The The ““goldgold standardstandard”” of of secondarysecondary IOL IOL implantationimplantation

in the in the MIVS eraMIVS era

“S. Maria delle Croci” Hospital – RavennaDept. of Ophthalmology

Director: Cesare Forlini M

C. Forlini MD A. Bratu MD, P. Rossini MD, M.Forlini MD

Secondary IOL implant:

which IOL?

Our favourite secondaryIOL implant

Scleral fixedIris fixed

( no Anterior Chamber IOL)

Secondary IOL implantIn case of no capsular support

Scleral fixed IOLs

Corneal Ultima IOL is our favourite since 1997

• Foldable hydrophilic acrylic IOL• Optic disc 6.5 mm• Total diameter 13 mm• Surgical techniques:

- conjunctival peritomy- scleral flaps - sutures threads- 4.5 mm corneal tunnel

(Video)

Problems with sulcus-fixed IOLs

• Large corneal tunnel (for unfoldable IOLs)• Most invasive technique• Astigmatism (tilting)• Lysis of suture threads• Risk of (sub)luxation …?…

Secondary IOL implantIn case of no capsular support

Scleral fixed IOLs

Secondary IOL implantIn case of no capsular support

IRIS FIXATED IOLArtisan Iris-claw IOL

• Material: PMMA• Width: 5.4 mm• Length: 8.5 mm • Optic diameter: 5.0 mm• Angle: 10°• ACD cost.: 115

(for the anterior chamber)

Secondary IOL implant

In case of no capsular supportIRIS FIXATED IOL

Artisan Iris-claw IOL

• Material: PMMA• Width: 5.4 mm• Length: 8.5 mm • Optic diameter: 5.0 mm• Angle: 10°• ACD cost.: 115

(for the anterior chamber)

ANTERIOR CHAMBER iris-claw IOL (K 115)

POSTERIOR CHAMBER iris-claw IOL (extimated K 116.5)

Post-operative features

(Baykara M. et al. Am J. Ophtalm 2007;144: 586-91)

(UBM image)

Iris claw lens: anterior and posterior iris surface fixation in the absence of capsular support during penetrating keratoplasty

Rijneveld WJ et al J Refr Corneal Surg 1994;10(1):14-9

Retropupillary fixation of the iris claw lens in aphakia.1 year outcome of a new implantation technique

Mohr A, Eckardt C. Ophthalmologe 2002;99(7):580-3

Posterior iris fixation of the iris-claw intraocular lens. Implantation through a scleral tunnel incision

Baykara M et al AJO 2007;144(4): 586-91

POSTERIOR IMPLANT OF IRIS-CLAW IOL

NEWNEWTRANSCONJUNCTIVAL ERATRANSCONJUNCTIVAL ERA

The irisThe iris--fixed IOL implantation is nowfixed IOL implantation is nowthe gold standardthe gold standard

because because we can we can avoid to open the conjunctivaavoid to open the conjunctiva

And (And (very importantvery important) ) change the approachchange the approachremoving the remants of capsula and removing the remants of capsula and

vitreous in the ciliar body areavitreous in the ciliar body area(shorter and more complete surgery)(shorter and more complete surgery)

When anterior meets posterior• For "middle earth" we intend the inclusive

anatomical area between the back surface of the iris and the anterior vitreous chamber

• It represents a border area among the anterior and posterior segment and often it is an uncertainty reason in the surgical treatment (it is not clear if it is pertinence of the anterior or posterior segment surgeon)

Middle Earth

When anterior meets posterior• In the ocular surgery there is an academic distinction that

interests the surgeons, according to which they operate on the anterior or posterior segment of the bulb. This often creates a separation of the roles and operational surgical ability, sometimes very well interdistincted.

• Often the vitreoretinal surgeon has the tendency to neglect the iris plane and its possible changes, as the surgeon of the anterior segment doesn't even conceive manipulations over this area and stops himself before the pupilpupil’’s "abysss "abyss””

Middle Earth

POST-TRAUMATIC CAPSULAR BAGAND IOL SUBLUXATION

IRIS-Claw in Marfan Syndrome

Anterior approach with 25 gauge system

IRIS-Claw in Marfan Syndrome

Anterior approach with 25 gauge system and pars plana vitrectomy

Ciliary bodies contraction in patient with multiple operations for PVR treatment

Endoscopy-assisted evaluation and membrane’s peeling

IOL and capsular bag removal and iris-claw IOL implant

Endoscopy-assisted evaluation of the IOL enclavation and stability

PUPIL PLASTY AND POSTERIOR IRIS-CLAW IOLIN SEVERELY INJURIED AND STIFF IRIS TISSUE

PUPIL PLASTY AND POSTERIOR IRIS-CLAW IOLIN IRIS LACERATION

POST-TRAUMATIC IRISI COLOBOMA AND IOL SUBLUXATION

Traumatic Cataract Anter VIT 23 G PC Iris Claw

Nucleous Luxation 23G VIT Pfcl PC Iris Claw

POST-TRAUMATIC CATARACT, ANTERIOR SYNAECHIE AND IOL DECENTRATION

PUPIL PLASTY AND POSTERIOR IRIS-CLAW IOLIN IRIS LACERATION

Blunt Trauma in PC Iris Claw RECENTERING

Posterior Iris-fixed IOL implant:why yes?

• Better hestetic result ( less tilting)• Preservation of the anatomy of the anterior segment• Respect of the iridocorneal angle• Less invasive and faster surgical technique• Low risk of spontaneous luxation (compared with scleral-

IOL)• Good post-operative mydriasis• Optimal clearance between iris and IOL

Posterior Iris-fixed IOL implant:Exclusion cryteria

• Total aniridia• Iris donesis• Iris rubeosis (GNV)• Pigmentary glaucoma

This is a typical example that showsThis is a typical example that showshow the new strategies how the new strategies

created for the posterior pole created for the posterior pole influence influence

the choices in the anterior segmentthe choices in the anterior segment

…And viceversa, like the capsulorhexis was for the ILM peeling technique…

OUR EXPERIENCE

• 1th June 2002 – 31th August 2008• 218 IOL implants into the posterior chamber:

(correction of aphakia, IOL exchange, complex traumas, cataract complications)

• Mean post-op. SE: +0.50 sf (∆ –1.50sf + 2.00 sf)• NO spontaneous luxation• 1 spontaneous subluxation (treated with re-clawation)• 1 luxation due to post-traumatic stiff iris (in previous

plasty)• No uveitis / iritis / iridocyclitis reactions

CONCLUSIONS

• The posterior iris-claw IOL implant is a safe and effective option

• The anatomic features of the anterior segment are preserved

• Spontaneous luxation (with contemporary haptics detachment) is a remote possibility

• The indications can be extended even in case of severe iris damage

• This kind of implant is the best choice in the trans-conjunctival era

TAKE HOME MESSAGES• It is often this “mental” limit that prevent the surgeon to use

adeguate tools to solve the problem

• Importance of iris treatment (both for aesthetical and functional reasons)

• The mini-invasive and transconjunctival approach to the "middle earth" and the "pole to pole" surgical strategy allow to reduce the induced surgical trauma and the post-operating inflammation

• The posterior iris-claw IOL implant can represent the gold standard in the treatment of cataract’s surgery complications

The The ““gold standardgold standard”” of of secondary IOL implantationsecondary IOL implantation

in the MIVS erain the MIVS era

“S. Maria delle Croci” Hospital – RavennaDept. of Ophthalmology

Director: Cesare Forlini MD

THANKSTHANKSC. Forlini MD

A. Bratu MD, P. Rossini MD, M.Forlini MD

Cataract surgery has a low Cataract surgery has a low incidence of intraoperative incidence of intraoperative

complicationscomplications

BUTBUT………………..

The patient is usually not The patient is usually not prepared to them prepared to them

(and the surgeon too) (and the surgeon too) …….!!!!.!!!!

CATARACT SURGERY COMPLICATION

IMMEDIATE TREATMENT IS THE BEST WAY FOR THE

PATIENT…. AND THE SURGEON

BUT…..Are you able?

Are you ready?

TRANSCONJUNCTIVAL MIVS ERAfacilitates the immediate approach

less surgical aggressionno conjunctiva openingmore surgical precision

no treatment limits

Trans-conjunctival mini-invasive approach to cataract surgery complication:

When and how to do it?Which different strategies?

Topical anesthesia (if short op. time) or conversion to peribulbar aneshtesia

Use only 25 (preferred) or 23 gauge instruments Anterior infusion (MY WAY) Phacoemulsification via-limbus into the anterior vitreous

(in selected cases, if the lens does not go beyond the equator)

TA-assisted high speed vitrectomy Ophthalmoscopic control

Approach to cataract surgery complications

EquatorEquator

Apre-equatorial

Bpost-equatorial

Equator

If the fragments do not beyond the equator: via-limbus approach

with Phako

If the fragments go beyond the equator: pars plana approach

with vitrectomy

WhichApproach?

Cecking by indirect ophthalmoscopy

Posterior capsule break:which implant?

Posterior iris surface iris-claw IOL implantGOLD STANDARD IN MIVS ERA

DOGMA : NEVER PHACO INTO THE VITREOUS…! ! !

My WAY..… CONTINUE WITH FACO ! ! !

Purpose:to remove as much as possible lens remnants

(even if into the vitreous), and to complete the treatment with 25/23 g pp vitrectomy.

This to reduce the fragments in order to avoid the use of pars plana phaco-probe

Nucleous dislocation during phaco:immediate 25+23g approach

Control the panic in the Operating Room!!!

Trans-conjunctival approach to complications of cataract surgery:

WHY?

“My way”to remove the dropped nucleous

Hard nucleous dislocation: 23 g approach

THANKS