ARTICLE

Pars plana vitrectomy combined with iris-claw intraocular lens implantation for lens nucleus and intraocular lens dislocation Elodie Labeille, MD, Carole Burillon, MD, PhD, Pierre-Loïc Cornut, MD, PhD

PURPOSE: To assess the medium-term efficacy and safety of treating nucleus and intraocular lens (IOL) dislocation with pars plana vitrectomy (PPV) combined with iris-claw IOL implantation. SETTING: Department of Ophthalmology, University of Lyon 1 Claude Bernard, Lyon, France. DESIGN: Retrospective case series. METHODS: The study comprised consecutive patients without capsule support having PPV combined with iris-claw IOL implantation for posterior dislocation of the nucleus or IOL between 2008 and 2012. The preoperative, intraoperative, and postoperative data were retrospectively analyzed. Patients were invited to a prospective final examination at least 6 months postoperatively. RESULTS: The study enrolled 32 eyes (31 consecutive patients). The dislocation was spontaneous in 8 cases and traumatic in 24 (intraoperative 17 cases, contusive 7 cases). The iris-claw IOL was on the anterior side of the iris in 19 cases and on the posterior side in 13 cases. The mean corrected distance visual acuity at the end of follow-up was 20/40 or better in 22 patients (69%). The mean spherical equivalent was C8.20 (SD) G 6.03 diopters (D) preoperatively and
0.51 G 1.14 D postoperatively. The median endothelial cell loss was 20.5% over the first 3 months. The complications were cystoid macular edema (n Z 8), retinal detachment (n Z 4), transient intravitreal hemorrhage (n Z 4), secondary glaucoma (n Z 2), and choroidal detachment (n Z 1). The final examination was performed in 27 eyes. CONCLUSION: Treatment of nucleus and IOL dislocation with PPV combined with iris-claw IOL implantation was effective and safe over the medium-term. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:1488–1497 Q 2014 ASCRS and ESCRS Supplemental material available at www.jcrsjournal.org.

Crystalline lens dislocation is a rare and severe disorder that causes substantial loss of visual acuity when it occurs in the context of multiple associated complications; it limits initial visual acuity to 20/200 or worse in 47% to 62% of cases.1,2 Its treatment raises the question of the choice of the aphakic correction from the following: spectacles (in cases of bilateral involvement), contact lenses or, more frequently, intraocular lens (IOL) implantation, if conditions allow. In most cases, IOL implantation will take place in absence of capsule support, requiring the use of an angle- or iris-supported anterior chamber IOL (AC IOL) or an iris-fixated or transsclerally sutured posterior chamber IOL (PC IOL).2 Because of the many long-term complications 1488

Q 2014 ASCRS and ESCRS Published by Elsevier Inc.

observed with AC IOLs, such as corneal decompensation, cystoid macular edema (CME), secondary glaucoma, hyphema, IOL decentration, pupil ovalization, and retinal detachment (RD), the use of such IOLs has considerably decreased.3,4 Although with intrascleral or transscleral fixation of a PC IOL the eye's anatomy is better preserved and there is less endothelial damage, intrascleral or transscleral fixation of a PC IOL is a long and complex surgical technique associated with a high rate of intraoperative and postoperative complications. These include IOL decentration or tilting, giant retinal tears, RD, choroidal hematoma, CME, and conjunctival erosion caused by transscleral sutures with an associated greater risk for endophthalmitis. 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.12.025

IRIS-CLAW IOL IMPLANTATION DURING VITRECTOMY

Since the introduction of the first iris-fixated IOL by Worst in the early 1980s, the design has improved considerably. The Artisan Verisyse IOL (Abbott Medical Optics, Inc.) is 1 of the latest versions of this type of IOL.5 This single-piece poly(methyl methacrylate) IOL attaches to the iris with clips on either side of the optic, with enclavation of a small fold of iris tissue by the surgeon. This IOL is relatively easy to place and is associated with favorable visual outcomes and low intraoperative and postoperative complication rates and is thus acceptable in aphakic patients, children, and adults.6–11 After more than 15 years of clinical experience in these populations, several studies6,9,12,13 have used these IOLs to treat lens dislocation; fewer data are available for simultaneous iris-fixated IOL implantation and vitrectomy for extraction of the dislocated material.8,10,13–16 The present study reports the medium-term efficacy and safety of combined pars plana vitrectomy (PPV) and primary iris-fixated IOL (Verisyse VRSA54, Abbott Medical Optics, Inc.) implantation in cases of posterior nucleus and IOL dislocation. PATIENTS AND METHODS All eyes with posterior dislocation of the nucleus or IOL without capsule support that had combined PPV with primary Verisyse VRSA54 iris-fixated IOL implantation in a single procedure between January 2008 and August 2012 were included. All surgeries were performed by the same surgeon (P-L.C.) at Edouard Herriot Hospital, Lyon France. Patients whose follow-up was fewer than 3 months were excluded from the study.

Data Collection For each patient, preoperative, intraoperative, and postoperative data were collected retrospectively. The clinical and surgical features, time to treatment, corrected distance visual acuity (CDVA), refraction, spherical equivalent (SE), intraocular pressure (IOP) (Goldmann applanation

Submitted: September 12, 2013. Final revision submitted: December 4, 2013. Accepted: December 6, 2013. From the Departments of Ophthalmology, L. Hussel Hospital (Labeille, Cornut), Vienne, Hospices Civils de Lyon (Burillon, Cornut), E. Herriot Hospital, University of Lyon 1 Claude Bernard, Lyon, and Pole Vision Val d’Ouest (Cornut), Ecully, France. Funding for English corrections by the Biblioth
eque Scientifique de 400 euros l’Association Generale de l’Internat de Lyon. Presented at the 119th Congress of the Societe Franc‚aise d’Ophtalmologie, Paris, France, May 2013. Corresponding author: Pierre-Lo€ıc Cornut, MD, PhD, Department of Ophtalmology, Pole Vision Val d’Ouest, 39 chemin de la Vernique, 69130 Ecully, France. E-mail: [email protected].

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tonometry), endothelial cell density (ECD) (Topcon SP1000, Topcon Corp.), assessment of macular anatomic status using optical coherence tomography (OCT) (Cirrus, Carl Zeiss Meditec AG), the duration of the hospital stay, and complications were reviewed. Postoperative examinations took place at 1 day, 1 week, and 1, 3, and 6 months. All patients were invited to a final examination at least 6 months after surgery (between June 2012 and October 2012). This standardized consultation, performed prospectively, comprised a complete ophthalmologic examination including measurement of CDVA, slitlamp evaluation, photographs of the anterior segment, IOP measurement, endothelial cell count (ECC) using the noncontact specular microscope, inspection of the dilated fundus, and systematic macular assessment using the OCT system.

Intraocular Lens Power Calculation The IOL correction necessary was determined using the data from biometric tests taken previously (mainly in cases of intraoperative dislocation occurring during cataract surgery). A new calculation was performed preoperatively, if possible, for both eyes with a noncontact optical biometer (IOLMaster, Carl Zeiss Meditec AG) or a contact ultrasound device (Ocuscan RxP, Alcon Laboratories, Inc.). The constant was adapted to the anterior (A Z 115.3) or posterior (A Z 117) location of the IOL in terms of its iris support.

Surgical Technique All patients had a PPV via a standard 20-gauge approach after superior conjunctival disinsertion or a 23-gauge transconjunctival system using an Accurus vitrectomy console (Alcon Laboratories, Inc.) or a Stellaris PC (Bausch & Lomb). The vitrectomy was performed using a contact wide-field system. After systematic posterior detachment of the vitreous, the vitrectomy was performed up to the extreme periphery to limit the risk for traction during extraction of the dislocated material. All patients were operated on under general or local anesthesia. In cases of nucleus dislocation or a lens fragment, the vitrectomy was followed by ablation of the dislocated material using a phaco fragmatome in patients with a high-density fragment or a vitreous cutter if the fragments were soft. When a fragmatome was used in a 23-gauge approach, the 10 o'clock sclerotomy was widened using a 20-gauge knife and sutured at the end of the procedure. If the IOL was dislocated in the vitreal cavity, complete vitrectomy was followed by opening the anterior chamber, which was filled with an ophthalmic viscosurgical device (OVD). This was followed by explantation of the lens raised in the anterior chamber using a membrane forceps with or without an aspiration back-flush cannula to be extracted through a 6.0 mm beveled corneal incision. After verification of the retinal periphery with the widefield lens system, the 2 superior sclerotomies were closed temporarily. The infusion was left in place and set at a lesser flow to stabilize the IOP during implantation. Intracameral acetylcholine chloride was used to constrict the pupil. The OVD was injected into the anterior chamber to protect the corneal endothelium. A corneal paracentesis was created at the 9 o'clock position. In cases of dislocated IOLs, the paracenteses were made before the superior corneal opening was created to extract the IOL. The IOL was inserted through a 6.0 mm corneal incision centered on the 12 o'clock position and then rotated to align on the horizontal position. Using a

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lens-fixation forceps (VRSimplant, Abbott Medical Optics, Inc.), the posterior iris-claw IOL was slipped through the pupillary area and then centered over the pupil behind the iris. At the same time, through the paracentesis, an IOL dialer was used for enclavation of the iris by applying gentle pressure over it through the slotted center of the IOL haptic. When an anterior iris-claw IOL was used, a second paracentesis was made at the 3 o'clock position. A Bonn forceps (Moria, Corp) was used for enclavation (anterior IOL) of the iris, enclosing a fold of iris tissue in the fixation. A peripheral superior iridectomy was performed with the vitreous cutter. The anterior chamber was cleared of all OVD at the end of the intervention. The corneal incision was sutured using 10-0 nylon. Suspected or definite tears or holes in the retina were treated with cryotherapy. Sclerotomies and conjunctiva were sutured with 7-0 polyglactin (Vicryl) if necessary. At the end of surgery, betamethasone was injected subconjunctivally.

Statistical Analysis The main outcome measures were variations in visual acuity, SE, ECD, and the onset of complications and whether they involved the anterior or posterior segment. The CDVA was measured using the Snellen scale converted to logMAR for the purposes of statistical analysis. SPSS software for Windows (Microsoft Corp.) was used for the statistical analysis. The Student t test was used to compare quantitative data; the Wilcoxon rank-sum test was used to compare the ECD between different visits. The chi-square test was used to compare qualitative data. Results were considered statistically significant if the P value was less than 0.05.

RESULTS Thirty-two eyes (18 right, 14 left eyes) of 31 patients (12 women and 19 men) were included in the series. The dislocation involved the lens of a phakic patient in 20 cases and the IOL of a pseudophakic patient in 12 cases (supplemental table, available at www.jcrsjournal. org). All patients had a follow-up of at least 3 months; the mean follow-up was 19.2 months G 13.8 (SD) (range 3 to 52 months). Three patients were lost to follow-up. The final prospective examination was performed in 27 eyes. Table 1 shows the preoperative characteristics of all patients. The patients' ages at surgery ranged from 45 to 88 years. Patients with a history of contusive trauma (including trauma immediately before dislocation and trauma in the remote past) were younger than the other patients (mean age 65 years versus 75 years; PZ.023), and men were overrepresented (8 men/1 woman versus 11 men/11 women). The most frequent preexisting ocular diseases were glaucoma, maculopathy, and pathologic myopia (
6.0 diopters [D] or more). The maculopathies were 3 cases of age-related macular degeneration (AMD) (2 exudative form, 1 atrophic form) and a macular choroiditis scar. The luxation risk factors were a history of ocular trauma (contusion), pseudoexfoliative syndrome, and contralateral dislocation occurring several

Table 1. Preoperative patient characteristics.

Characteristic Mean age (y) Male/female (n) Glaucoma (n) Pseudoexfoliative syndrome (n) History of trauma (n) Marfan syndrome (n) History of intraocular surgery (n) History of RD (n) Myopia (n) Preexisting maculopathy (n) Mean IOP (mm Hg) Mean CDVA (logMAR) Mean time between diagnosis and surgery (d) Mean axial length Corneal edema (n) Dislocated material (n) All of nucleus Fragments

P Value Lens IOL Between All Dislocation Dislocation Groups Patients 70 15/5 3 2

75 4/8 4 4

7

3

1

0

2

4

.17z

6

1 2 4

1 1 0

1.0x 1.0x .27x

2 3 4

23.7

20.4

.40*

22.4

1.3

1.1

.59*

1.2

1.0

2.5

.43{

1.5

23.5 10

23.9 5

.33* .73x

23.6 15

0 0

d d

12 8

.13* .02†,z .34x .17x .70x

72 19/13 7 6 10 1

12 8

CDVA Z corrected distance visual acuity; IOL Z intraocular lens; IOP Z intraocular pressure; RD Z retinal detachment *Student t test for independent samples † Statistically significant z Chi-square test of independence x Fisher exact test { Mann-Whitney rank test

years previously (3 eyes). The patient with Marfan syndrome presented with subluxation of the contralateral lens and had a family history of ectopia lentis. The other preexisting ophthalmologic conditions were RD, diabetic retinopathy, and uveitis. Findings at Presentation The mean preoperative CDVA was 20/400 (median 20/100; range light perception to 2/32). Thirteen eyes were hypertensive (IOP O21 mm Hg) at admission; in all patients, the IOP range was 10 to 45 mm Hg. Visual acuity before vitrectomy and initial IOP were not available for 3 patients in whom vitrectomy was performed on the same day as lens dislocation immediately after the initial surgery.

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significant difference in CDVA, ECD, and the occurrence of other complications.

Figure 1. Type of dislocation material, causative factors, and complications (IOL Z intraocular lens; CME Z cystoid macular edema; lens Z nucleus; RD Z retinal detachment).

In eyes with corneal edema at presentation, the edema was graded as mild in 5 eyes (16%), moderate in 7 eyes (22%), and pronounced in 3 eyes (9%). The mean axial length ranged from 21.45 to 26.81 mm. The dislocation mechanism was zonulysis in 21 (68%) cases, posterior capsule rupture in 10 (32%) cases, and unknown in 1 case. Twelve eyes (38%) presented with intraoperative lens dislocation during phacoemulsification and 5 eyes (16%) had intraoperative or immediate postoperative dislocation of the PC IOL. Recent trauma was responsible for lens dislocation in 7 eyes (22%). In 8 patients (25%), no causative factor was found (Figure 1). No RD was present before the vitrectomy or during the initial fundus examination or on B-mode ultrasound.

Pars Plana Vitrectomy Timing The vitrectomy associated with IOL implantation was performed the same day as the cataract surgery in 3 eyes (9%). The median time between the first consultation for lens dislocation and vitrectomy was 1.5 days (range 0 to 280 days). For patients who had presented with intraoperative dislocation, the median time between cataract surgery and its complication and the vitrectomy was 2.5 days (range 0 to 20 days). In patients who presented with intraoperative lens or IOL dislocation, the surgery was significantly longer (median 72 minutes versus 60 minutes) when the surgery was performed before the second day (PZ.028, Mann-Whitney test). The patients who had surgery the earliest were less hypertensive at admission (initial IOP median 15 mm Hg versus 25 mm Hg; PZ.045, Mann-Whitney test). The same trend was found at 1 month, although the result was not statistically significant (hypertension at month 1, 67% versus 14%; PZ.060, Fisher exact test). However, there was no

Pars Plana Vitrectomy Thirty (94%) surgeries were performed under general anesthesia and 2 (6%) under peribulbar anesthesia. The mean duration of surgery was 66 minutes (range 35 to 120 minutes). The mean was 71 minutes for phacofragmentation and 57 minutes for explantation of the IOL (PZ.043). There was no correlation between the duration of surgery and clinical presentation. A standard 20-gauge system was used in 23 cases (72%), whereas 9 eyes (28%) had a transconjunctival sutureless 23-gauge approach. The surgery was shorter with the 23-gauge system (mean 55 minutes versus 70 minutes; PZ.042); however, interpretation of this outcome should take into account that 7 of the 9 surgeries performed with the 23-gauge system involved IOL dislocations. Perfluorocarbon fluid was used in 3 eyes (9%). In 14 cases, a fragmatome was used to remove the hard nucleus. In 6 cases, lens fragments were removed with a vitreous cutter. Moderate hyphema occurred after iridectomy in 2 patients. The iris-fixated IOL was placed in front of the iris in 19 eyes and behind the iris in 13 eyes. At-risk retinal lesions were identified and treated with cryoapplication during the vitrectomy procedure in 6 eyes (19%). The mean duration of the hospital stay was 2.7 days (range 1 to 7 days). Postoperative Visual Acuity Figure 2 shows the postoperative versus preoperative CDVA. Table 2 shows the changes in the mean

Figure 2. Postoperative CDVA compared with initial CDVA. The points below the line of equal distribution represent patients whose visual acuity increased.

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Table 2. Changes in mean CDVA, SE, astigmatism, IOP, and corneal characteristics from preoperatively to postoperatively. Mean G SD Exam

CDVA (LogMAR)

Preoperative Postoperative 1 month 3 months 6 months Final

SE (D)

Astigmatism (D)

IOP (mm Hg)

ECD (Cells/mm2)

1.22 G 0.90

8.2 G 6.0


0.9 G 1.1

22.4 G 10.1

1940

0.59 G 0.59 0.43 G 0.67 0.56 G 0.86 0.53 G 0.84


0.7 G 2.1
0.6 G 1.3
0.5 G 1.2
0.5 G 1.1


5.2 G 2.9
3.0 G 2.2
2.1 G 1.3
2.0 G 1.2

15.7 G 6.4 14.9 G 5.4 13.8 G 3.7 14.7 G 3.2

d 1570 d 1350

CDVA Z corrected distance visual acuity; ECD Z endothelial cell density; IOP Z intraocular pressure; SE Z spherical equivalent

corneal edema. Data were also missing because of the retrospective design of the study. The mean ECD decreased by 31% over the total follow-up (Table 2); the decrease was statistically significant (PZ.001). The median ECD decreased by 20.5% 3 months after surgery from the preoperative median (PZ.003). The endothelial cell loss during the first 3 months was significantly greater in the operated eye than in the fellow eye (median 20.5% versus 3.7%; PZ.004) (Table 3). There was no statistically significant difference between cell loss in the operated eye and in the fellow eye beyond the third postoperative month (median 9.8% versus 2.3%; PZ.169). Endothelial cell loss at 3 months was comparable between eyes in which the iris-fixated IOL was implanted in front of the iris and eyes in which it was implanted behind the iris (PZ.38). Endothelial cell loss beyond the third month was not compared between these 2 groups because of a significantly different followup period; the patients who had posterior IOL implantation were among those who had their surgery

preoperative and postoperative CDVA, SE, astigmatism, IOP, and ECD. There was a statistically significant increase in the mean CDVA at all postoperative visits compared with the preoperative visit. The improvement was also significant between the visits at 1 month and 3 months (PZ.004). At the final evaluation, the CDVA had improved in 28 eyes (87.5%). The mean Snellen CDVA improved from 20/320 preoperatively to 20/63 at the final follow-up visit (PZ.002). The CDVA at the end of follow-up was 20/40 or better in 22 cases (69%), between 20/50 and 20/200 in 5 cases (16%), and worse than 20/200 in 5 cases (16%). The improvements in the mean SE from preoperatively to postoperatively and in the mean astigmatism from 1 month to 6 months postoperatively were statistically significant (both P!.001). The corneal sutures were removed between the first and third month in 30 patients (94%). Endothelial Cell Count The preoperative ECC was available in 18 cases. An initial ECC was not obtained in patients with severe

Table 3. Endothelial cell density (cells/mm2) results of the Wilcoxon test. P Value (Wilcoxon Test) Operated Eye

Operated Eye Initial ECD 3-mo ECD Final ECD Fellow eye Initial ECD 3-mo ECD Final ECD 3-mo EC loss O3-mo EC loss

Fellow Eye

Operated Eye

Initial ECD

3-Mo ECD

Final ECD

Initial ECD

3-Mo ECD

Final ECD

3-Mo EC Loss

O3-mo EC loss

d .003 .001

.003 d .024

.001 .024 d

.256 d d

d .016 d

d d .005

d d d

d d d

.256 d d d d

d .016 d d d

d d .005 d d

d .308 .003 d d

.308 d .074 d d

.003 .074 d d d

d d d .004 d

d d d d .169

O3-Mo Z between 3-month and final visit; ECD Z endothelial cell density; EC Z endothelial cell

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most recently (mean follow-up 9 months versus 26 months; P%.001). No eye developed corneal edema or decompensation. The use of a fragmatome was not associated with higher endothelial cell loss (PZ.94). Optical Coherence Tomography At the last visit (27 patients), the mean central macular thickness was 317 G 103 mm in the operated eye versus 262 G 62 mm in the contralateral eye (PZ.021). An epiretinal membrane was observed on OCT in 19 eyes (70%), causing CME or subretinal fluid accumulation in 4 eyes. Macular edema was present in 10 eyes (37%) at the last visit; in 5 eyes, it was secondary to another disease (neovascular AMD, central retinal vein occlusion, diabetes, choroidal neovascularization in high myopia). Thus, macular edema was not considered a direct complication related to surgery. Postoperative Complications Epiretinal membrane (19/27 [70.0%]), CME (8/28 [29.0%]), RD (4/32 [12.5%]), and secondary glaucoma (2/32 [6.0%]) were the most common postoperative complications. The CME resolved with topical nonsteroidal antiinflammatory treatment in 3 eyes. The onset of CME did not seem to be influenced by the implantation site (PZ1.0, Fisher exact test). Of the 9 patients with glaucoma at the end of followup, 7 had preexisting glaucoma. Early postoperative mild vitreous hemorrhage developed in 4 eyes (12.5%); in all cases, it resolved spontaneously. Choroidal detachment occurred in 1 eye (3%); it resolved spontaneously and was associated with a favorable functional result (final CDVA 20/25). There were no cases of IOL dislocation, uveitis, or endophthalmitis. The time to onset of RD was between 9 days and 3 months after surgery. One patient developed a total RD. In all cases, the retina was reattached in a single procedure (vitrectomy, retinopexy, internal gas tamponade) with no need to remove the IOL. Three of the 4 patients had a final CDVA of 20/32 or better. The patient with a total RD also had exudative AMD (CDVA limited to counting fingers). A fragmatome was used during the vitrectomy in 3 of the 4 patients who presented with an RD; however, no statistically significant relationship was found (PZ.52, Fisher exact test). The median endothelial cell loss in patients operated for RD was 46.0% (range 0% to 12%), whereas it was 26.5% (range 0% to 50%) in patients who did not have RD. The difference was not statistically significant (PZ.182, Mann-Whitney rank test). The incidence of CME in these patients was not higher than in the other patients (25% versus

18%, PZ1.0, Fisher exact test). No risk factors for RD onset were found. At the last visit, there were 5 cases of IOL decentration with no effect on functional results. An irregular pupil was noted in 9 eyes, iris atrophy in 13 eyes, and heterochromia in 5 eyes. One haptic of a posterior iris-claw IOL was transfixed in 1 eye; however, the IOL was centered and stable (logMAR CDVA, 0.2). There was no significant difference in the occurrence of complications between the locations of the IOL (in front of or behind the iris) between eyes with contusive dislocations and eyes without contusive dislocations. Mediocre Visual Results A history of maculopathy (PZ.007), CDVA at 1 month of 20/200 or worse (PZ.006), and the presence of CME at the final OCT examination (PZ.039) were associated with less favorable functional results, with the CDVA limited to worse than 20/40 (Table 4). All patients with poor visual results (worse than 20/ 200) had maculopathy independent of the surgery; that is, 2 cases of exudative AMD, 1 case of choroidal Table 4. Statistical significance of parameters as determinants of poor visual outcome. Number of Eyes Parameter Age R85 years Preexisting maculopathy Previous trauma IOP R30 mm Hg* Corneal edema* Timing of vitrectomy† 0–1 day R 2 days Use of fragmatome Perfluorocarbon liquid IOL insertion AC PC Hyphema Choroidal detachment Cystoid macular edemaz Retinal detachment CDVA at 1 month ! 20/200

P VA R20/40 VA !20/40 Valuex (n Z 22) (n Z 10) 1 0 7 6 10

3 4 3 2 5

.079 .007{ 1.0 1.0 1.0

4 5 9 3

1 4 5 0

.58 .58 .71 .53

13 9 3 1 4 3 1

6 4 0 0 6 1 5

1.0 1.0 .53 1.0 .039{ 1.0 .006{

AC Z anterior chamber; CDVA Z corrected distance visual acuity; IOL Z intraocular lens; IOP Z intraocular pressure; PC Z posterior chamber *At presentation (n Z 29) † After cataract surgery (n Z 14) z At final examination (n Z 27) x Fisher exact test { Statistically significant

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neovascularization complicating high myopia, 1 case of choroiditis scar, and 1 case of macular edema with retinal venous occlusion. DISCUSSION In this study, treatment of nucleus and PC IOL dislocation with simultaneous PPV and iris-claw IOL implantation was an effective and safe treatment at the middle term. This result supports the conclusions of several recent studies of the use of iris-claw IOLs for aphakic correction.6–13,15–19 Management of aphakia in lens dislocation in the absence of capsule support has long required anglesupported AC IOLs and PC IOLs sutured to the sclera or the iris.2–4 The problems and complications inherent in these techniques have encouraged surgeons to turn to simpler and/or less risk-laden alternatives. Hara et al.17 compared iris-claw PC IOL implantation with transscleral fixation. In their prospective study of 32 eyes, the surgical time required for implantation was 20 minutes for the iris-claw IOLs versus approximately 50 minutes for the transscleral suturing procedure. In addition, complications were more frequent and visual rehabilitation slower with transsclerally sutured IOLs.16,17 Implantation is still frequently performed as a procedure separate from vitrectomy.1,18,20 In our department, between 2008 and 2012, 67 eyes of 66 patients had surgery for posterior dislocation or subluxation of the lens (72%) or the IOL (28%) performed by 1 of us (P-L.C.). Eight patients (12%) had an IOL in the capsular bag or the sulcus. Thirty-three eyes (49%) had iris-claw IOL implantation during the vitrectomy, and 25 eyes (37%) were aphakic after the vitrectomy (most had subsequent IOL implantation). This work is original in that it studied only patients who had iris-claw IOL implantation during vitrectomy. Most studies included patients who received IOLs during the initial cataract surgery as well as patients who received IOLs during vitrectomy or subsequently.10,12,13 To our knowledge, only 4 studies of 9 to 15 eyes evaluated PPV and placement of an irisclaw IOL performed during the same surgical procedure. Two studied lens subluxation, 1 of adults after trauma8 and 1 in children with no trauma.18 Patil et al.15 and Farrahi et al.16 evaluated populations that were comparable to the one in the present study; the CDVA was 20/40 or better in 40% to 75% of the patients (69% in our series) and the complication rate comparable to ours. The studies of secondary implantation6,7,9,17,18 report better visual results (up to 87% with a visual acuity of better than 20/40) and a lower complication rate (notably for CME and RD), which seems logical because they evaluated the results of implantation only but not the complications related

to the vitrectomy and the initial injury. In addition, it is probable these studies included only eyes that did not develop early complications. Performing IOL implantation during vitrectomy does not seem to significantly lengthen the surgical time or lead to a higher rate of intraoperative or postoperative complications. Over 2 years, the mean duration of surgery in our study was reduced to fewer than 60 minutes. Combined implantation and vitrectomy also reduces the number of interventions for the patient and provides faster visual rehabilitation by correcting aphakia earlier. Thus, the strategy seems advantageous for cases in which the anatomic conditions are suitable. The efficacy of this technique was confirmed in that the desired anatomic result was obtained in all patients in our study. Our visual results are comparable to those reported in the literature,1,20–22 with 69% of patients having a final CDVA of 20/40 or better compared with 40% to 70% in the other series. The mean postoperative SE in our study (
0.49 G 1.19 D at 6 months) is also comparable to that in other studies (from 0.0 to
1.7 D).8,13,18 The precision in IOL power calculation might be better with iris-claw fixation than with transscleral fixation, in which it is more difficult to predict the distance between the optic and the retinal plane because of the variable location of the sutures.15 Use of a flexible injectable irisfixated IOL could make it possible to reduce the visual recuperation time because the smaller incision would induce less astigmatism. As expected, we observed a significant increase in the mean CDVA between the first and third postoperative months as a result of suture removal during this period, with the mean astigmatism decreasing from
5.2 G 2.87 D to
2.1 G 1.31 D between the first and sixth postoperative months. The majority of the surgeries during this study were performed early on; the median was 2.5 days after the initial surgery in patients who presented with intraoperative or early postoperative dislocation. A metaanalysis by Vanner and Stewart23 concluded that the optimum time is within the 7 days after complicated cataract surgery, citing an increased risk for complications (hypertonia, inflammation, macular edema, RD) if surgery is delayed. In our study, although the surgeries performed before the second day after a complicated cataract surgery were longer than those performed on the second day or later, the postoperative results were comparable. Preoperative hypertonia and a tendency toward early postoperative hypertonia seemed to occur more frequently in patients whose surgery was delayed the longest. Studies have measured endothelial cell loss in eyes with iris-claw AC IOLs, mainly implanted to provide refractive correction in phakic patients.24 In our patients, endothelial cell modifications seemed to occur mainly

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during the intraoperative period. The rate of early (at 3 months) endothelial cell loss in our series was 20.5%, which seems high compared with the data in the literature. This result must be interpreted with caution; it is probable that this rate of cell loss was influenced by the initial injury (complicated cataract surgery or severe contusion in most cases) and by the vitrectomy combined with IOL implantation. Longer term cell loss is much more difficult to quantify. Although the endothelial cell loss in our patients seemed greater in the operated eye than in the fellow eye at the end of follow-up (9.8% versus 2.3% between 3 months and the final visit), this difference was not statistically significant (PZ.169). Some studies with a high number of patients (70 to 155) found no endothelial cell loss in the medium term in phakic patients with a refractive IOL24; in others, the annual endothelial cell loss decreased with time and then began to stabilize at 3 years, approaching the 0.6% per year loss seen in normal eyes.12,25 Beyond the context of refractive surgery, and despite the small number of patients, studies of aphakic patients provide higher, but highly variable, endothelial cell loss rates of 15.0% at 1 month,8 4.7% to 20.0% at 1 year,6,9 24.0% at 16 months,18 and 10.9% at 3 years. 9 It is difficult to draw conclusions about long-term endothelial loss because the measurements are, to a large extent, related to the low reproducibility of the technique of counting endothelial cells. One third of the variation reportedly depends on the precision of the measuring instruments and two thirds on the variability of the endothelial cell population in the same eye.25 Iris-claw PC IOL implantation could theoretically limit the risk for endothelial injury. The complication rate in our patients was comparable to rates published in other series of lens dislocations. The main severe complications in our patients were CME (29.0%), RD (12.5%), resolving intravitreal hemorrhage (12.5%), secondary glaucoma (6.0%), and resolving choroidal detachment (3.0%). The incidence of RD after vitrectomy for lens dislocation is estimated to be between 8% and 21%.14,22,26,27 The onset of RD is associated with worse visual results.1,20,22,26 The 4 patients (1 with an AC IOL, 3 with a PC IOL) who presented with RD during the follow-up obtained favorable anatomic and visual results (20/32 or better) after 1 intervention, except for 1 patient who presented with AMD. Some surgeons advise against performing AC IOL implantation and vitrectomy to extract dislocated material in the same setting to limit the risk for endothelial complications induced by the gas used if the retina detaches. Under this assumption, posterior fixation of the IOL can limit, as much as possible, the risk for contact between the IOL and the cornea if internal gas tamponade performed. Macular edema complicates 5% to 28% of lens dislocations and frequently becomes a chronic

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condition.1,10,20–22,27,28 Eight of our patients presented with postoperative CME; 3 were successfully treated with topical antiinflammatory medications. Of the 5 patients with CME related to the surgery, 4 developed an associated epimacular membrane by the end of the follow-up. An epiretinal membrane was found during the final OCT examination in 70% of eyes. Its presence probably explains the difference in the central macular thickness between the operated eye and the fellow eye (mean 317 G 103 mm versus 262 G 62 mm; PZ.021). Acar et al.18 describe a significant increase in macular thickness 3 months postoperatively; however, they did not mention whether there was an associated membrane. The presence of an epimacular membrane was considered responsible for CDVA worse than 20/40 in only 1 of our patients who had surgical peeling of the membrane. We found no comparative data in the literature on the incidence of epimacular membrane after IOL dislocation treatment, given the absence of systematic postoperative OCT. A membrane has been cited as leading to a poor visual result in 0.5% to 7.0% of cases, which corresponds to our results (3.0%).1,15,20,21 Although IOL disenclavation or dislocation is frequently mentioned in studies of iris-claw IOLs (incidence 0% to 20%),13,16,17,19 these complications did not occur in our study. We observed 5 cases of slight decentration; however, the IOL did not have to be replaced in any of the cases. One patient reported fluctuating vision when he bent forward, which could be explained by the mobility of the iridolenticular plane effected by gravity; we found no other similar descriptions in the literature. There were no cases of endophthalmitis in our study. The IOL was attached on the posterior side of the iris in 13 patients in our study. This technique has been described for nearly 20 years in corneal grafting and for fewer than 10 years in aphakic patients.7,13,15,17 In addition to more closely respecting the eye's anatomy with, the main advantage of PC IOL implantation is that it spares the corneal endothelium by increasing the distance between the IOL and the cornea. The shorter follow-up in patients who had surgery more recently in our study makes it impossible to confirm this hypothesis. Studies reporting the results of posterior IOL implantation7,13,15,17 had a limited follow-up and therefore could not confirm the technique has a role in protecting the endothelium. The factors in a poor visual prognosis we identified were preexisting maculopathy, poor visual acuity 1 month after surgery, and the presence of macular edema at the end of follow-up. No statistical relationship was found between a poor final CDVA and initial CDVA, or onset of RD, all of which have been cited in the literature.1,20,22,26

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Our study also emphasizes the effects of the learning curve for the surgeon over 4 years. As the surgeon mastered the technique, the duration of surgery decreased; this is also explained by the much more rapid implantation of the PC IOL and the use of the 23-gauge transconjunctival system.19,29,30 The main limitations of this study are its retrospective design and the small number of patients. In addition, the population was heterogeneous, including patients who presented with an ocular contusion that was responsible for the dislocation, intraoperative dislocations, and spontaneous dislocations. Analysis of these subgroups showed no difference in the visual results or in the onset of complications. The size of the population and the duration of follow-up (mean 19 months; median 17 months) allow us, however, to conclude that the surgical technique in this study is safe. Pending prospective comparative studies with other implantation techniques and studies with longer follow-up, notably those of endothelial cell loss and iris-claw IOL implantation during vitrectomy for lens or IOL dislocation, can confirm whether the combined technique we used is a satisfactory method to correct aphakia in the absence of capsule support. The combined treatment of dislocation and aphakia in the same surgical intervention provides a rapid anatomic and functional rehabilitation. WHAT WAS KNOWN  Iris-claw IOL implantation to correct aphakia in the absence of capsule support yields good outcomes and favorable complication rates. WHAT THIS PAPER ADDS  Pars plana vitrectomy combined with primary iris-claw IOL implantation reduced the number of interventions and provided faster visual rehabilitation by correcting aphakia earlier.

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First author: Elodie Labeille, MD Departments of Ophthalmology, L. Hussel Hospital, Vienne, France