- Visibility 159 Views
- Downloads 18 Downloads
- Permissions
- DOI 10.18231/j.ijceo.2023.078
-
CrossMark
Study of visual outcome and complications of primary and secondary retropupillary iris claw lens implantation in absence of adequate capsular support
- Author Details:
-
Paramveer Singh *
-
Ramswaroop Harsolia
-
Rakesh Porwal
Paramveer Singh *
Abstract
Aim: This study was conducted to assess and compare the visual outcome and complications of retropupillary iris claw lens implantation in absence of adequate capsular support.
Materials and Methods: This prospective, comparative, intervention, was conducted. All the patients who reported ophthalmology indoor department were divided into two groups. In 1st group patients with IMSC/MSC/Traumatic cataract/Repaired corneal tear with traumatic cataract/Subluxated IOL in which primary retropupillary iris claw lens implantation was done in the department of Ophthalmology through SICS/Phacoemulsificstion were categorised. In 2nd group patients with Aphakia in which cataract surgery was performed through SICS/Phacoemulsification and were left aphakic due to PCR in the department of Ophthalmology, JLN Medical College & Hospital and outside indoor patients at various ophthalmology centres.
Result: In primary RPICL in 23(76.7%) patients found to be BCVA between 6/36 to 6/18 and in secondary RPICL 26(86.7%) patients found to be BCVA between 6/12 to 6/6. In primary cases RPICL ovalisation of pupil in 6(20%), tilted IOL with raised IOP in 3(10%) optic capture in 3(10%), iridodialysias in 3(10%), bullous keratopathy in 3(10%). In secondary RPICL optic capture in 2(6.67%), CME with raised IOP in 1(3.33%), ovalisation of pupil in 1(3.33%) was found.
Conclusion: Results of present study suggest that secondary cases (group II) showed better visual outcome and lesser complications when compared with primary cases (group I) after retropupillary iris claw lens implantation.
Introduction
Cataract’ is in fact the most common cause of blindness if untreated.[1] This disorder involves the unclear opacified lens which obscures the passage of light; hence this progressive disorder requires treatment.[2], [3], [4], [5], [6] Its global prevalence is 15.2 million people became blind and 78.8 million people remained visually impaired. Posterior capsular rent is one of the potential complications of cataract surgery. Which was seen to occur in 0.45%–5.2% of cases.[7], [8] Cataract surgery can result in adverse outcome in case of an improperly managed Posterior capsular rent. Patients who are left aphakic are visually impaired without glasses which result in increased prevalence of blindness which is not treatable. Thus, cataract surgery won’t reduce the prevalence of blindness. ‘Loss of vitreous’ is most important factor which determines the visual acuity in post-surgery scenerio. [9]
Primary Iris claw implantation means that the IC-IOL which is to be implanted, is done in the same sitting after cataract removal. While secondary Iris claw lens implant is done in aphakic eyes without capsular support and can be done post cataract surgeries (In the second sitting) when the eye is left aphakic due to complications like lens drop/nucleus drop/vitreous loss occurred because of posterior capsular rupture.[10]
Because of its peculiar means of fixation, to the mid peripheral iris, the IC-IOL implantation can be done in any eye with sufficient support to iris. In addition, the iris claw lenses are much better than angle-supported Anterior chamber lenses when compared in terms of endothelial cell loss. IC-IOL placement can be done either anterior to the iris or can be retro fixated. An anterior fixated IC-IOL may show many complications, like those caused by AC-IOL, for example endothelial decompensation. Therefore, most of the surgeons like to prefer retropupillary fixation of IC-IOL so as to enhance endothelial safety. Hereby, in this study we have compared the outcomes of primary and secondary retropupillary fixated iris claw lenses.
Conventional secondary IOL implantation via scleral sutures is the treatment of choice, as the position of the scleral-fixated IOL (SF-IOL) is also ideal with respect to the anatomy of the eye. However, this technique necessitates the use of sutures and sufficient operative experience, and has a longer surgical time.[7] Secondary IOL scleral fixation can also lead to other severe intraocular complications, such as vitreous hemorrhage, retinal detachment, choroidal detachment, and suture-related complications.[8]
This RPICL implantation technique also gained popularity after Mohr et al. released the 1-year clinical outcomes for this technique in 2008.[9] Structurally, RPICL provides better stability and lowers the risks of IOL tilt or dislocation as compared to iris- or scleral-sutured lenses. Further, the absence of sutures for IOL scleral fixation lowers the risk of suture-related complications, like conjunctival erosion, scleromalacia, and endophthalmitis.[10], [11] Many previous studies have also supported the secondary RPICL to be a safe and efficacious technique for correcting various aphakic conditions with[12], [13], [14], [15], [16], [17], [18] or without IOL dislocation.[7], [19]
Materials and Methods
This prospective study was conducted after taking an informed consent from patients or their relatives who was attending the OPD in Department of Ophthalmology, J.L.N. Medical College and Associated group of Hospitals, Ajmer (Raj.) over a period of 18 months (Oct. 2020 to March 2022) after obtaining ethical committee approval.
Inclusion criteria
All patients of Surgical aphakia during surgery with no capsular support due to posterior capsular rupture in an extracapsular cataract extraction surgery (SICS/Phaco) where PCIOL implantation was not possible to implant (primary cases).
All patients of traumatic, surgical aphakia or subluxated PCIOL (secondary cases).
Exclusion criteria
Patients having no perception of light (PL) and defective projection of rays (PR) in traumatic cataract
Significant iris pathology
Glaucoma
Chronic or recurrent uveitis/iritis
Severe diabetic eye disease
Corneal pathology: Corneal scarring, irregularities, or opacities
All patients were investigated thoroughly, and proper consent was taken.
Study design
This study was a hospital based, prospective, interventional, clinical study conducted in a tertiary eye care centre. We studied the secondary iris-claw IOL implantation in 60 patients who fulfilled the criteria discussed above, over a period of 24 months. All patients were thoroughly investigated before undergoing secondary iris-claw lens implantation. Post-operatively, best-corrected visual acuity (BCVA), intraocular pressure (IOP) and complication encountered were noted at a regular follow-up of immediate post-operatively, 1 week, 1 month, 2 month & 3 months. 60 eyes of 60 patients in which 30 patients with primary retropupillary iris claw lens and 30 with secondary retropuillary iris claw lens fulfilled the above mentioned criteria. ([Figure 3], [Figure 4])
Results
Group I: Primary cases
Group II: Secondary cases
Distant vision (BCVA) at 3rd month follow up: The BCVA in both group I and group II was noted during the 3rd month follow-up, it was observed that, 1 (3.3%) and 26 (86.7) patients had 6/12 to 6/6visual acuity from group I and group II cases respectively. Similarly, 6 (20%) patients had BCVA between 3/60 to 6/60 in group I but none of the patients were in group II. In group I and group II cases, 23 (76.7%) and 4 (13.3%) patients respectively had BCVA between 6/36 to 6/18.
Various complications in group I and group II at 3rd month follow up: Complications were documented at 3rd month follow-up from each patient from group I and group II cases; it was observed that, high refractive surprise was found in high in 8(26.67%) patients in group II and 6 (20%) patients in group I. Ovalisation of pupil was found in 6 (20%) patients in group I and 1(3.33%) patient in group II. Raised IOP was also noticed in 4 (13.33%) and 2 (6.67%) patients from group I and group II respectively. Optic capture was found in 3(10%) and 2 (6.67%) patients from group I and group II respectively. Displaced/Tilted IOL with raised IOP, Iridodialysis and Bullous Keratopathy were found in 3(10%) patients from group I but none were found in group II. Further, CME was noticed in 2 (6.67%) and 1(3.33%) patient from group I and group II. Iridodialysis with raised IOP and CME with raised IOP were noticed only in 1(.33%) patient from group II, but none were found in group I.
Overall data has conferred a statistical significance with P value of 0.001 in both groups.([Figure 1], [Figure 2])
Discussion
In observational study done by Ashwini R Mahajan et al[20] (2014) found that, 73.4% patients with ICIOL were having final BCVA 6/18 to 6/6 and 23.33% ICIOL patient were having BCVA between 6/60 to 6/24 group which is in accordance with our study results in secondary cases and higher than our study results in primary cases.
In observational study done by Navya C et al[21] (2020) found final BCVA 6/18 to 6/6 in 86.67% cases which is in accordance with our study results in secondary cases and higher than our study results in primary cases.
In observational study done by Kanekar et al[22] (2020) found BCVA from 6/18 to 6/6 in 85% cases which is in accordance with our study results in secondary cases and higher than our study results in primary cases.
Ravindra et al (1994)[23] reported a BCVA of 6/18 or better in 80.7% cases which is in accordance with our study results in secondary cases and higher than our study results in primary cases.
In a cross-sectional observational study done by Trivedi K et al (2021)[24] found that, nearly 39.62% eyes had best-corrected visual acuity in the range of 6/18–6/36, which is lower than our study results in primary cases and higher than our study
In observational study done by Gonnermann et al[25] (2012) ovalization of pupil was found in 24.8% cases, which was found in accordance with our study results in primary cases and lower than our study results in secondary cases. Tilted IOL in 8.7% cases, which is in accordance with our study result in primary cases CME in 8.7% cases which are in accordance with our study result in both primary and secondary cases.
In observational study done by Kalode V et al[26] (2019) ovalization of pupil found in 12% cases which is lower than our study results in primary group and higher than our study result in secondary group.
In observational study done by Shanida HS et al[27] (2018), optic capture found in 6.6% cases which is lower than our study result in primary cases and in accordance with our study results in secondary cases.
In observational study done by Sumita CV et al[17] (2020), pseudophakic bullous keratopathy found in 16.7% cases, which is higher than in our study results in both primary and secondary cases. Tilted IOL in 11.1% cases which is in accordance in our study results in primary cases and higher than our study results in secondary cases. 25% cases having ovalization of pupil which is in accordance our study result in primary cases results and higher than our study results in secondary cases.
Conclusion
Results of present study suggest that secondary cases (group II) showed better visual outcome and lesser complications when compared with primary cases (group I) after retropupillary iris claw lens implantation.
Source of Funding
None.
Conflict of Interest
None.
References
- Bettadapura G, Donthi K, Datti N, Ranganath B, Ramaswamy S, Jayaram T. Assessment of avoidable blindness using the rapid assessment of avoidable blindness methodology. N Am J Med Sci. 2012;4(9):389-93. [Google Scholar]
- Nizami A, Gulani A, Cataract. Cataract. [Updated 2022 Jul 5]. StatPearls [Internet]. 2022. [Google Scholar]
- . GBD 2019 Blindness and Vision Impairment Collaborators; Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: The Right to Sight: An analysis for the Global Burden of Disease Study . Lancet Glob Health. 2021;9(2):e144-60. [Google Scholar] [Crossref]
- . National Blindness and Visual Impairment Survey India 2015-2019. . 2015. [Google Scholar]
- . India Ophthalmology Devices Market Report 2022: Technological Advancements in the Field of Ophthalmology Driving Growth - ResearchAndMarkets.com. . 2022. [Google Scholar]
- . India National Census. Census of India 2011 [Internet]. New Delhi: Indian National Census. . 2011. [Google Scholar]
- RV, Sharma N, Dada T, Gupta V, Kumar A, Dada V. Management of posterior capsule tears. Surv Ophthalmol. 2021;45(6):473-88. [Google Scholar]
- Greenberg P, Tseng V, Wu W, Liu J, Jiang L, Chen C. Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans. Ophthalmology. 2011;118(3):507-14. [Google Scholar] [Crossref]
- Mohr A, Hengerer F, Eckardt C. Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation techniques. Ophthalmologe. 2002;99(7):580-3. [Google Scholar] [Crossref]
- Kwong Y, Yuen H, Lam R, Lee V, Rao S, Lam D. Comparison of outcomes of primary scleral-fixated versus primary anterior chamber intraocular lens implantation in complicated cataract surgeries. Ophthalmology. 2007;114(1):80-5. [Google Scholar]
- Sen P, Kumar V, PS, Bhende P, PR, Rishi E. Surgical outcomes and complications of sutured scleral fixated intraocular lenses in pediatric eyes. Can J Ophthalmol. 2018;53(1):49-55. [Google Scholar] [Crossref]
- Brandner M, Thaler-Saliba S, Plainer S, Vidic B, El-Shabrawi Y, NA. Retropupillary fixation of iris-claw intraocular lens for aphakic eyes in children. PLoS ONE. 2015;10(6). [Google Scholar] [Crossref]
- Forlini M, Soliman W, Bratu A, Rossini P, Cavallini G, Forlini C. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: a retrospective analysis. BMC Ophthalmol. 2015;15. [Google Scholar] [Crossref]
- Kristianslund O, Raen M, Ostern AE, Drolsum L. Late in-the-bag intraocular lens dislocation: A randomized clinical trial comparing lens repositioning and lens exchange. Ophthalmology. 2017;124(2):151-9. [Google Scholar]
- Toro M, AL, TA, KN, CG, ST. Five-year follow-up of secondary iris-claw intraocular lens implantation for the treatment of aphakia: Anterior chamber versus retropupillary implantation. PLoS ONE. 2019;14(4). [Google Scholar] [Crossref]
- Madhivanan N, Sengupta S, MS, Nivean P, Kumar M, Ariga M. Comparative analysis of retropupillary iris claw versus scleral-fixated intraocular lens in the management of post-cataract aphakia. Indian J Ophthalmol. 2019;67(1):59-63. [Google Scholar]
- Sumitha C, Pai V, Thulasidas M. Retropupillary iris-claw intraocular lens implantation in aphakic patients. Indian J Ophthalmol. 2020;68(4):597-602. [Google Scholar]
- Mansoori T, Agraharam S, Sannapuri S, Manwani S, Balakrishna N. Surgical outcomes of retropupillary-fixated iris-claw intraocular lens. J Curr Ophthalmol. 2020;32(2):149-53. [Google Scholar] [Crossref]
- Rao R, Sasidharan A. Iris claw intraocular lens: A viable option in monocular surgical aphakia. Indian J Ophthalmol. 2013;61(2):74-5. [Google Scholar] [Crossref]
- Mahajan A, Datti N. Comparison of iris claw lens and scleral fixated intraocular lens in terms of visual outcome and complications. J Clin Biomed Sci. 2014;4(4):357-60. [Google Scholar]
- Navya C, Hatti A. Comparative study of secondary implantation of iris-claw lens and scleral-fixation intraocular lens in terms of visual outcome and complications. J Clin Ophthalmol Res. 2020;8:100-3. [Google Scholar]
- Kanekar P, Patare S, Naik D. omparative analysis of secondary implantation of Iris claw intraocular lens (ICIOL) & Scleral fixated intraocular lens (SFIOL) in terms of visual outcome and complications. VIMS Health Sci J. 2020;7(4):110-7. [Google Scholar]
- Ravindra B, Mallik A. Role of nonlinear dissipation in soft Duffing oscillators. Phys Rev E. 1994;49(6):4950-4. [Google Scholar]
- Trivedi K, Koley S. Mathematical modeling of breakwater-integrated oscillating water column wave energy converter devices under irregular incident waves. Renewable Energy. 2021;178:403-19. [Google Scholar]
- Gonnermann J, Klamann M, Maier A, Rjasanow J, Joussen A, Bertelmann E. Visual outcome and complications after posterior iris-claw aphakic intraocular lens implantation. J Cataract Refract Surg. 2012;38(12):2139-42. [Google Scholar]
- Kalode V, Daigavane S. Study of visual outcome and complications of iris-claw intraocular lens implantation to correct aphakia. J Datta Meghe Inst Med Sci Univ. 2019;14(3):141-54. [Google Scholar]
- Shanida H, Narayan S, Rajini KC. Visual outcome and complications of posterior iris-claw intraocular lens implantation: A follow-up analysis. Kerala J Ophthalmol. 2018;30:107-11. [Google Scholar]