This document discusses options for intraocular lens (IOL) implantation when the eye's natural capsular support is absent. It reviews causes of ectopia lentis and traumatic/surgical aphakia. Three main IOL options are described: scleral fixation, iris-claw fixation, and iris suturing of the IOL. Each option is evaluated based on surgical techniques, published studies, outcomes, complications, and patient factors. The document concludes by proposing protocols for IOL implantation based on individual patient and ocular characteristics to provide the best visual outcomes while minimizing risks of complications requiring long-term follow-up.
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IOL implantation in the absence of capsular bag
1. Choices of IOL implantation
when there is no capsular
support
Jaume Català-Mora, MD
Hospital Sant Joan de Déu. Esplugues de Llobregat
Oftalpilar. Barcelona
No financial relationships to disclose
2. IOL in the absence of capsular support
• Aetiologies
• Ectopia lentis
• Traumatic/surgical aphakia
• Initial approach
• Surgical pearls and videos
• Correction of aphakia
• Meta analysis
• Proposal of a protocol & conclusion
3. Causes of ectopia lentis
• Secondary ectopia lentis:
• Traumatic dislocation:
• Blunt trauma
• Penetrating injury
• Buftalmos
• Aniridia
• Chronic uveitis
• High myopia
• Silicone oil tamponade
• Congenital weakness of
zonula/capsula:
• Non systemic involvement:
• Isolated ectopia lentis
• Ectopia lentis et pupillae,…
• Systemic involvement:
• Marfan disease
• Homocystinuria
• Weil-Marchesiani, sulphite oxidase
deficiency, hyperlysinaemia, …
Dureau, P. Pathophysiology of zonular diseases. Current Opinion in Ophthalmology. 2008; 19: 27–30
4. Ophthalmic examination ectopia lentis
• Age, history of trauma or surgery
• BCVA, amblyopia, Strabismus
• Retinoscopy and refraction: myopia
& astigmatism
• Slit lamp examination
• Corneal diameter (megalocornea)
• Iris & Pupillae
• Lens position, visual axis & lens edge
• IOP
• Fundus examination
• Think about systemic involvement
5. Causes absence of capsular/zonular support
• Penetrating injury
• Complicated cataract surgery
• Previous Lensectomy
7. Indication for surgery
Ectopia Lentis
• VA loss due to lens subluxation
with visual axis involvement
• Anterior chamber lens luxation
• Vitreous lens luxation with good
potential VA
Traumatic/Surgical aphakia
Good potential VA
• Unable or unwilling to use
aphakia spectacles
• Intolerance to contact lens
Endothelial Cell Count
Eye Biometry
8. Conservative Aphakia management
• Aphakia spectacle correction
• Safe, reliable, easily adjustable
• Optical aberration, non suitable for
unilateral cases, poor cosmetics
• Extended-wear contact lens
correction + Binocular spectacle
• Reliable and easily adjustable
• Difficult management, potential
complications, intolerance
• Good temporary option in young
children
9. Intraocular lens implant in the absence of
capsular support
Requirements:
• Good potential VA
• Close life-long follow-up
• Postop bifocal correction
Contraindications:
• Uncontrolled glaucoma
• Active, chronic or recurrent uveitis
• Severe anterior segment structural
abnormalities
• ECC < 2000 cs; AC depth< 3 mm (prepupillary
IOL options: Iris claw lens)
• Scleral fixated IOL
• Iris Claw IOL:
• Prepupillary
• Retropupillary
• Iris Sutured IOL
10. Ectopia lentis: surgical management
• Lensectomy in the bag
• Posterior vitrectomy
• Acetylcholine
• Superior iridectomy
• Aphakia/IOL implant
11. Traumatic o surgical aphakia: surgical
management
• Vitreoretinal approach:
• Infusion line (pressurize/stabilize
the eye)
• Eliminate any vitreous adherences
to the iris or anterior chamber
• Check the capsular remnants. Will
they be able to support an IOL?
Condon, G. P. Simplified small-incision peripheral iris fixation of an AcrySof intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003;29:1663–1667.
12. Scleral fixated IOL
• Scleral flaps at 2/4 & 8/10
• Insertion and suture of the IOL
haptics
• Limbal or scleral 7 mm incision
• Implant and center IOL behind
the iris
• Removal of viscoelastic
Corneal/Scleral suture & IC
cefuroxime
14. Iris Claw IOL
• Biometry. AC constant:
• Prepupillary: 115
• Retropupillary: 116.9
• Avoid IOL sutures
• Superior Iridectomy
• Limbal or scleral 6 mm incision
• Dispersive viscoelastic
• Implant of the IOL
• Enclavation technique:
• Anterior (prepupillary)
• Posterior (retropupillary)
• Removal of viscoelastic
• Limbal/scleral suture& IC Cefuroxime
15. Iris claw IOL (prepupillary)
Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Endothelial loss Complications
Sminia ML 2011 Retrospective 20 10 Marfan, Idiopathic 7,50 12,00 N/A
comparable to
mean normal but
wider range
N/A
Sminia ML 2007 Retrospective 5 5 Traumatic 7,80 11,00
100 % improve
vision
40 % mean 1 RD
Cleary C 2012 Prospective 8 5 Marfan, Idiopathic 12,60 2,00
62,5 % improve
vision
14% loss Endothelial loss
Siddiqui SN 2012 Retrospective 18 11 Marfan, Idiopathic 11,58 1,00 17,1% loss Endothelial loss
Català J 2014 Prospective 27 14 Marfan, Idiopathic 6,80 3,40
80 % improve
vision
18,4% loss
RD,
desinclavation,
aseptic uveitis
GLOBAL 78 45
Marfan,
Idiopathic,
Trauma
9,26 5,88
Endothelial
cell loss, IOL
luxation
Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Endothelial loss Complications
Gonnermann J 2013 Retrospective 7 4 Marfan, Idiopathic 12 2
100% improve
vision
6,4% loss
1 traumatic
dislocation
Iris claw IOL (retropupillary)
16. Iris sutured IOL
• Limbal 3.5 mm incision
• 3 piece acrylic IOL
• Moustache IOL folding & implant
• Haptics in posterior chamber &
optic captured above the iris
• 10/0 prolene suture the haptics to
the iris (Siepser iris suture)
• Placement of the optic posterior to
the iris
• Removal of viscoelastic
• Corneal suture & IC cefuroxime
Stutzman RD, Stark WJ. Surgical technique for suture fixation of an acrylic intraocular lens in the absence of capsule support. J Cataract Refract Surg 2003; 29:1658-1662
Siepser, S. B. The closed chamber slipping suture technique for iris repair. Ann Ophthalmol 1994;26(3):71–72
17. Iris sutured IOL
Article Year Design Eyes Patients Ethiologies Age implantation Follow-up (years) Results VA Suture Complications
Dureau, P 2006 retrospective 17 9
Marfan,
idiopathic
4,80 1,30
100 % improve
VA
Prolene 10/0
Hyphema, ectopia
pupillae, aseptic
uveitis
Yen KG 2009 retrospective 17 12
Marfan,
idiopathic, trauma
7,20 1,00
76% improve
vision
Prolene 10/0
RD, Dislocation,
Iris capture
GLOBAL 34 21
Marfan,
idiopathic,
trauma
6,00 1,15
IOL
dislocation,
Ectopia
pupillae,
Hyphema
18. Discussion
• Scleral fixated IOL:
• No iris support
• Combination with iris prosthesis
• Polypropylene 9/0 or Goretex 8/0
sutures are recommended
• Iris Claw IOL:
• Easier & quicker technique
• Corneal endothelial risk
• Consider retropupillary
enclavation
• Iris sutured IOL:
• Smaller corneal incision
• Difficult management/exchange
• Risk of prolene degradation & IOL
dislocation
Hirashima DE, Soriano ES, Meirelles RL, et al. Outcomes of iris-claw anterior chamber versus iris-fixated foldable intraocular lens in subluxated lens secondary to Marfan syndrome. Ophthalmology. 2010;117(8):1479–85
Gonnermann J, Torun N, Klamann MKJ, et al. Posterior iris-claw aphakic intraocular lens implantation in children. Am J Ophthalmol. 2013;156(2):382–386.e1
Buckley EG. Pediatric sutured intraocular lenses: trouble waiting to happen. Am J Ophthalmol. 2009;147(1):3–4
19. Protocol for surgical management
of ectopia lentis
< 4 yo
Inability to follow-up
VA< 0.3 due to lens luxation
Vitreous or AC lens luxation
Contact lenses
&/or aphakia
spectacles
> 4 yo
ECC pre & every 6 months
AC OCT/BMU yearly
Lensectomy +
iridectomy
Damaged/absent iris Normal iris
Lensectomy + Scleral
sutured IOL Prolene
9/0 +
Iris reconstruction
Lensectomy +
iridectomy
Retropupillary iris claw
ECC pre & every 6 months
AC OCT/BMU yearly
20. Protocol for secondary IOL implant
in the absence of capsular support
Uveitis
Uncontrolled
glaucoma
Inability to follow-up
Good potential VA
Inability/Intolerance/Unwilling
Spectacles/Contact lens
Surgery
contraindicated
Damaged/absent iris Normal iris
Scleral sutured IOL
Prolene 9/0 +
Iris reconstruction
Retropupillary iris claw
ECC pre & every 6 months
AC OCT/BMU yearly
21. Conclusion
• No evidence of the best option of IOL implant
• Aphakia correction & primary vs secondary IOL implant:
• Age
• Aetiology
• Cornea & Iris status
• Surgeon preference
• Traumatic patients require individualized management
• Implanted patients will require a life-long follow-up:
• Endothelial Cell Count
• AC OCT/BMU
• Risk of IOL dislocation
• Retinal detachment
• Glaucoma
• Bifocal / Multifocal optical correction
22. Aknowledgements
• Dr. Jesús Díaz-Cascajosa
• Ophthalmology department HSJD
• Optometry team HSJD & Oftalpilar
• Surgical team HSJD
Editor's Notes
Good Morning I will like to thank the EPOS organization his invitation to attend this meeting. I will talk about the choices of IOL implantation when there is no capsular support
The two main situations are ectopia lentis and traumatic or surgical aphakia. We’ll review the initial approach. I will show different surgical pearls and videos of the different options for the aphakia correction. We’ll dive in a metaanalysis of these different options and I will propose a protocol of management of these patients.
If we look at the causes of ectopia lentis, Blunt trauma & Buftalmos are the most frequent cases of secondary ectopia lentis. Congenital causes include isolated ectopia lentis and different systemic diseases like Marfan or homocystinuria.
Marfan disease AD: Chr 15, FBNI gene. 1/10000; Cardiovascular disease, hiperlaxity,
Weill–Marchesani syndrome (ar: ADAMTS10 gene, AD: fibrilline gene) connective tissue disorder: short stature, brachydactyly and joint stiffness, microespherophakia, myopia, glaucoma
Homocystinuria (ar) Clinical similar to Marfan disease + protrombotic disease (tx: supplement with pirodoxine) Dx: blood and urinary dosage of homocysteine
Sulphite oxidase deficiency (ar): profound mental retardation, epylepsia, spasticity, ectopia lentis (substitution of cysteine) Dx: elevated urinary thiosulfate level. No treatment, very poor prognosis
Hyperlysinaemia (ar) half of the patients are healthy. Others: psychomotor retardation, epilepsy, spasticity, ataxia, short stature, joint laxity and spherophakia. Dx: plasma levels of lysine.
When we examine these patients we have to ask for trauma or previous surgery. At the slit lamp we should evaluate the position of the lens edge related to the visual axis and it is important to keep in mind an associated systemic disease.
On the other hand we can find an absence of capsular and zonular support after a penetrating injury, a complicated cataract surgery or a previous lensectomy.
Best corrected visual acuity and possibility of amblyopia should be documented. We have to look for vitreous in the anterior chamber and existence and disposition of capsular remnants.
Indications for surgery in ectopia lentis is visual acuity loss due to lens subluxation, usually with visual axis involvement; anterior chamber lens luxation or vitreous lens luxation with good potential visual acuity.
Patients with traumatic or surgical aphakia with good potential visual acuity will be considered for surgery it they are unable or unwilling to use aphakia spectacles or if the don’t tolerate contact lens.
We should perform an endothelium cell count and eye biometry prior to surgery.
In certain cases of ectopia lentis the best and safest option will be aphakia with spectacle correction or contact lens, but many times it is only a temporary option.
Many times patients or families prefer an IOL implant. We consider these option in cases with good potential VA, when patients will be able of a closed follow-up. Patients should know that they will need a postop bifocal correction. Contraindications for IOL implant include uncontrolled glaucoma, active uveitis, severe anterior abnormalities and low endothelium cell count if we are planning to implant a prepupillary iris claw IOL.
We
Surgical management of ectopia lentis will include a lensectomy in the bag followed by a posterior vitrectomy. Acetylcholine injection will provoke myosis so a superior iridectomy with the vitreous cutter is easily done. At these point we can leave the patient aphakic or we’ll choose an IOL implant.
When we deal with traumatic or surgical aphakia we prefer a vitreoretinal approach. The infusion line helps to pressurize an stabilize the usually soft pediatric eyes. We should eliminate any vitreous adhesions in the anterior chamber and check for the capsular remnants. If they are not able to support a sulcus placed IOL then we have to choose one of the techniques of suspension of the IOL
In the placement of an scleral fixated IOL we suture the haptics to the scleral bed and then we implant and center the IOL behind the iris.
In 1999 Zettersröm published the first pediatric series of cases with scleral fixated IOL.
Since then most of the papers report good visual results, but in the long term polypropylene suture breakage and IOL luxation occur in 24 % of children after 5 years and it is a life-long concern in these children.
10-0 polypropylene suture cannot be relied on to secure a posterior chamber IOL to the sclera over the lifetime of a child
Caution should be exercised in the use of 10-0 polypropylene suture to fixate an IOL to the sclera in children, and an alternative material or size (such as 9-0 polypropylene) should be considered
Fortunately, the IOL is not long enough (13.5 mm) to reach the macular area
Iris Claw IOL were proposed to solve these problems. The IOL can be placed prepupillary or retropupillary.
Prepupillary IOL in children have been used for 40 years and the main concern is the endothelial cell loss. Our prospective series of patients with anterior chamber IOL placement shows a worrying endothelial cell loss in some of the patients. To solve these problem, in the last years there is a trend towards the retropupillary placement of Iris claw IOL that seems safer for the endothelium.
Iris sutured IOL have the advantage of a smaller incision whereas the implantation technique is way more difficult and time-consuming.
In the series published in children the main complication was IOL dislocation and Prolene degradation.
Caution on the long term use of Prolene 10/0, Iritis, Pigmentary dispersion
Iris claw IOL are an easy, quick an reversible technique. Retropupillary enclavation could solve the endothelium cell loss in the long-term.
Iris sutured IOL have the advantage of a smaller corneal incision but the technique is difficult and time-consuming, the risk of polypropylene degradation has also to be considered.
Finally Scleral fixated IOL are the best option in cases where there is not iris support. We recommend the use of Prolene 9/0 to prevent suture breakage.
Our protocol for the surgical management of ectopia lentis include patients with visual loss due to lens luxation. In patients under 4 yo or non collaborative we perform lensectomy and iridectomy and they are managed with contact lenses or aphakia spectacles.
More collaborative patients, usually over 4 yo with damaged iris have a lensectomy and scleral sutured IOL with prolene 9/0 and iris reconstruction. If the iris is normal we perform lensectomy, iridectomy and retropupillary iris claw implant.
Difficult endothelial follow-up
Eye-rubbing
Secondary IOL implant when intolerance
When we are facing a secondary IOL implant we have to consider that patients with active uveitis, uncontrolled glaucoma or unable to be followed shouldn’t be operated.
Children with good potential visual acuity and intolerance to contact lens with damaged iris are managed with scleral sutured IOL with prolene 9/0 while those with normal iris receive a retropupillary iris claw.
In conclusion there is no clear evidence of one best option of IOL implant in the absence of capsular support.
Aphakia correction and IOL implant will depend on the age of the patient, aetiology, cornea and iris status and also on surgeon preference.
Traumatic patients usually require an individualized management.
All the implanted patients will require a life-long close follow-up. All children will require bifocal optical correction.
