ARTICLE

Air-Assisted Implantation of Anterior Chamber Intraocular Lens Tushar Agarwal,

M.D.,

Sandeep Gupta, M.D., Namrata Sharma, and Vishal Jhanji, M.D.

Purpose: We describe a technique of air-assisted anterior chamber intraocular lens (ACIOL) implantation. Methods: Lens aspiration and ACIOL implantation was performed in patients with progressive subluxation of lenses associated with systemic disorders. Results: Surgery was performed in nine eyes of six patients. No intraoperative adverse events were noted. There was air leak from the main port in three patients while inserting the intraocular lens; however the ACIOL was successfully implanted after re-injecting air from the side port. The mean best-corrected visual acuity improved from 0.67 to 0.25 log of minimal angle of resolution at 6-month follow-up. Mean intraocular pressure preoperatively was 14.54+1.38 mm Hg and 15.16+1.15 mm Hg at 6-month follow-up. Mean corneal endothelial count was 3,151+240.49 cells per square millimeter in the preoperative period and 2,947+194.9 cells per square millimeter at 6-month follow-up. Conclusions: Air-assisted ACIOL implantation seems to be a safe and effective technique for implantation of ACIOL in cases with progressive lens subluxation. Key Words: Anterior chamber intra ocular lens—Intraocular lens implantation—Surgical technique. (Eye & Contact Lens 2015;41: 164–166)

A

nterior chamber intraocular lens (ACIOL) implantation is one of the modalities of visual rehabilitation after cataract surgery in cases with insufficient capsular support. It is a relatively simple, cheap, and safe technique with an easy accessibility to most of the cataract surgeons.1 The standard technique of ACIOL implantation uses viscoelastics for anterior chamber (AC) formation while inserting the intraocular lens (IOL).2 We describe a technique of air-assisted ACIOL implantation thereby obviating complications associated with viscoelastic removal/retention after IOL implantation.

From the Dr Rajendra Prasad Centre (T.A., S.G., N.S., S.K.), All India Institute of Medical Sciences, Ansari Nagar, New Delhi; and Department of Ophthalmology and Visual Sciences (V.J.), The Chinese University of Hong Kong, Hong Kong. The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www. eyeandcontactlensjournal.com). Address correspondence and reprint requests to Tushar Agarwal, M.D., Dr Rajendra Prasad Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi; e-mail: [email protected] Accepted August 31, 2014. DOI: 10.1097/ICL.0000000000000096

164

M.D.,

Sudarshan Khokhar,

M.D.,

METHODS Surgical Technique We describe this technique in nine eyes of six patients of progressive subluxation of lens where we performed lens removal with ACIOL implantation. Intravenous 20% mannitol (1 g/kg body weight) is administered to the patient 1 hour before the surgery to prevent vitreous up thrust and inadvertent vitreous loss during surgery. Surgery is performed using peribulbar anesthesia—4 mL lidocaine hydrochloride 2% (Xylocaine) and 2 mL bupivacaine hydrochloride 0.5% (Sensorcaine) (Video, Supplemental Digital Content 1, http://links.lww.com/ICL/A21). Superior approach is preferred; however, in cases with superior or superonasal subluxation of lens, a temporal approach is applied. A 6-mm mark is made with calipers at limbus. Radial clear corneal beveled tunnel incision is made using 2.8 mm keratome (Alcon Laboratories, Bangalore, India) at the same site. Side port incision is made with an micro vitreoretinal blade (Alcon Laboratories) 90 degrees temporal to the main incision. Anterior capsule is stained with 0.1 mL of 0.06% trypan blue (Auroblue). Anterior chamber is formed using 1% sodium hyaluronate (Healon) and a capsulorxesis is performed with Utrata’s forceps (Fig. 1A). Hydro-dissection and delineation is performed to loosen the cortical matter as much as possible. The cortex is removed with coaxial irrigation aspiration (IA) (Infinity; Alcon Laboratories) (Fig. 1B). In most cases, viscoelastic injected during capsulorhexis is also evacuated during this step; however, if part of it is still retained, it is also removed with the IA probe. Capsular bag is left intact to cause minimal disturbance to anterior vitreous face and is removed only if it is encroaching on the pupillary area (Fig. 1C). Anterior chamber is formed by injecting sterile air using 0.22 mm Millipore filter from the side port. Intracameral 0.5% pilocarpine is injected and the iris is gently stroked centripetally using a sinskey hook to reduce the pupil size as much as possible. The AC, angles, and pupillary margins are swept with a sinskey hook introduced from the side port incision to release any vitreous tags. The endpoint of this maneuver is a small pupil with no peaking (Fig. 1D). A vitrectomy probe (Infinity; Alcon Laboratories) is introduced in aspiration (100 mm Hg) and cutting (700 cuts per minute) mode and a peripheral iridectomy is performed.3 Sterile air is again injected into the AC. Care is taken not to overfill the chamber with air as increased pressurization of AC may cause the air to migrate to the posterior chamber and can also cause dilatation of the pupil, which may impede ACIOL implantation (Fig. 1E). The primary 2.8-mm corneal tunnel incision is enlarged to 6 mm after measurement with calipers keeping the valve intact for the whole 6 mm. Kelman multiflex design 6 mm flexible open-loop ACIOL (Appasamy Associates, Chennai, India) is introduced into the AC using an Eye & Contact Lens  Volume 41, Number 3, May 2015

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Eye & Contact Lens  Volume 41, Number 3, May 2015

Air-Assisted Implantation of ACIOL

FIG. 1. (A) Capsulorhexis in a temporally subluxated lens. (B) Irrigation aspiration with a coaxial IA handpiece. (C) Intact capsular bag after complete cortical removal with irrigation and aspiration. (D) Miosed pupil with peripheral iridectomy and AC formed with air. (E) Air-assisted ACIOL implantation. (F) Well-centered ACIOL and a mobile air bubble in AC. AC, anterior chamber; IOL, intraocular lens; IA, irrigation aspiration.

RESULTS

IOL holding forceps ensuring minimal pressure on the posterior lip of the wound. The valvular incision, air in AC, and straight entry of IOL with a forceps ensures that the AC does not collapse during this step. However, sometimes, if the valve is not properly constructed, air may leak during ACIOL implantation. If the AC does become shallow, it can be supplemented with an air injection from the side port. It is important to tuck the trailing haptic of the ACIOL behind the posterior lip of the main incision. The superior incision is closed with three equidistant interrupted 10-0 nylon sutures and the knots are buried in the cornea. At the end of the surgical procedure, some of the air in the AC is burped out by opening the wound between the sutures to leave a partial airfilled chamber and a mobile air bubble (Fig. 1F). Subconjunctival injection of dexamethasone and gentamicin is given. Postoperatively, prednisolone acetate 1% eye drops every 4 hours and moxifloxacin hydrochloride 0.5% eye drops three times a day are given. TABLE 1.

Summary of Patients Undergone Air-Assisted Anterior Chamber Intraocular Lens Implantation BCVA (LogMAR)

Number

Age/Sex

1 2 3 4 5 6 7 8 9

21/F 21/F 18/M 18/M 22/F 22/F 23/M 16/M 23/F

Lens aspiration and ACIOL implantation was performed with our technique in nine eyes of six patients with progressive subluxation of lenses associated with systemic disorders, that is, Marfan syndrome and homocystinuria. No intraoperative adverse events were noted. There was air leak from the main port in three patients while inserting the IOL; however the ACIOL was successfully implanted after re-injecting air from the side port. The mean best-corrected visual acuity improved from 0.67 to 0.25 log of minimal angle of resolution at 6-month follow-up (Table 1). Mean intraocular pressure preoperatively was 14.54 +1.38 mm Hg and 15.16+1.15 mm Hg at 6-month follow-up. Mean corneal endothelial count was 3,151+240.49 cells per square millimeter in the preoperative period and 2,947+194.9 cells per square millimeter at 6-month follow-up.

Intraocular Pressure (mm Hg)

Corneal Cell Count (Cells/mm2)

Pre op

Post-op 6 mo

Pre-op

Post-op 6 mo

Pre-op

Post-op 6 mo

0.77 0.6 0.77 1.0 0.6 0.77 0.47 0.47 0.6

0.176 0.176 0.3 0.47 0.176 0.176 0.176 0.3 0.3

14.4 13.4 15.2 16.3 14.4 15.3 16.3 12.2 13.4

16.3 14.2 14.3 16.0 15.4 16.2 16.4 13.2 14.5

3,420 3,012 2,922 3,342 2,946 3,432 2,798 3,146 3,342

3,144 2,841 2,824 3,192 2,800 3,213 2,690 2,816 3,004

BCVA, best-corrected visual acuity; F, female; M, male; pre-op, preoperative; post-op, postoperative.

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Eye & Contact Lens  Volume 41, Number 3, May 2015

T. Agarwal et al.

DISCUSSION Planned extracapsular cataract extraction (ECCE) with phacoemulsification and primary insertion of a posterior chamber intraocular lens (PCIOL) is at present the procedure of choice for managing cataracts in adults. In cases with insufficient capsule and zonular support after phacoemulsification or planned ECCE, a variety of options are available, which include bag fixation with a capsular tension ring/Cionni ring, ACIOL, sutured/glued scleralfixated IOLs (SFIOLs), iris fixated ACIOL/PCIOL, and iris claw lenses. Out of these options, ACIOL implantation and SFIOLs are the most suitable in cases with progressive subluxation of lens.4 Scleral-fixated IOL implantation techniques are still evolving.5 Challenges with this technique compared with ACIOL implantation include the greater technical complexity, increased surgical time, entry tracks into the eye, and surgical manipulations in the region of the ciliary body. Inaccurate placement and erosion of the scleral fixation sutures/flaps have been reported to be associated with lens tilt, suprachoroidal hemorrhage, retinal detachment, and even endophthalmitis. Long-term visual and anatomical outcomes of ACIOL implantation in eyes undergoing cataract surgery with inadequate capsular support are better in comparison with SFIOL implantation in similar situations.6 Open-loop, flexible, AC lenses of the Kelman Multiflex type are the preferred ACIOLs because of the high rate of complications encountered with previous closed loop variety.7,8 The standard implantation techniques use viscoelastic materials such as sodium hyaluronate and methyl cellulose during ACIOL implantation to protect the endothelium.2 However, it is the removal of viscoelastic after ACIOL implantation, which can create problems. There is entrapment of viscoelastic between ACIOL and the iris, which may not be amenable to total removal with IA. Also, turbulence in the AC during irrigation and aspiration to remove viscoelastic leads to pupillary dilation, optic capture of the IOL, and egress of viscoelastic in the posterior chamber causing escape of vitreous in the AC through the pupil.

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These can lead to chronic uveitis, glaucoma, cystoid macular edema, and endothelial cell loss.1,9 Because we do not use viscoelastic during ACIOL implantation, there is no need for any surgical maneuvers in AC following the implant to remove the viscoelastic, hence obviating the problems of viscoelastic removal and retention. The air in the AC allows compartmentalization similar to that of viscoelastics, thereby providing adequate endothelium protection and AC formation during the ACIOL implantation. In conclusion, air-assisted ACIOL implantation seems to be a safe and effective technique for implantation of ACIOLs in cases where indicated. REFERENCES 1. Rattigan SM, Ellerton CR, Chitkara DK, et al. Flexible open-loop anterior chamber intraocular lens implantation after posterior capsule complications in extracapsular cataract extraction. J Cataract Refract Surg 1996; 22:243–246. 2. Raju NS. Anterior chamber intra ocular lens implantation. Indian J Ophthalmol 1989;37:73–74. 3. Khokhar S, Gupta S, Kumar G, et al. Achieving patent peripheral iridectomy: “23G vitrector: Sectoral pupil flutter technique”. Int Ophthalmol 2013;33: 567–570. 4. Lim ES, Apple OJ, Tsai JC, et al. An analysis of flexible anterior chamber lenses with special reference to the normalized rate of lens explantation. Ophthalmology 1991;98:243–246. 5. Solomon K, Gussler JR, Gussler C, et al. Incidence and management of complications of transsclerally sutured posterior chamber lenses. J Cataract Refract Surg 1993;19:488–493. 6. Kwong YY, Yuen HK, Lam RF, et al. Comparison of outcomes of primary scleral-fixated versus primary anterior chamber intraocular lens implantation in complicated cataract surgeries. Ophthalmology 2007;114:80–85. 7. Moses L. Complications of rigid anterior chamber implants. Ophthalmology 1984;91:819–825. 8. Weene LE. Flexible open-loop anterior chamber intraocular lens implants. Ophthalmology 1993;100:1636–1639. 9. David R, Yagev R, Shneck M, et al. The fate of eyes with anterior chamber intraocular lenses. Eur J Ophthalmol 1993;3:42–46.

Eye & Contact Lens  Volume 41, Number 3, May 2015

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Air-assisted implantation of anterior chamber intraocular lens.

We describe a technique of air-assisted anterior chamber intraocular lens (ACIOL) implantation...
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