http://www.tvrs.gr/

1. TheThe ““goldgold standardstandard”” ofof
secondarysecondary IOLIOL implantationimplantation
in thein the MIVS eraMIVS era
“S. Maria delle Croci” Hospital – Ravenna
Dept. of Ophthalmology
Director: Cesare Forlini M
C. Forlini MD
A. Bratu MD, P. Rossini MD, M.Forlini MD

2. Secondary IOL implant:
which IOL?

3. Our favourite secondary
IOL implant
Scleral fixed
Iris fixed
( no Anterior
Chamber IOL)

4. Secondary IOL implant
In 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)

5. 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 implant
In case of no capsular support
Scleral fixed IOLs

6. Secondary IOL implant
In case of no capsular support
IRIS 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)

7. Secondary IOL implant
In case of no capsular support
IRIS 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)

8. ANTERIOR CHAMBER iris-claw IOL (K 115)
POSTERIOR CHAMBER iris-claw IOL (extimated K 116.5)

9. Post-operative features
(Baykara M. et al. Am J. Ophtalm 2007;144: 586-91)
(UBM image)

10. 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

11. NEWNEW
TRANSCONJUNCTIVAL ERATRANSCONJUNCTIVAL ERA
The irisThe iris--fixed IOL implantation is nowfixed IOL implantation is now
the gold standardthe gold standard
becausebecause
we canwe can avoid to open the conjunctivaavoid to open the conjunctiva
And (And (very importantvery important)) change the approachchange the approach
removing the remants of capsula andremoving 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)

12. 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

13. 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

14. POST-TRAUMATIC CAPSULAR BAG
AND IOL SUBLUXATION

15. IRIS-Claw in Marfan Syndrome
Anterior approach with 25 gauge system

16. IRIS-Claw in Marfan Syndrome
Anterior approach with 25 gauge system and pars plana vitrectomy

17. Ciliary bodies contraction in patient with
multiple operations for PVR treatment

18. Endoscopy-assisted evaluation and membrane’s peeling
IOL and capsular bag removal and iris-claw IOL implant

19. Endoscopy-assisted evaluation
of the IOL enclavation and stability

20. PUPIL PLASTY AND POSTERIOR IRIS-CLAW IOL
IN SEVERELY INJURIED AND STIFF IRIS TISSUE

21. PUPIL PLASTY AND POSTERIOR IRIS-CLAW IOL
IN IRIS LACERATION

22. POST-TRAUMATIC IRISI COLOBOMA
AND IOL SUBLUXATION

23. Traumatic Cataract Anter VIT 23 G PC Iris Claw

24. Nucleous Luxation 23G VIT Pfcl PC Iris Claw

25. POST-TRAUMATIC CATARACT, ANTERIOR SYNAECHIE
AND IOL DECENTRATION

26. PUPIL PLASTY AND POSTERIOR IRIS-CLAW IOL
IN IRIS LACERATION

27. Blunt Trauma in PC Iris Claw RECENTERING

28. 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

29. Posterior Iris-fixed IOL implant:
Exclusion cryteria
• Total aniridia
• Iris donesis
• Iris rubeosis (GNV)
• Pigmentary glaucoma

30. This is a typical example that showsThis is a typical example that shows
how the new strategieshow the new strategies
created for the posterior polecreated for the posterior pole
influenceinfluence
the choices in the anterior segmentthe choices in the anterior segment
…And viceversa, like the capsulorhexis
was for the ILM peeling technique…

31. 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

32. 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

33. 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

34. TheThe ““gold standardgold standard”” ofof
secondary IOL implantationsecondary IOL implantation
in the MIVS erain the MIVS era
“S. Maria delle Croci” Hospital – Ravenna
Dept. of Ophthalmology
Director: Cesare Forlini MD
THANKSTHANKSC. Forlini MD
A. Bratu MD, P. Rossini MD, M.Forlini MD

35. Cataract surgery has a lowCataract surgery has a low
incidence of intraoperativeincidence of intraoperative
complicationscomplications
BUTBUT………………..
The patient is usually notThe patient is usually not
prepared to themprepared to them
(and the surgeon too)(and the surgeon too) …….!!!!.!!!!

36. CATARACT SURGERY COMPLICATION
IMMEDIATE TREATMENT
IS THE BEST WAY FOR THE
PATIENT…. AND THE SURGEON
BUT…..
Are you able?
Are you ready?

37. TRANSCONJUNCTIVAL MIVS ERA
facilitates the immediate approach
less surgical aggression
no conjunctiva opening
more surgical precision
no treatment limits

38. 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

39. Approach to cataract surgery complications
EquatorEquator
A
pre-equatorial
B
post-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
Which
Approach?
Cecking by indirect
ophthalmoscopy

40. Posterior capsule break:
which implant?
Posterior iris surface iris-claw IOL implant
GOLD STANDARD IN MIVS ERA

41. 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

42. Nucleous dislocation during phaco:
immediate 25+23g approach

43. Control the panic in the Operating Room!!!
Trans-conjunctival approach
to complications of cataract surgery:
WHY?

44. “My way”
to remove the dropped nucleous

45. Hard nucleous dislocation: 23 g approach

46. THANKS