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Correction of Correction of Correction of Correction of Correction of Correction of Correction of Correction of AphakiAphakiAphakiAphakiAphakiAphakiAphakiAphakiaaaaaaaa
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NoNoNoNoNoNoNoNo Financial Interest !Financial Interest !Financial Interest !Financial Interest !Financial Interest !Financial Interest !Financial Interest !Financial Interest !
University Eye University Eye University Eye University Eye University Eye University Eye University Eye University Eye ClinicClinicClinicClinicClinicClinicClinicClinic
Paracelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University Salzburg
Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.--------Prof. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther Grabner
University Eye University Eye University Eye University Eye University Eye University Eye University Eye University Eye ClinicClinicClinicClinicClinicClinicClinicClinic
Paracelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University Salzburg
Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.--------Prof. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther Grabner
AphakiaAphakia
� Aphakia = absence of natural crystalline lens
� Western World: very uncommon
� Phako / ECCE with IOL-implantation
in the capsular bag
� Aphakia = absence of natural crystalline lens
� Western World: very uncommon
� Phako / ECCE with IOL-implantation
in the capsular bag
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� Reasons
� After complicated cataract surgery
� Post-traumatic dislocation of crystalline lens
� Capsular loss
� Ectopia lentis
� Marfan syndrome, Weill-Marhesani syndrome, hyperlysinaemia,
homocystinuria, sulfite oxidase deficiency, Ehlers-Danlos syndrome
� Reasons
� After complicated cataract surgery
� Post-traumatic dislocation of crystalline lens
� Capsular loss
� Ectopia lentis
� Marfan syndrome, Weill-Marhesani syndrome, hyperlysinaemia,
homocystinuria, sulfite oxidase deficiency, Ehlers-Danlos syndrome
Conservative Correction ?Conservative Correction ?
� Spectacles
� Reduced peripheral vision
� Ring scotoma (prismatic effect)
� „Jack in the box“
� Aniseokonia
� Spectacles
� Reduced peripheral vision
� Ring scotoma (prismatic effect)
� „Jack in the box“
� Aniseokonia
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� Aniseokonia
� Contact lenses
� Fitting, removal, cleaning…
� Aniseokonia
� Contact lenses
� Fitting, removal, cleaning…
Surgical CorrectionSurgical Correction
� Angle supported AC-IOL
� Endothelial cell loss (1 year: 6-45%)
� Pseudophakic bullous keratopathy (PBK)
� UGH-syndrome
� Scleral fixation of PC-IOL
� Choroidal haemorrhage
� Angle supported AC-IOL
� Endothelial cell loss (1 year: 6-45%)
� Pseudophakic bullous keratopathy (PBK)
� UGH-syndrome
� Scleral fixation of PC-IOL
� Choroidal haemorrhage
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� Choroidal haemorrhage
� Retinal detachment
� Vitreous incarceration
� Chronic inflammation
� IOL-iris contact
� IOL decentration
� Pigmentary dispersion
� High aqueous flare
� CME
� Choroidal haemorrhage
� Retinal detachment
� Vitreous incarceration
� Chronic inflammation
� IOL-iris contact
� IOL decentration
� Pigmentary dispersion
� High aqueous flare
� CME
Surgical CorrectionSurgical Correction
� Iris-Claw aphakic IOL
� Best choice for primary or secondary implantation in aphakic eyes
� Safer then open-loop-angle supported AC-IOLs
� Surgery easier, shorter and safer then sclera sutured IOLs
� Some cases of PBK
� Iris-Claw aphakic IOL
� Best choice for primary or secondary implantation in aphakic eyes
� Safer then open-loop-angle supported AC-IOLs
� Surgery easier, shorter and safer then sclera sutured IOLs
� Some cases of PBK
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� Some cases of PBK
� Endothelial cell loss – caused by surgical trauma ?
� Some cases of PBK
� Endothelial cell loss – caused by surgical trauma ?
Prof. Jan Worst Model 205T Worst Iris Claw® Lens
Model 205Y or VRSA54 ARTISAN™ VERISYSE ™
Aphakia Lens
1978 1986
Verisyse® AphakiaVerisyse® Aphakia
� VRSA54 Verisyse
� Primary or secondary implantation after ICCE, ECCE and Phaco
� Dioptric power: +2,0 D to +30,0 D (14.5 to 24.5 in 0.5 D steps)
� VRSA54 Verisyse
� Primary or secondary implantation after ICCE, ECCE and Phaco
� Dioptric power: +2,0 D to +30,0 D (14.5 to 24.5 in 0.5 D steps)
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
(14.5 to 24.5 in 0.5 D steps)
� Optical Diameter: 5.0 mm
� Overall Diameter: 8.5 mm
� Biconvex design
� A-constant:
�115 for AC implantation
�116.8 for retropupillary implantation (ULIB)
(14.5 to 24.5 in 0.5 D steps)
� Optical Diameter: 5.0 mm
� Overall Diameter: 8.5 mm
� Biconvex design
� A-constant:
�115 for AC implantation
�116.8 for retropupillary implantation (ULIB)
University Eye Clinic Salzburg 1996 – 2010
Aphakic Iris claw IOL
FrequencyFrequency
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� 1996 – 2005: 78 = 8 / year
� 2006 – 2009: 50 = 14 / year
� 2009 – 2010: 22 = 22 / year
� 1996 – 2005: 78 = 8 / year
� 2006 – 2009: 50 = 14 / year
� 2009 – 2010: 22 = 22 / year
Total 150150150150
SUBLUXATED lenses 82
� Primary surgery (Marfan´s syndrome) 25
FrequencyFrequency
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� Posttraumatic 25
� Spontaneous IOL dislocation (PEX) 32
Positioning of Verisyse® AphakiaPositioning of Verisyse® Aphakia
� Anterior� Anterior
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� Posterior
� Risk of endothelial cell loss decreases
� AC is deeper
� Distance from haptics to endothelium is larger
� Irido-corneal angle is wider
� Posterior
� Risk of endothelial cell loss decreases
� AC is deeper
� Distance from haptics to endothelium is larger
� Irido-corneal angle is wider
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
Advantages
� Very safe for corneal endothelium
� Produces less glare
� Only a very small ↑ of HOA1
Advantages
� Very safe for corneal endothelium
� Produces less glare
� Only a very small ↑ of HOA1
Posterior approachPosterior approach
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� Only a very small ↑ of HOA1
� „Physiological“ space for an IOL is behind the iris
� Only a very small ↑ of HOA1
� „Physiological“ space for an IOL is behind the iris
1 Kaymak C, Mester U. paper at ESCRS-Meeting, Lissabon 2005.
Disadvantages
� Extensive anterior vitrectomy required
� Special intruments are useful in order to avoid IOL-
drop into the vitreous cavity during implantation
Disadvantages
� Extensive anterior vitrectomy required
� Special intruments are useful in order to avoid IOL-
drop into the vitreous cavity during implantation
Posterior approachPosterior approach
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
drop into the vitreous cavity during implantationdrop into the vitreous cavity during implantation
Sekundo, Eur J Ophthalmol 2008
Special Special instrumentsinstruments usefullusefull toto avoidavoid a a tiltingtilting ofof thethe IOL IOL duringduring implantationimplantation procedureprocedure
Posterior approachPosterior approach
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� Mohr et al. Ophthalmologe 2002
� 48 aphakic cases
� 2/48 reversible CME
� Wolter-Roessler et al. Klin Monatsbl Augenheilkd. 2008
� 48 aphakic cases, 14 Months
� 2/48 reversible CME
� 2/48 traumatic haptic dislocation
� Mohr et al. Ophthalmologe 2002
� 48 aphakic cases
� 2/48 reversible CME
� Wolter-Roessler et al. Klin Monatsbl Augenheilkd. 2008
� 48 aphakic cases, 14 Months
� 2/48 reversible CME
� 2/48 traumatic haptic dislocation
Posterior approachPosterior approach
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
� 2/48 traumatic haptic dislocation
� 1/48 retinal detachment
� 1/48 pupillary block > iridectomy mandatory
� Hara et al. J Refract Surg. 2011
� 11 eyes retropupillary Verisyse
� No complications
� 21 eyes transscleral sutured IOL
� 5/21 ciliary choroidal body haemmorhage
� 1/21 CME
� 1/21 IOL dislocation
� 2/48 traumatic haptic dislocation
� 1/48 retinal detachment
� 1/48 pupillary block > iridectomy mandatory
� Hara et al. J Refract Surg. 2011
� 11 eyes retropupillary Verisyse
� No complications
� 21 eyes transscleral sutured IOL
� 5/21 ciliary choroidal body haemmorhage
� 1/21 CME
� 1/21 IOL dislocation
Anterior chamber IOL´s� Angle-supported
� Iris-claw
Anterior chamber IOL´s� Angle-supported
� Iris-claw
Posterior chamber IOL´s
� Sclera-fixated� Iris-sutured
Posterior chamber IOL´s
� Sclera-fixated� Iris-sutured
Posteriorly
enclavated
Iris-claw lens
� VERY FEW COMPARATIVE LONG-TERM studies� Need for a prospective, long-term (multi-center) study
ConclusionConclusion
University Eye Clinic Salzburg Paracelsus Medical University [email protected]
Decision tree for the very different clinical situations
University Eye Clinic Salzburg Paracelsus Medical University [email protected] 16