic cataract, aniridia, and corneal scarring
CASE REPORT
Transscleral sulcus fixation of a small-diameter iris-diaphragm intraocular lens in combined penetrating keratoplasty and cataract extraction for correction of traumatic cataract, aniridia, and corneal scarring Paul M. Phillips, MD, Neda Shamie, MD, Edwin S. Chen, MD, Mark A. Terry, MD
We present the case of a 36-year-old Hispanic man who presented with photophobia and hand motion acuity from a lacerated cornea. Primary repair had been performed 13 years earlier. In addition to a densely scarred cornea and a fibrotic, partially resorbed cataract, more than 300 degrees of iris loss was noted. The patient was treated with penetrating keratoplasty, cataract extraction, and implantation of a transsclerally fixated, small-diameter aniridic intraocular lens (IOL). Despite the significant iris loss, a small-diameter IOL was chosen over a standard larger aniridic IOL to allow safer, more controlled insertion through an 8.0 mm trephination. Following surgery, the visual acuity improved to 20/25 with no symptoms of glare or photophobia. J Cataract Refract Surg 2008; 34:2170–2173 Q 2008 ASCRS and ESCRS
Although not currently approved by the United States Food and Drug Administration (FDA), black diaphragm aniridic intraocular lenses (IOLs) have been used in Europe to treat congenital aniridia and aniridia secondary to trauma for more than a decade.1 In previous studies, the most commonly used aniridic IOLs were the Morcher models 67D, 67F, and 67G. These black diaphragm poly(methyl methacrylate) IOLs have a diaphragm diameter of 10.0 mm. The 67D and 67F models have a length of 13.5 mm, and the 67G model has a length of 12.5 mm. The IOLs are designed to be inserted through a 10.0 mm limbal incision after cataract extraction and placed in the sulcus or transsclerally sutured, although they have also been successfully placed in the capsular bag.2,3
Accepted for publication June 19, 2008. From the Devers Eye Institute (Phillips, Shamie, Chen, Terry) and the Lions Vision Research Laboratory of Oregon (Terry), Portland, Oregon. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Paul M. Phillips, MD, Devers Eye Institute, 1040 Northwest 22nd Avenue, Portland, Oregon 97210, USA. E-mail: [email protected].
2170
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
Multiple series report the successful placement of these IOLs through the intended 10.0 mm limbal incision, with encouraging short-term and long-term results.1,2,4–10 Previous reports describe the use of 10.0 mm diameter aniridic IOLs in combination with penetrating keratoplasty (PKP). Although successful placement has been reported, many authors report considerable difficulty when inserting these IOLs through an open-sky approach.1,4,8,10 The difficulty of placing these aniridic IOLs at the time of PKP stems from the significant manipulation and trauma that is induced while an additional limbal incision is created for insertion or, alternatively, while the large 10.0 mm diameter IOL is implanted through a standard PKP corneal trephination that is generally between 7.0 mm and 9.0 mm in diameter. Some authors1,10 suggest staging 2 operations rather than combining the PKP with insertion of the aniridic IOL. However, in these already compromised eyes, reducing the number of surgical interventions is desirable. We report a case of PKP combined with placement of a small-diameter aniridic IOL for treatment of traumatic cataract and aniridia with corneal scarring. CASE REPORT A 36-year-old Hispanic man presented with hand motion visual acuity, significant photophobia, and pain in the left eye 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.06.048
CASE REPORT: TRANSSCLERAL SULCUS FIXATION OF SMALL IRIS-DIAPHRAGM IOL
2171
Figure 1. A: Preoperatively, the eye is noted to have significant corneal scaring and a dense and fibrotic cataract with anterior and posterior synechias of the remaining iris located in the inferonasal quadrant. B: Direct illumination on day 5. C: Retroillumination on day 5. D: Direct illumination at 3 months. E: Retroillumination at 3 months.
due to a traumatic cataract and corneal scarring with associated corneal decompensation from endothelial failure (Figure 1). The injury had been sustained 13 years earlier, with a primary repair performed in Mexico. Examination revealed no afferent pupillary defect. There was a horizontal linear scar inferiorly in the midperipheral cornea. The cornea also had extensive stromal opacification from chronic endstage bullous keratopathy. There was extensive iris loss with significant iris present for only a few clock hours inferonasally. B-scan ultrasonography showed the presence of an attached retina with no signs of additional pathology. After detailed informed consent as well as investigative review board and FDA approval for the use of a non-FDA-approved device under a compassionate use clause were obtained, PKP, open-sky extraction of the fibrotic cataract/capsular complex, and an anterior vitrectomy were performed. A small-diameter (8.0 mm) aniridic IOL (Morcher 67E) (Figure 2) was easily inserted through the 8.25 mm corneal trephination and transsclerally fixated with a 10-0 polypropylene (Prolene) suture (Figure 3). This biconvex IOL has a 13.5 mm total diameter, an 8.0 mm diaphragm, and a 4.0 mm optic. The IOL periphery is treated with a black copolymer, rendering the peripheral 4.0 mm opaque. The IOL power was C16.5 diopters (D) and the intended approximate postoperative refraction, 1.00 D. The surgery was completed by securing an 8.75 mm donor cornea with 16 interrupted 10-0 nylon sutures. On postoperative day 1, the uncorrected visual acuity was 20/400, 20/80C with pinhole. The intraocular pressure (IOP) was 45 mm Hg. The patient was placed on dorzolamide hydrochloride timolol maleate ophthalmic solution (Cosopt), as well as prednisolone acetate, moxifloxacin, and nepafenac. There was progressive corneal clearing and IOP improvement by day 5 (Figure 1). At 3 weeks, the IOP remained stable at 19 mm Hg without dorzolamide hydrochloride timolol maleate ophthalmic solution. By 4 months, the patient denied any symptoms of glare or photophobia. The cornea remained clear, and the best spectacle-corrected visual acuity was 20/25 with 8.00 C1.25 75 (Figure 1). Glare testing with a brightness acuity meter demonstrated no loss of vision at low level lighting. Visual acuity declined to 20/40 at the medium light level. Fundus examination revealed a healthy posterior pole.
DISCUSSION Although several series using aniridic IOLs for prosthetic replacement of congenital or traumatic aniridia exist, only a few cases describe the use of these IOLs in combination with PKP.1,2,4,7,8,10 Ideally, a prosthetic iris IOL would completely replace the missing iris for its full peripheral extension along 360 degrees. Unfortunately, currently existing large-diameter IOLs have
Figure 2. Intraoperative image of the Morcher 67E IOL.
J CATARACT REFRACT SURG - VOL 34, DECEMBER 2008
2172
CASE REPORT: TRANSSCLERAL SULCUS FIXATION OF SMALL IRIS-DIAPHRAGM IOL
Figure 3. Surgical montage. A: View of fibrotic lens capsular complex after trephination of recipient cornea. B: Anterior vitrectomy and lensectomy performed with automated vitrectomy unit. C: Insertion and transscleral fixation of aniridic IOL performed without stress on the wound. D: Intraoperative result after completion of PKP.
a diameter of 10.0 mm, are rigid, and cannot fit easily through standard penetrating corneal trephinations, which often range from 7.0 to 8.5 mm. In their initial series of 13 eyes treated for aniridia with the large-diameter Morcher 67D IOL, Sundmacher et al.1 performed a PKP with placement of an aniridic IOL in 2 eyes. In 1 eye, a 170-degree limbal incision was created for insertion of the IOL at the time of PKP. However, the authors stated that the procedure was ‘‘potentially too traumatic’’ and therefore it was abandoned in later cases in favor of the authors’ preferred technique of a 2-stage approach, with the PKP performed first, followed 3 months later by insertion of the IOL through a 170-degree limbal incision. This technique was used for the second PKP in the series.1 An alternative suggestion by the authors was insertion of the IOL first, followed later by a PKP; however, this technique requires a cornea that is clear enough to sufficiently view the anterior chamber.
In 1999, Thompson et al.8 reported their experience using another large-diameter aniridic IOL (Morcher 67G) in 7 patients with traumatic aniridia. Four cases were combined with PKP. In this report, IOLs were placed directly through the corneal trephine opening. The authors noted ‘‘moderate difficulty’’ inserting 3 of 4 IOLs and ‘‘extreme difficulty’’ inserting 1 IOL. Although all 4 eyes had improved visual acuity postoperatively, 1 eye sustained an intraoperative vitreous hemorrhage and another developed a postoperative retinal detachment. Tanzer and Smith11 reported successful combined PKP and implantation of a large aniridic IOL (Morcher 67F), presumably through the open-sky trephination; however, surgical details were not presented and it is not known what size trephination was performed or whether there was any difficulty inserting the IOL. It was also not clear whether a limbal incision was made for the insertion.
J CATARACT REFRACT SURG - VOL 34, DECEMBER 2008
CASE REPORT: TRANSSCLERAL SULCUS FIXATION OF SMALL IRIS-DIAPHRAGM IOL
In this report, we have demonstrated the successful use of an 8.0 mm diameter IOL to replace traumatic iris loss in a patient with a traumatic cataract and a densely scarred cornea. Because of the extensive iris loss, we believed that debilitating glare and photophobia would have persisted if a standard IOL had been implanted. For this reason, we believed placement of an aniridic IOL was appropriate. We are generally in agreement with Sundmacher et al.’s assessment that insertion of a larger aniridic IOL through a large limbal incision followed by PKP, while feasible in some settings, specifically in a large eye with a clear view of the anterior chamber, would have been too traumatic in this case. In this patient, the poor view of the anterior chamber because of the extensive corneal scarring and the added obstacles of anterior synechias and severe fibrosis of the lens and capsule would have made such an insertion impractical. Therefore, we believed that inserting the IOL through an open sky was the safest option. The smaller Morcher 67E IOL was chosen because we thought it would be sufficient to prevent such symptoms, especially in the setting of a nearly opaque peripheral corneal scar that would aid in reducing peripheral glare. Since larger aniridic IOLs are difficult to insert through a standard corneal trephination, the smaller 67E IOL was considered ideal. We believe that the use of this IOL was a good option for this patient, resulting in satisfactory visual rehabilitation, improved cosmesis, and symptomatic relief of photophobia. The use of a small-diameter IOL may not be successful in all cases of combined surgery and PKP, especially when a clear peripheral recipient cornea is present. Additionally, our patient had a relatively darkly pigmented choroid and it is possible that a patient with a less pigmented choroid might not have the same complete alleviation of glare symptoms.
2173
However, in a select population of patients with peripheral scarring, placement of a small-diameter aniridic IOL may be ideal.
REFERENCES 1. Sundmacher R, Reinhard T, Althaus C. Black diaphragm intraocular lens in congenital aniridia. Ger J Ophthalmol 1994; 3:197–201 2. Menezo JL, Martı´nez-Costa R, Cisneros A, Desco MC. Implantation of iris devices in congenital and traumatic aniridias: surgery solutions and complications. Eur J Ophthalmol 2005; 15:451–457 3. Mavrikakis I, Casey JMH. Phacoemulsification and endocapsular implantation of an artificial iris intraocular lens in traumatic cataract and aniridia [letter]. J Cataract Refract Surg 2002; 28:1088–1091 4. Beltrame G, Salvetat ML, Chizzolini M, Driussi GB, Busatto P, Di Giorgio G, Barosco F, Scuderi B. Implantation of a black diaphragm intraocular lens in ten cases of post-traumatic aniridia. Eur J Ophthalmol 2003; 13:62–68 5. Dong X, Yu B, Xie L. Black diaphragm intraocular lens implantation in aphakic eyes with traumatic aniridia and previous pars plana vitrectomy. J Cataract Refract Surg 2003; 29:2168–2173 6. Omulecki W, Synder A. Pars plana vitrectomy and transscleral fixation of black diaphragm intraocular lens for the management of traumatic aniridia. Ophthalmic Surg Lasers 2002; 33:357–361 7. 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 8. Thompson CG, Fawzy K, Bryce IG, Noble BA. Implantation of a black diaphragm intraocular lens for traumatic aniridia. J Cataract Refract Surg 1999; 25:808–813 9. Reinhard T, Sundmacher R, Althaus C. Irisblenden-IOL bei traumatischer Aniridie. [Iris black diaphragm intraocular lenses in traumatic aniridia.] Klin Monatsbl Augenheilkd 1994; 205: 196–200 10. Sundmacher R, Reinhard T, Althaus C. Black-diaphragm intraocular lens for correction of aniridia. Ophthalmic Surg 1994; 25:180–185 11. Tanzer DJ, Smith RE. Black iris-diaphragm intraocular lens for aniridia and aphakia. J Cataract Refract Surg 1999; 25: 1548–1551
J CATARACT REFRACT SURG - VOL 34, DECEMBER 2008
Transscleral sulcus fixation of a small-diameter iris-diaphragm intraocular lens in combined penetrating keratoplasty and cataract extraction for correction of traumatic cataract, aniridia, and corneal scarring Paul M. Phillips, MD, Neda Shamie, MD, Edwin S. Chen, MD, Mark A. Terry, MD
We present the case of a 36-year-old Hispanic man who presented with photophobia and hand motion acuity from a lacerated cornea. Primary repair had been performed 13 years earlier. In addition to a densely scarred cornea and a fibrotic, partially resorbed cataract, more than 300 degrees of iris loss was noted. The patient was treated with penetrating keratoplasty, cataract extraction, and implantation of a transsclerally fixated, small-diameter aniridic intraocular lens (IOL). Despite the significant iris loss, a small-diameter IOL was chosen over a standard larger aniridic IOL to allow safer, more controlled insertion through an 8.0 mm trephination. Following surgery, the visual acuity improved to 20/25 with no symptoms of glare or photophobia. J Cataract Refract Surg 2008; 34:2170–2173 Q 2008 ASCRS and ESCRS
Although not currently approved by the United States Food and Drug Administration (FDA), black diaphragm aniridic intraocular lenses (IOLs) have been used in Europe to treat congenital aniridia and aniridia secondary to trauma for more than a decade.1 In previous studies, the most commonly used aniridic IOLs were the Morcher models 67D, 67F, and 67G. These black diaphragm poly(methyl methacrylate) IOLs have a diaphragm diameter of 10.0 mm. The 67D and 67F models have a length of 13.5 mm, and the 67G model has a length of 12.5 mm. The IOLs are designed to be inserted through a 10.0 mm limbal incision after cataract extraction and placed in the sulcus or transsclerally sutured, although they have also been successfully placed in the capsular bag.2,3
Accepted for publication June 19, 2008. From the Devers Eye Institute (Phillips, Shamie, Chen, Terry) and the Lions Vision Research Laboratory of Oregon (Terry), Portland, Oregon. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Paul M. Phillips, MD, Devers Eye Institute, 1040 Northwest 22nd Avenue, Portland, Oregon 97210, USA. E-mail: [email protected].
2170
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
Multiple series report the successful placement of these IOLs through the intended 10.0 mm limbal incision, with encouraging short-term and long-term results.1,2,4–10 Previous reports describe the use of 10.0 mm diameter aniridic IOLs in combination with penetrating keratoplasty (PKP). Although successful placement has been reported, many authors report considerable difficulty when inserting these IOLs through an open-sky approach.1,4,8,10 The difficulty of placing these aniridic IOLs at the time of PKP stems from the significant manipulation and trauma that is induced while an additional limbal incision is created for insertion or, alternatively, while the large 10.0 mm diameter IOL is implanted through a standard PKP corneal trephination that is generally between 7.0 mm and 9.0 mm in diameter. Some authors1,10 suggest staging 2 operations rather than combining the PKP with insertion of the aniridic IOL. However, in these already compromised eyes, reducing the number of surgical interventions is desirable. We report a case of PKP combined with placement of a small-diameter aniridic IOL for treatment of traumatic cataract and aniridia with corneal scarring. CASE REPORT A 36-year-old Hispanic man presented with hand motion visual acuity, significant photophobia, and pain in the left eye 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2008.06.048
CASE REPORT: TRANSSCLERAL SULCUS FIXATION OF SMALL IRIS-DIAPHRAGM IOL
2171
Figure 1. A: Preoperatively, the eye is noted to have significant corneal scaring and a dense and fibrotic cataract with anterior and posterior synechias of the remaining iris located in the inferonasal quadrant. B: Direct illumination on day 5. C: Retroillumination on day 5. D: Direct illumination at 3 months. E: Retroillumination at 3 months.
due to a traumatic cataract and corneal scarring with associated corneal decompensation from endothelial failure (Figure 1). The injury had been sustained 13 years earlier, with a primary repair performed in Mexico. Examination revealed no afferent pupillary defect. There was a horizontal linear scar inferiorly in the midperipheral cornea. The cornea also had extensive stromal opacification from chronic endstage bullous keratopathy. There was extensive iris loss with significant iris present for only a few clock hours inferonasally. B-scan ultrasonography showed the presence of an attached retina with no signs of additional pathology. After detailed informed consent as well as investigative review board and FDA approval for the use of a non-FDA-approved device under a compassionate use clause were obtained, PKP, open-sky extraction of the fibrotic cataract/capsular complex, and an anterior vitrectomy were performed. A small-diameter (8.0 mm) aniridic IOL (Morcher 67E) (Figure 2) was easily inserted through the 8.25 mm corneal trephination and transsclerally fixated with a 10-0 polypropylene (Prolene) suture (Figure 3). This biconvex IOL has a 13.5 mm total diameter, an 8.0 mm diaphragm, and a 4.0 mm optic. The IOL periphery is treated with a black copolymer, rendering the peripheral 4.0 mm opaque. The IOL power was C16.5 diopters (D) and the intended approximate postoperative refraction, 1.00 D. The surgery was completed by securing an 8.75 mm donor cornea with 16 interrupted 10-0 nylon sutures. On postoperative day 1, the uncorrected visual acuity was 20/400, 20/80C with pinhole. The intraocular pressure (IOP) was 45 mm Hg. The patient was placed on dorzolamide hydrochloride timolol maleate ophthalmic solution (Cosopt), as well as prednisolone acetate, moxifloxacin, and nepafenac. There was progressive corneal clearing and IOP improvement by day 5 (Figure 1). At 3 weeks, the IOP remained stable at 19 mm Hg without dorzolamide hydrochloride timolol maleate ophthalmic solution. By 4 months, the patient denied any symptoms of glare or photophobia. The cornea remained clear, and the best spectacle-corrected visual acuity was 20/25 with 8.00 C1.25 75 (Figure 1). Glare testing with a brightness acuity meter demonstrated no loss of vision at low level lighting. Visual acuity declined to 20/40 at the medium light level. Fundus examination revealed a healthy posterior pole.
DISCUSSION Although several series using aniridic IOLs for prosthetic replacement of congenital or traumatic aniridia exist, only a few cases describe the use of these IOLs in combination with PKP.1,2,4,7,8,10 Ideally, a prosthetic iris IOL would completely replace the missing iris for its full peripheral extension along 360 degrees. Unfortunately, currently existing large-diameter IOLs have
Figure 2. Intraoperative image of the Morcher 67E IOL.
J CATARACT REFRACT SURG - VOL 34, DECEMBER 2008
2172
CASE REPORT: TRANSSCLERAL SULCUS FIXATION OF SMALL IRIS-DIAPHRAGM IOL
Figure 3. Surgical montage. A: View of fibrotic lens capsular complex after trephination of recipient cornea. B: Anterior vitrectomy and lensectomy performed with automated vitrectomy unit. C: Insertion and transscleral fixation of aniridic IOL performed without stress on the wound. D: Intraoperative result after completion of PKP.
a diameter of 10.0 mm, are rigid, and cannot fit easily through standard penetrating corneal trephinations, which often range from 7.0 to 8.5 mm. In their initial series of 13 eyes treated for aniridia with the large-diameter Morcher 67D IOL, Sundmacher et al.1 performed a PKP with placement of an aniridic IOL in 2 eyes. In 1 eye, a 170-degree limbal incision was created for insertion of the IOL at the time of PKP. However, the authors stated that the procedure was ‘‘potentially too traumatic’’ and therefore it was abandoned in later cases in favor of the authors’ preferred technique of a 2-stage approach, with the PKP performed first, followed 3 months later by insertion of the IOL through a 170-degree limbal incision. This technique was used for the second PKP in the series.1 An alternative suggestion by the authors was insertion of the IOL first, followed later by a PKP; however, this technique requires a cornea that is clear enough to sufficiently view the anterior chamber.
In 1999, Thompson et al.8 reported their experience using another large-diameter aniridic IOL (Morcher 67G) in 7 patients with traumatic aniridia. Four cases were combined with PKP. In this report, IOLs were placed directly through the corneal trephine opening. The authors noted ‘‘moderate difficulty’’ inserting 3 of 4 IOLs and ‘‘extreme difficulty’’ inserting 1 IOL. Although all 4 eyes had improved visual acuity postoperatively, 1 eye sustained an intraoperative vitreous hemorrhage and another developed a postoperative retinal detachment. Tanzer and Smith11 reported successful combined PKP and implantation of a large aniridic IOL (Morcher 67F), presumably through the open-sky trephination; however, surgical details were not presented and it is not known what size trephination was performed or whether there was any difficulty inserting the IOL. It was also not clear whether a limbal incision was made for the insertion.
J CATARACT REFRACT SURG - VOL 34, DECEMBER 2008
CASE REPORT: TRANSSCLERAL SULCUS FIXATION OF SMALL IRIS-DIAPHRAGM IOL
In this report, we have demonstrated the successful use of an 8.0 mm diameter IOL to replace traumatic iris loss in a patient with a traumatic cataract and a densely scarred cornea. Because of the extensive iris loss, we believed that debilitating glare and photophobia would have persisted if a standard IOL had been implanted. For this reason, we believed placement of an aniridic IOL was appropriate. We are generally in agreement with Sundmacher et al.’s assessment that insertion of a larger aniridic IOL through a large limbal incision followed by PKP, while feasible in some settings, specifically in a large eye with a clear view of the anterior chamber, would have been too traumatic in this case. In this patient, the poor view of the anterior chamber because of the extensive corneal scarring and the added obstacles of anterior synechias and severe fibrosis of the lens and capsule would have made such an insertion impractical. Therefore, we believed that inserting the IOL through an open sky was the safest option. The smaller Morcher 67E IOL was chosen because we thought it would be sufficient to prevent such symptoms, especially in the setting of a nearly opaque peripheral corneal scar that would aid in reducing peripheral glare. Since larger aniridic IOLs are difficult to insert through a standard corneal trephination, the smaller 67E IOL was considered ideal. We believe that the use of this IOL was a good option for this patient, resulting in satisfactory visual rehabilitation, improved cosmesis, and symptomatic relief of photophobia. The use of a small-diameter IOL may not be successful in all cases of combined surgery and PKP, especially when a clear peripheral recipient cornea is present. Additionally, our patient had a relatively darkly pigmented choroid and it is possible that a patient with a less pigmented choroid might not have the same complete alleviation of glare symptoms.
2173
However, in a select population of patients with peripheral scarring, placement of a small-diameter aniridic IOL may be ideal.
REFERENCES 1. Sundmacher R, Reinhard T, Althaus C. Black diaphragm intraocular lens in congenital aniridia. Ger J Ophthalmol 1994; 3:197–201 2. Menezo JL, Martı´nez-Costa R, Cisneros A, Desco MC. Implantation of iris devices in congenital and traumatic aniridias: surgery solutions and complications. Eur J Ophthalmol 2005; 15:451–457 3. Mavrikakis I, Casey JMH. Phacoemulsification and endocapsular implantation of an artificial iris intraocular lens in traumatic cataract and aniridia [letter]. J Cataract Refract Surg 2002; 28:1088–1091 4. Beltrame G, Salvetat ML, Chizzolini M, Driussi GB, Busatto P, Di Giorgio G, Barosco F, Scuderi B. Implantation of a black diaphragm intraocular lens in ten cases of post-traumatic aniridia. Eur J Ophthalmol 2003; 13:62–68 5. Dong X, Yu B, Xie L. Black diaphragm intraocular lens implantation in aphakic eyes with traumatic aniridia and previous pars plana vitrectomy. J Cataract Refract Surg 2003; 29:2168–2173 6. Omulecki W, Synder A. Pars plana vitrectomy and transscleral fixation of black diaphragm intraocular lens for the management of traumatic aniridia. Ophthalmic Surg Lasers 2002; 33:357–361 7. 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 8. Thompson CG, Fawzy K, Bryce IG, Noble BA. Implantation of a black diaphragm intraocular lens for traumatic aniridia. J Cataract Refract Surg 1999; 25:808–813 9. Reinhard T, Sundmacher R, Althaus C. Irisblenden-IOL bei traumatischer Aniridie. [Iris black diaphragm intraocular lenses in traumatic aniridia.] Klin Monatsbl Augenheilkd 1994; 205: 196–200 10. Sundmacher R, Reinhard T, Althaus C. Black-diaphragm intraocular lens for correction of aniridia. Ophthalmic Surg 1994; 25:180–185 11. Tanzer DJ, Smith RE. Black iris-diaphragm intraocular lens for aniridia and aphakia. J Cataract Refract Surg 1999; 25: 1548–1551
J CATARACT REFRACT SURG - VOL 34, DECEMBER 2008