Recently gaining recognition as a viable option compared with conventional methods of scleralsutured lenses, the retropupillary iris claw intraocular lens (IOL) (Artisan Aphakia model 205; Ophtec BV, Groningen, Netherlands) is a sutureless, posterior iris-fixated, polymethylmethacrylate IOL that has been demonstrated to be safe and efficient in correcting various conditions of aphakia1–4 and IOL dislocation. We introduce a modified technique for easier enclavation of retropupillary iris claw IOL in patients requiring secondary IOL implantation.
Traditionally, the retropupillary iris claw IOL is fixated to the posterior iris by switching hands and enclavation needle to enclavate both the right and left haptics, through paracentesis incisions of 1.2 mm, on either side of the main incision site. This process is cumbersome and time-consuming with several involved steps. It requires switching hands while holding the IOL behind the iris and may induce anterior chamber shallowing while switching hands. This necessitates additional placement of viscoelastics for anterior chamber reformation before proceeding with the enclavation of the other haptics. Moreover, if additional placement of viscoelastics is required during the enclavation procedure, the enclavation needle must be removed first from the eye to switch the instrument, and thus an additional step is required for injection of viscoelastics into the anterior chamber. Finally, switching hands while holding the IOL with the forceps could potentially result in slippage of the IOL and its dislocation into the vitreous cavity.
This procedure can be demanding for beginning surgeons because of the bimanual dexterity required; further, it may interfere with best positioning and centration of the retropupillary iris claw IOL. We describe a new method for enclavation that reduces the number of steps involved while increasing the ease and safety of retropupillary iris claw IOL enclavation.
A 60-year-old man presented with a partially dislocated IOL in his left eye. His corrected distance visual acuity (CDVA) at that time was 20/40. He had a history of prior cataract surgery at a different center 3 years ago, and had received prior vitrectomy with pneumatic displacement for macula-sparing retinal detachment 2 years prior at our center. He underwent prompt surgery to remove the dislocated IOL and implant a retropupillary iris claw IOL using our modified technique. We obtained informed consent from the patient regarding the use of images and video of his surgery for this report.
Our technique uses the 27-gauge Healon cannula connected to the viscoelastics device (Abbott Medical Optics Inc., Abbott Park, IL). We carefully bend the cannula with forceps at a distance of at least 13 to 16 mm from the cannula tip to form an approximately 60° angle (Figure 1A). This instrument is then inserted through a single paracentesis incision that is created 90° from the main incision site, depending on the surgeon's preference (Figures 1B–1C). Grasping the retropupillary iris claw IOL with the Artisan implantation forceps (Ophtec BV), we proceed to enclavate first the distal (Figure 1D) and then the proximal (Figure 1E) haptics in one connected step, while simultaneously injecting additional viscoelastics as needed to prevent chamber collapse or increase the working space. Finally, we remove all instruments from the eye, checking for proper centration and fixation of the retropupillary iris claw IOL.
(A) After successful removal of the dislocated intraocular lens (IOL), a 27-gauge cannula connected to the viscoelastics device is carefully bent with forceps to form an approximately 60º angle. (B) A single side port incision is created 90º from the main incision site. (C) The bent cannula is inserted, and the chamber is deepened with viscoelastics. (D) Grasping the IOL with forceps, the distal haptics are gently enclavated with the tip of the bent cannula while viscoelastics are being injected to provide counter pressure on the iris against the haptics, facilitating precise enclavation of the haptics and centration. (E) Next, the proximal haptics are enclavated in the same manner. (F) The IOL is well-centered and fixed to the iris with minimal pupil distortion.
At his most recent follow-up at 2 years postoperatively, the patient's retropupillary iris claw IOL remained stable and well centered (Figure 1F), and he had an uncorrected visual acuity of 20/20. He experienced little discomfort with no signs of complications. A short clip of the surgical highlights can be found in Video 1 (available in the online version of this article).
Using this method, in our own yet-to-be-published retrospective case series of 68 eyes with dislocated IOLs, we observed excellent postoperative results with significant long-term CDVA improvement and a low incidence of complications.
Using a bent Healon cannula in this manner facilitates easier enclavation with no additional cost, providing the surgeon with an option for immediate injection of additional viscoelastics throughout the entire process and eliminating the need for switching hands or instruments during the strenuous procedure. Injection of additional viscoelastics during the enclavation process allows better visualization of the haptics behind the iris as the viscoelastics provide counter-pressure and push the iris down against the haptics, facilitating precise enclavation of the haptics and centration.
We believe that our simple, modified technique is useful, not only for beginners but also for advanced surgeons, because of its advantages of enhanced stability, increased efficiency, and ease of use.
- Forlini M, Soliman W, Bratu A, Rossini P, Cavallini GM, Forlini C. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: a retrospective analysis. BMC Ophthalmol. 2015;15:143. doi:10.1186/s12886-015-0146-4 [CrossRef]
- Rao R, Sasidharan A. Iris claw intraocular lens: a viable option in monocular surgical aphakia. Indian J Ophthalmol. 2013;61:74–75. doi:10.4103/0301-4738.107198 [CrossRef]
- Brandner M, Thaler-Saliba S, Plainer S, Vidic B, El-Shabrawi Y, Ardjomand N. Retropupillary fixation of iris-claw intraocular lens for aphakic eyes in children. PLoS One. 2015;10:e0126614. doi:10.1371/journal.pone.0126614 [CrossRef]
- Kristianslund O, Raen M, Ostern AE, Drolsum L. Late in-the-bag intraocular lens dislocation: a randomized clinical trial comparing lens repositioning and lens exchange. Ophthalmology. 2017;124:151–159. doi:10.1016/j.ophtha.2016.10.024 [CrossRef]