Reenclavation of a partially disenclavated retropupillary iris-clipped intraocular lens in a child with Marfan Syndrome. Slide deck was the basis of an e-poster presented at the 6th Asean Ophthalmology Congress in conjunction with the Philippine Academy of Ophthalmology Annual Convention held at the SMX Convention Center, Pasay City, MetroManila, Philippines October 2023.

1. September 30, 2023
Reenclavation of a
partially dis-enclavated
retropupillary iris-clipped
intraocular lens in a child
with Marfan Syndrome
Alvina Pauline Dy Santiago, MD
https://actamedicaphilippina.upm.edu.ph/index.ph
p/acta/article/view/6184/4414

2. INTRODUCTION
Surgical management
of lens with inadequate
capsular support
● Lens extraction (LE), contact lenses
● LE with Capsular tension ring and IOL
● LE with Anterior chamber IOL
● LE with Sulcus fixated IOL
● LE with Scleral-fixated IOL
● LE with Iris-clipped IOL
● LE with retropupillary iris-clipped IOL (1,2)
1. Mohr A, Hengerer F, Eckardt C. Retropupillare Fixation der Irisklauenlinse bei Aphakie. Einjahresergebnisse einer neuen Implantationstechnik
[Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation techniques]. Ophthalmologe. 2002 Jul;99(7):580-3. doi:
10.1007/s00347-001-0563-z.
2. Mohr A. Retropupillary fixation of artisan aphakia [Internet]. October 10, 2013. [cited 2013 Oct]. Available from: https://www.
youtube.com/watch?v=cI9AwYE6uUc
https://actamedicaphilippina.upm.edu.ph/index.ph
p/acta/article/view/6184/4414

3. INTRODUCTION
Long term follow-up of
Retropupillary fixation
of iris-clipped IOL for
children with
inadequate support
● Follow-up at least 5 years
● Improved vision with 20/100 to 20/20
● Focal iris atrophy
● No loss of enclavation
Santiago APD, Cariño NS. Long Term Follow-up of Retropupillary Fixation of Iris-clipped Intraocular Lens for Children with Inadequate Capsular
Support. Acta Med Philipp [Internet]. 2023Feb.27 [cited 2023Sep.28];57(2). Available from:
https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/6184

4. • s/p lensectomy, core vitrectomy,
retropupillary iris clipped IOL
• Doing well for 5 years, best VA
20/30 either eye.
• About a month from publication, left
eye was hit by a water bottle
causing immediate blurring of vision,
that improved in the prone position.

5. 3 days after trauma to left eye
Dry Refraction +7.50 sphere
Vision with +7.50 Finger counting, improved to 20/150 only
Slit lamp examination Enclavated haptic at 9 o’clock visible, no enclavation at 3 o’clock
Fundus No retinal detachment, no wrinkling of retina
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6. IOL peeking, hanging
from nasal enclavation

7. Trochar Insertion

8. IOL supported with spatula as
haptic anteriorized on top of iris

9. IOL reenclavation

10. IOL temporal
reenclavation completed

11. Day 1
Reenclavation
Ocular Hypotony
• Sutured
Sclerostomy
Postoperative Course
Day 1
Hypotony Repair

12. 6 months post-op
VISUAL ACUITY
OD -2.00 -0.50 x 90 20/25
OS -2.50 -1.00 x 90 20/20
PUPILS
Ovoid

13. DISCUSSION
Prior Total Vitrectomy for significant lens
subluxation worked in our favor
Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular
Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A
Report by the American Academy of Ophthalmology. Ophthalmology. 2020
Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID:
32507620.
• Indication for total vitrectomy: Significant lens subluxation of 75%
• Simplified reenclavation, using fluid to float IOL
• No vitrectomy required
• Prevented traction and retinal detachment

14. DISCUSSION
Traumatic Disenclavation
on Posterior Iris-claw
IOL
• Tilted Haptics
• Decentered and twisted fixation
• Haptics did not provide adequate closure
Brockmann T, Gonnermann J, Brockmann C, Torun N, Joussen AM,
Bertelmann E. Morphologic alterations on posterior iris-claw intraocular lenses
after traumatic disenclavation. Br J Ophthalmol. 2014 Sep;98(9):1303-7. doi:
10.1136/bjophthalmol-2014-305364. Epub 2014 Jul 1. PMID: 24985724.
Spontaneous
Disenclavation on
Posterior Iris-claw IOL
• Symmetric haptics
• Centered iris claws
• Adequate closure still provided
LUCK of PATIENT: Despite traumatic disenclavation, haptics remained symmetric, with centered
iris-claws and adequate closure.

15. DISCUSSION
Prevent Ocular Hypotony
Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular Lens Implantation in the Absence of
Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology. Ophthalmology. 2020
Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID: 32507620.
Turaga K, Senthil S, Jalali S. Recurrent spontaneous scleral rupture in Marfan's syndrome. BMJ Case Rep. 2016 May
19;2016:bcr2016214764. doi: 10.1136/bcr-2016-214764. PMID: 27199441; PMCID: PMC4885340.
• Suture sclerostomy site
• Sclera in Marfan syndrome have defective collagen tissue and maybe a little bit more leaky
than normal
• Recurrent spontaneous scleral rupture in Marfan Syndrome reported (Turaga et al 2016)
• Histopath disorganized collagen and focal hyalinization

16. DISCUSSION
Prevent traumatic injury to eye
• Eyeglasses or protective goggles
• Avoid contact sports and rough play
• Protect the eyes and face
Retropupillary Iris-claw IOL
• Remains relatively safe
• Requires more vigilance in protecting the eye from trauma
• Vitrectomy to prevent traction retinal detachment recommended

17. REFERENCES
1. Mohr A, Hengerer F, Eckardt C. Retropupillare Fixation der Irisklauenlinse bei Aphakie. Einjahresergebnisse einer neuen
Implantationstechnik [Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation
techniques]. Ophthalmologe. 2002 Jul;99(7):580-3. doi: 10.1007/s00347-001-0563-z.
2. Mohr A. Retropupillary fixation of artisan aphakia [Internet]. October 10, 2013. [cited 2013 Oct]. Available
from:https://www.youtube.com/watch?v=cI9AwYE6uUc
3. Santiago APD, Cariño NS. Long Term Follow-up of Retropupillary Fixation of Iris-clipped Intraocular Lens for Children
with Inadequate Capsular Support. Acta Med Philipp [Internet]. 2023Feb.27 [cited 2023Sep.28];57(2). Available from:
https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/6184
4. Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular Lens Implantation in the
Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology.
Ophthalmology. 2020 Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID: 32507620
5. Turaga K, Senthil S, Jalali S. Recurrent spontaneous scleral rupture in Marfan's syndrome. BMJ Case Rep. 2016 May
19;2016:bcr2016214764. doi: 10.1136/bcr-2016-214764. PMID: 27199441; PMCID: PMC4885340.
6. Brockmann T, Gonnermann J, Brockmann C, Torun N, Joussen AM, Bertelmann E. Morphologic alterations on posterior
iris-claw intraocular lenses after traumatic disenclavation. Br J Ophthalmol. 2014 Sep;98(9):1303-7. doi:
10.1136/bjophthalmol-2014-305364. Epub 2014 Jul 1. PMID: 24985724.

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CLINICAL CASE
2023