TECHNIQUE

Modified implantatio

n of black diaphragmintraocular lens in traumatic aniridia

Jun Li, MD, Gongqiang Yuan, MD, PhD, Liang Ying, MD, Bin Yu, MD, Xiaoguang Dong, MD

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We describe a modified technique of black diaphragm intraocular lens (IOL) implantation in eyeswith traumatic aniridia, aphakia, and previous vitrectomy. During black diaphragm IOL implanta-tion, a double-armed 10-0 polypropylene suture is used to fixate the IOL in the ciliary sulcus. Two10-0 polypropylene sutures are subsequently placed in front of the IOL to block its forwarddisplacement and thus prevent its contact with the anterior chamber angle and corneal endothe-lium. This modified implantation technique reduces long-term complications following blackdiaphragm IOL implantation in patients with traumatic aniridia.

Financial Disclosure: No author has a financial or proprietary interest in any material or methodmentioned.

J Cataract Refract Surg 2013; 39:822–825 Q 2013 ASCRS and ESCRS

Online Video

Severe traumatic rupture of the globe may result inaniridia. Because of spherical aberration and chro-matic dispersion caused by defects in the iris, photo-phobia, glare, and visual dysfunction often occurafter surgery for ocular trauma. The black diaphragmintraocular lens (IOL) is specifically designed to treataniridia or severe iris defects. Good clinical effectshave been reported in eyes with aniridia andaphakia1–4; however, long-term complications, in-cluding secondary glaucoma, IOL decentration anddislocation, and corneal endothelial decompensation,may arise secondary to the implantation.5–7 Improvedvision may decrease again. We describe a modifiedtechnique of black diaphragm IOL implantation toreduce the long-term complications and present ourexperience in 7 cases that achieved favorable results.

y 18, 2012.ubmitted: January 17, 2013.ary 17, 2013.

g Eye Institute, Shandong Academy of Medicaluan, Ying, Yu, Dong), Qingdao, China.

to prepare the manuscript.

a poster at the annual meeting of the Americanhthalmology, Orlando, Florida, USA, October 2011.

author: Xiaoguang Dong, MD, Shandong Eyeanerdao Road, Qingdao 266071, China. E-mail:tmail.com.

SCRS and ESCRS

by Elsevier Inc.

SURGICAL TECHNIQUE

An infusion port to maintain intraoperative intraocu-lar pressure (IOP) is inserted and fixed inferotempor-ally through the pars plana 4.0 mm posterior to thelimbus. A scleral tunnel, 10.0 mm long and 4.0 mmwide, is made without penetrating the eye just poste-rior to the superior limbus with formation of a scleralflap. After another triangular scleral flap is preparedat 6 o'clock to cover the IOL fixation suture, a double-armed 10-0 polypropylene suture is passed into theanterior chamber under the 12 o'clock scleral flapand pulled out under the 6 o'clock scleral flap, both2.0 mm posterior to the limbus. A 3.2 mm keratomeis then introduced via the superior scleral tunnel.The suture is retrieved via the superior limbal inci-sion and cut in the middle, after which each end is se-cured to a haptic eyelet of the black diaphragm IOLto be implanted. The black diaphragm IOL is insertedvia the superior incision, and the superior scleraltunnel is sutured after IOL insertion. Finally, two10-0 polypropylene sutures are added 3.0 mm poste-rior to the limbus and in front of the lens (Figure 1).The video (available at http://jcrsjournal.org) illus-trates the technique.

Results

Seven procedures in 7 patients with a mean age of44.6 years (range 24.0 to 59.0 years) were performedbetween November 2008 and December 2010(Table 1). The iris was completely disrupted in all

0886-3350/$ - see front matter

http://dx.doi.org/10.1016/j.jcrs.2013.03.001

Figure 1. Transscleral IOL fixation. A: Theblack diaphragm IOL is placed in the sulcus,and the sutures are drawn tightly. B: Two10-0 polypropylene sutures are then added3.0 mm posterior to the limbus and in frontof the IOL.

823TECHNIQUE: BLACK DIAPHRAGM IOL IN TRAUMATIC ANIRIDIA

eyes as a result of a global rupture injury. All sur-geries were completed uneventfully with resolutionof photophobia. Mild anterior chamber inflamma-tion reaction subsided within 1 month of surgery.The corrected visual acuity improved by at least 2Snellen lines in 6 eyes during the follow-up periodof 16 to 40 months and remained at 1.0 before andafter black diaphragm IOL implantation in 1 eye(Case 3). One patient (Case 5) required secondaryvitrectomy at 1 week for vitreous hemorrhagecaused by the scleral tunnel incision. Two patients(Cases 1 and 5) required antiglaucoma medicationsto control the IOP for 6 to 10 months, followingwhich medications were discontinued and the IOPnormalized.

During the follow-up, there was no supraphysiolo-gical decline (PZ.558, t Z .619) in the number of cor-neal endothelial cells. The ultrasound biomicroscopicexamination showed that the haptics of the black dia-phragm IOLwere well located in the ciliary sulcus anddid not contact the cornea (Figure 2). No severecomplications, such as bullous keratopathy and un-controlled glaucoma, were observed (Table 2 andFigure 3).

Table 1. Preoperative patient status.

Patient Sex Age (Y)

Visual AcuityIntraocularPressure Cornea StatusUDVA CDVA

1 M 54 0.02 0.6 Normal Transparent2 M 43 FC/BE 0.5 Normal Transparent3 M 36 0.05 1.0 Normal Transparent4 M 58 FC/BE 0.7 Normal Transparent5 M 38 FC/30 cm 0.8 Normal with

timololTransparent

6 M 59 0.02 0.6 Normal Transparent7 M 24 0.05 0.3 Normal Scar

BE Z before eye; C Z central; CDVA Z corrected distance visual acuity; FC Z fi

J CATARACT REFRACT SURG

DISCUSSION

The black diaphragm IOL has been used world-wide for 20 years for the simultaneous improve-ment of visual acuity and elimination ofphotophobia.1 However, a substantial proportionof the patients have been reported to develop seri-ous complications following implantation. A de-cline in the number of corneal endothelial cellscan lead to corneal opacity and thus bullous kerat-opathy, resulting in visual loss and even long-term,potentially intractable, pain. Penetrating kerato-plasty and IOL removal may be required for furthermanagement.5

In previous clinical observations,5 we found thatthe long-term complications were related to the pre-operative degree of damage to the anterior chamberangle and iris defects, as well as to the position of theimplanted black diaphragm IOL. The black dia-phragm IOL is larger and heavier than the averagescleral-fixated IOL, which makes it difficult to fixatestably with support from only the capsular bag or 2suspension sutures. Movement of the black dia-phragm IOL with postural changes and contact ofthe IOL edge with the anterior chamber angle and

Endothelial CellDensity (cells/mm2) Lens Status

Duration from Injury toHospital Presentation (Mo)

2257 Aphakic 161720 Aphakic 242397 Aphakic 82955 Aphakic 82531 Aphakic 8.5

2526 Aphakic 61298 (C)2279 (T)

Aphakic 13

nger counting; T Z temporal; UDVA Z uncorrected distance visual acuity

- VOL 39, JUNE 2013

Figure 3. The surgical result in 1 patient 20 monthsafter black diaphragm IOL implantation. A: Theanterior eye segment photograph shows the well-located IOL. B: Ultrasound biomicroscopic examina-tion shows that the sutures (arrows) are tight in frontof the IOL. C: There was no supraphysiological de-cline in the number of corneal endothelial cells.

Figure 2. The IOL haptics (arrows) are well fixated at the ciliary sulcus and not displaced during the follow-up.

824 TECHNIQUE: BLACK DIAPHRAGM IOL IN TRAUMATIC ANIRIDIA

J CATARACT REFRACT SURG - VOL 39, JUNE 2013

Table 2. Postoperative patient status.

PatientFollow-up

(Mo)

Visual AcuityIntraocularPressure

EndothelialCell Density(cells/mm2)UDVA CDVA

1 40 0.3 1.0 Normal withtimolol

2132

2 23 0.3 0.8 Normal 18113 28 0.1 1.0 Normal 23954 22 0.05 1.0 Normal 28705 20 0.1 1.0 Normal with

timolol2985

6 16 0.3 1.0 Normal 24717 24 0.2 0.6 Normal 1339 (C)

1952 (T)

C Z central; CDVA Z corrected distance visual acuity; T Z temporal;UDVA Z uncorrected distance visual acuity

825TECHNIQUE: BLACK DIAPHRAGM IOL IN TRAUMATIC ANIRIDIA

cornea may cause chronic irritation to the trabecularmeshwork and peripheral cornea, resulting inchronic damage to the blood–aqueous barrier andcorneal endothelial cell loss, particularly in eyeswith aniridia, which lose the blocking effect of theiris to the lens.

We modified the technique of black diaphragm IOLimplantation in traumatic aniridia by adding 2 su-tures in front of the IOL to block its forward move-ment and limit the space for IOL rotation after theIOL was transsclerally fixated. The IOL haptics werewell fixated in the ciliary sulcus and not displaced.The number of corneal endothelial cells remainedstable.

Traumatic aniridia is often accompanied by sub-stantial damage to the anterior segment. ElevatedIOP is the most common postoperative complica-tion following implantation of the black diaphragmIOL.2,4,6,8 The mechanism remains unclear, al-though it may be attributable to direct compressionof the trabecular meshwork by the IOL haptics.6,7

The proportion of secondary glaucoma in our caseseries did not exceed that in previous reports, andmedical treatment successfully controlled the IOPin all eyes.

In summary, our modified technique of black di-aphragm IOL implantation enhances the stabilityof the IOL in eyes with traumatic aniridia andreduces the risk for severe complications. Further

J CATARACT REFRACT SURG

investigations with a longer follow-up period areneeded.

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WHAT WAS KNOWN

� Severe complications may occur during the long-termfollow-up after implantation of black diaphragm IOLs ineyes with traumatic aniridia.

WHAT THIS PAPER ADDS

� In our modified technique, 2 sutures are added in front ofthe black diaphragm IOL to block forward displacementafter the IOL is transsclerally fixated in eyes withtraumatic aniridia. This modified technique reducedlong-term complications after IOL implantation.

REFERENCES1. Sundmacher R, Reinhard T, Althaus C. Black diaphragm intra-

ocular lens in congenital aniridia. Ger J Ophthalmol 1994;

3:197–201

2. Beltrame G, Salvetat ML, Chizzolini M, Driussi GB, Busatto P,

Di Giorgio G, Barosco F, Scuderi B. Implantation of a black dia-

phragm intraocular lens in ten cases of post-traumatic aniridia.

Eur J Ophthalmol 2003; 13:62–68

3. Chen Y-J, Wu P-C. Favorable outcome using a black diaphragm

intraocular lens for traumatic aniridia with total iridectomy.

J Cataract Refract Surg 2003; 29:2455–2457

4. Dong X, Yu B, Xie L. Black diaphragm intraocular lens implanta-

tion in aphakic eyes with traumatic aniridia and previous pars pla-

na vitrectomy. J Cataract Refract Surg 2003; 29:2168–2173

5. Dong X, Xu H, Yu B, Ying L, Xie L. Long-term outcome of black

diaphragm intraocular lens implantation in traumatic aniridia. Br

J Ophthalmol 2010; 94:456–459

6. Reinhard T, Engelhardt S, Sundmacher R. Black diaphragm anir-

idia intraocular lens for congenital aniridia: long-term follow-up.

J Cataract Refract Surg 2000; 26:375–381

7. Aslam SA, Wong SC, Ficker LA, MacLaren RE. Implantation of

the black diaphragm intraocular lens in congenital and traumatic

aniridia. Ophthalmology 2008; 115:1705–1712

8. OmuleckiW,Synder A. Pars plana vitrectomyand transscleral fix-

ation of black diaphragm intraocular lens for the management of

traumatic aniridia. Ophthalmic Surg Lasers 2002; 33:357–361

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L 39, JUNE 2013

First author:Jun Li, MD

Shandong Eye Institute,Shandong Academy of MedicalSciences Qingdao, China