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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 690-697

Evaluation of aphakic iris-claw intraocular lens implantation


Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission05-Nov-2018
Date of Acceptance30-Dec-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Ahmed M Shebl Fayed
Department of Ophthalmology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_363_18

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  Abstract 

Objectives
To evaluate the technique of aphakic iris-claw (IC) intraocular lens (IOL) implantation, the visual outcome, and the incidence of postoperative complications.
Background
Several techniques are available for visual rehabilitation of eyes with inadequate capsular support following complicated cataract surgery or owing to lens subluxation or dislocation. IC-IOL is an effective option with several advantages over other techniques.
Patients and methods
Patients with inadequate capsular support underwent aphakic IC-IOL implantation. We used two techniques: anterior chamber (AC) and retropupillary fixation of IC lens. Eyes were evaluated for uncorrected and corrected distance visual acuity, intraocular pressure (IOP), and the incidence of postoperative complications.
Results
The study comprised 12 eyes of 11 patients. Indications for surgery included aphakia following complicated cataract surgery (n = 8), lens dislocation (n = 1), and lens subluxation (n = 3). Eight eyes had AC IC lens implantation and four eyes underwent retropupillary implantation. The final postoperative uncorrected and corrected distance visual acuity improved significantly compared with preoperative values. There was no statistically significant difference between preoperative and postoperative IOP. Postoperative complications included corneal edema, IOP elevation, inflammatory reaction, pupil ovalization, vitreous hemorrhage, and lens disenclavation. There was no statistically significant difference between the two techniques of implantation regarding any of the studied variables.
Conclusion
Aphakic IC-IOL is an effective option for visual rehabilitation in eyes with inadequate capsular support, providing a good visual outcome and high safety profile. Both AC and retropupillary fixation can achieve a satisfactory outcome.

Keywords: aphakia, iris-claw, lens dislocation, lens subluxation


How to cite this article:
El-Saadany AKI, Khairy HA, Rajab GZ, Shebl Fayed AM. Evaluation of aphakic iris-claw intraocular lens implantation. Menoufia Med J 2019;32:690-7

How to cite this URL:
El-Saadany AKI, Khairy HA, Rajab GZ, Shebl Fayed AM. Evaluation of aphakic iris-claw intraocular lens implantation. Menoufia Med J [serial online] 2019 [cited 2019 Sep 17];32:690-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/690/260893




  Introduction Top


Posterior chamber (PC) intraocular lens (IOL) implantation in the capsular bag remains the ideal outcome following cataract extraction. However, this might not be feasible under certain circumstances when there is insufficient capsular or zonular support for either intracapsular or PC sulcus placement of the IOL. Examples include aphakia following complicated cataract surgery, predominantly after posterior capsule rupture or significant zonular dehiscence; congenital lens subluxation as in Marfan syndrome or Weill–Marchesani syndrome; and acquired zonular weakness because of trauma, pseudoexfoliation syndrome, pathological myopia, uveitis, or hypermature cataract. In such cases, alternative methods of IOL fixation need to be considered[1].

Presently, several methods are available for dealing with IOL requirements in the absence of adequate IOL support. The most frequently used methods include angle-supported anterior chamber (AC) IOLs, sutured scleral fixation (SF) of PC-IOLs, and iris-claw lenses (IC-IOL)[2].

Iris-claw IOL was initially designed by Jan Worst in 1978[3]. It is a one-piece biconvex lens made of poly-methyl methacrylate. It has a total length of 8.5 mm (7.5) mm for pediatric patients), and an optic diameter of 5.4 mm with a 5 mm clear optical zone. Two unique flexible haptic 'claws' support the central optic [Figure 1]. They are used to fix the lens to the mid-peripheral iris by a technique known as enclavation. It is available in refractive powers ranging from 2 D to 30 D in 1D increments, and from 14.5 D to 24.5 D in 0.5 D increments[4].
Figure 1: Schematic representation of the Verisyse aphakic intraocular lens.

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The claw haptics are anchored to the mid-peripheral iris, placing the lens at a safe distance from the corneal endothelium and the irido-corneal angle, which lowers the risk for damage of the corneal endothelium and the angle structures. Therefore, the IC lens is less likely to cause corneal decompensation or secondary glaucoma compared with angle-supported IOLs[5]. The technique of IC lens implantation is easier and quicker than fixating the IOL to the sclera[6]. The mid-peripheral iris has low vascularity and is virtually immobile, so the IC lens does not interfere with mydriasis. The optic vaults away from the iris to reduce the risk of pupil block and pigment dispersion[7].

Originally, IC-IOL was designed for implantation in the AC. However, in recent years, retropupillary fixation of IC lenses has become popular because it is implanted in a physiological and theoretically safer position, reducing the risk of corneal endothelial damage. Therefore, retropupillary IC-IOL implantation might be particularly useful in cases with shallow AC or in combination with penetrating keratoplasty[8]. The aim of this study was to evaluate the visual outcome and safety profile of aphakic IC-IOL implantation in eyes with inadequate capsular support. We also tried to determine whether AC (prepupillary) or retropupillary location can influence the final visual and anatomical results.


  Patients and Methods Top


This is a descriptive case series study. The patients were selected from the Ophthalmology Outpatient Clinic, Menoufia University Hospital, between May 2015 and May 2017. A written informed consent was obtained from all participants. The study was approved by the Ethics Committee of Human Rights, Faculty of Medicine, Menoufia University, and carried out in accordance with the tenets of the World Medical Association's Declaration of Helsinki.

The inclusion criteria were aphakia with insufficient capsular or zonular support following complicated cataract surgery with posterior capsule rupture or significant zonular dehiscence, congenital and traumatic lens subluxation, and anterior or posterior lens dislocation. All eyes had AC depth, measured from the corneal epithelium to the anterior surface of the crystalline lens, of 3.2 mm or greater; scotopic pupil diameter less than 5.5 mm; and sufficient iris tissue that allowed a stable IOL placement.

The exclusion criteria included patients with decompensated corneas; patients with posterior segment pathologies like choroidal neovascular membrane, proliferative diabetic retinopathy, and optic atrophy; patients with insufficient iris tissue or scotopic pupil diameter greater than the lens optic size (5.5 mm); and those with AC depth measured from the corneal epithelium to the anterior surface of the crystalline lens less than 3.2 mm.

Preoperative evaluation

Detailed history was obtained from all patients, including the demographic data, etiology of aphakia, previous surgeries, and any pre-existing ocular pathology. The patients underwent complete ophthalmological examination, including uncorrected distance visual acuity (UDVA) and best-corrected distance visual acuity (CDVA), manifest and cycloplegic refraction, detailed slit-lamp examination of the anterior segment with emphasis on position of previous surgical peripheral iridectomy and pupil, Goldmann applanation tonometry, fundus examination with 90 D lens, and indirect ophthalmoscopy. Snellen visual acuity values were expressed as the decimal values for statistical analysis.

The lens power to be implanted was calculated with the Saunders, Retzlaf, and Kraff (SRK-II) formula using A-constant 115 for AC IC-IOL implantation and 117 for retropupillary IC-IOL implantation. Keratometry was performed using Javal-Schiotz keratometer as well as axial length and AC depth measurement by A-scan ultrasonography.

Surgical procedure

For AC fixation, the surgical procedure comprised a 5.5-mm chord length half-thickness limbal section and creation of two small corneal paracenteses at 2 and 10 o'clock positions. This was followed by full-thickness completion of the superior corneal incision, injection of intracameral acetylcholine chloride 1%, and then cohesive viscoelastic into the AC, and then insertion of the IOL vertically into the AC. The IOL was rotated such that the claw haptics were orientated depending on the amount of iris tissue present. This was followed by enclavation of the iris between the claws using a special enclavation needle inserted through the paracenteses.

For retropupillary fixation, the surgical procedure comprised a 5.5-mm chord length half-thickness limbal section and creation of two small corneal paracenteses at 3 and 9 o'clock positions. This was followed by full-thickness completion of the superior corneal incision and injection of cohesive viscoelastic into the AC. The inverted IC-IOL was introduced vertically into the AC followed by rotating it horizontally or otherwise according to the amount of iris tissue present. The lens was held with a special fixation forceps (Shepard forceps) through the corneoscleral tunnel and slipped through the pupil area. The IOL was recentered behind the iris plane and then lifted against the iris plane in a way that the haptics became apparent through the iris stroma. This was followed by enclavation of the mid-peripheral iris between the claw haptics with a small spatula or Sinskey hook by applying gentle pressure.

In all cases, the procedure was completed with creation of a superior peripheral iridectomy; suturing the large corneal wound with 10-0 nylon suture, and washing out the AC.

In patients with lens subluxation, IOL implantation was preceded by lensectomy and anterior vitrectomy. In addition, anterior vitrectomy was required before IOL insertion in some aphakic eyes. In these cases, the pupil was dilated preoperatively. Acetylcholine chloride 1% was injected intracameral following vitreous clearance.

Postoperative medications comprised topical steroid (prednisolone acetate) and antibiotic (moxifloxacin) eye drops that were prescribed for 1 month.

Postoperative evaluation

Follow-up of the cases was continued over a 6-month period. Data collection was done on the first postoperative day and after 1 week, 1 month, and 6 months postoperatively. The following data were obtained: UDVA and best CDVA, manifest refraction, complete slit-lamp examination, Goldmann applanation tonometry, fundus examination with 90 D lens, and reporting of the incidence of any postoperative complications including corneal decompensation, secondary glaucoma, uveitis, pupillary distortion, hyphema, vitreous hemorrhage, cystoid macular edema, retinal detachment, and IOL decentration or displacement.

Statistical analysis

The database was prepared using Excel software, Microsoft office version 2013. All statistical analyses were performed using statistical package for the social sciences program, version 20 (IBM, Armonk, NY, USA) on a personal computer. Quantitative data were expressed as mean ± SD. Qualitative data were expressed as numbers and percentages. Wilcoxon's signed rank test was used for comparison of changes in time (preoperative and postoperative) for quantitative variables. Mann–Whitney test (nonparametric test) was used for comparison between two groups having non-normally distributed quantitative variables. χ2 test of independence was used for comparison between qualitative variables in different groups. A P value of less than 0.05 was considered statistically significant.


  Results Top


The study included 12 eyes of 11 patients; of whom 7 (63.63%) were males and four (36.36%) were females. Their age ranged from 10 to 70 years with mean age of 46.42 ± 24.55 years [Table 1].
Table 1: Demographic and clinical data of the studied group

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The indications of surgery were as follows: Eight eyes (66.67%) had inadequate capsular support after cataract surgery and underwent secondary implantation of aphakia iris-claw IOL, two eyes (16.67%) of the same patient had congenital lens subluxation due to Marphan syndrome and one eye (8.33%) had traumatic lens subluxation. The three eyes underwent lensectomy with aphakia iris-claw IOL implantation. One eye (8.33%) had congenital posterior lens dislocation and underwent pars plana vitrectomy with lensectomy and aphakia iris-claw IOL implantation. In eight eyes (66.67%), iris-claw IOL was implanted in the anterior chamber and the remaining four eyes (33.33%) underwent retro-pupillary fixation of iris-claw IOL [Figure 2],[Figure 3] [Table 1].
Figure 2: Anterior chamber iris-claw intraocular lens – first day postoperative.

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Figure 3: Retropupillary iris-claw intraocular lens – 1 week postoperative.

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The preoperative uncorrected distance visual acuity (UDVA) ranged from 0.01 to 0.05, with a mean of 0.023 ± 0.026. The preoperative corrected distance visual acuity (CDVA) ranged from 0.015 to 0.2, with a mean of 0.11 ± 0.084. The preoperative IOP ranged from 6 to 30 mmHg with a mean of 14.67 ± 5.99 mmHg.

The postoperative data were as follows: regarding the uncorrected distance visual acuity, on the first postoperative day, the UDVA ranged from 0.01 to 0.15 with a mean of 0.07 ± 0.056. After the first postoperative week, the UDVA ranged from 0.01 to 0.2 with a mean of 0.08 ± 0.068. After the first postoperative month, the UDVA ranged from 0.05 to 0.2 with a mean of 0.15 ± 0.118. After the first 6 month postoperatively, the UDVA ranged from 0.01 to 0.2 with a mean of 0.13 ± 0.067. In all these visits, the postoperative UDVA was significantly better than preoperative UDVA (P = 0.017, 0.01242, 0.002 and 0.003 respectively) [Table 2].
Table 2: Comparison between preoperative and postoperative uncorrected distance visual acuity, corrected, and intraocular pressure

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Regarding the corrected distance visual acuity (CDVA), On the first postoperative day, the CDVA ranged from 0.01 to 0.2 with a mean of 0.08 ± 0.064, with no statistically significant difference between it and preoperative CDVA (P = 0.191). After the first postoperative week, the CDVA ranged from 0.01 to 0.3 with a mean of 0.1 ± 0.086, with no statistically significant difference between it and preoperative CDVA (P = 0. 943). After the first postoperative month, the CDVA ranged from 0.1 to 0.7 with a mean of 0.24 ± 0.185, which is significantly better than preoperative CDVA (P = 0.022). After the first 6 month postoperatively, the CDVA ranged from 0.1 to 0.6 with a mean of 0.28 ± 0.193, which is significantly better than preoperative CDVA (P = 0.003)[Table 2].

The postoperative intraocular pressure (IOP) ranged from 8 to 32 mmHg with a mean of 17 ± 7.141 mmHg on the first postoperative day. After the first postoperative week, it ranged from 10 to 28 mmHg with a mean of 14.33 ± 5.314 mmHg. After the first postoperative month, it ranged from 10 to 16 mmHg with a mean of 12.83 ± 2.329 mmHg. After 6 months postoperatively, IOP ranged from 10 to 16 mmHg with a mean of 13.17 ± 1.992 mmHg. There was no statistically significant difference between preoperative and postoperative IOP at any of the postoperative visits [Table 2].

Comparing the two techniques of implantation, there has been no statistically significant difference regarding postoperative uncorrected or best-corrected visual acuity, intraocular pressure or the incidence of postoperative complications between the two techniques at any of the postoperative visits [Table 3] and [Table 4].
Table 3: Comparison between postoperative uncorrected distance visual acuity after anterior chamber versus retropupillary fixation of iris-claw intraocular lens

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Table 4: Postoperative complications after anterior chamber versus retropupillary fixation of iris-claw intraocular lens

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Regarding the postoperative complications, during the early postoperative period, four (33.3%) eyes showed mild corneal edema, three (25%) eyes had transient IOP elevation more than 20 mmHg, three (25%) eyes had AC inflammatory reaction, two (16.7%) eyes showed pupillary distortion, and one (8.3%) eye had moderate degree vitreous hemorrhage. During the late postoperative period, one (8.3%) eye had IOL disenclavation of one haptic following blunt ocular trauma that occurred 6 months postoperatively. Surgical re-enclavation was performed successfully.


  Discussion Top


IC-IOL implantation is an effective method for the correction of aphakia in the absence of capsular support. Several studies have demonstrated it has several advantages and fewer complications, with its easy placement and good visual outcome, when compared with the trans-scleral sutured PC-IOLs and angle-supported AC-IOLs[9]. Being fixated to the mid-peripheral iris, in a location that is away from the AC angle, it is less likely to damage the angle structures. The optic vaults away from the iris to reduce the risk of pupil block and pigment dispersion. No sutures are required to support the lens. The lens is implanted at a safe distance from the corneal endothelium reducing the risk of endothelial damage[7]. Furthermore, retropupillary implantation has recently become popular, allowing the iris to act as barrier protecting the corneal endothelium from damage by the IOL and preserving the anatomy of the anterior segment[8],[10],[11],[12].

In this study, the mean UDVA significantly improved from the first postoperative day. On the contrary, the mean postoperative CDVA was worse than the mean preoperative CDVA over the first postoperative week, but there was no statistically significant difference. Visual recovery occurred in the subsequent visits, and the mean postoperative CDVA was significantly better than preoperative value at 1 and 6 months postoperatively. Postoperative corneal edema or intraocular inflammation can limit the CDVA in the early postoperative period. There was no statistically significant difference between UDVA and CDVA following AC and retropupillary fixation of aphakia IC-IOL at any of the postoperative visits.

The final CDVA was better than the preoperative value in 11 (91.67%) eyes and was unchanged in one (8.33%) eye. Worsening of the final CDVA did not occur in any case of our study. The final mean CDVA was 0.28 ± 0.193 (0.28 ± 0.196 for AC implantation and 0.3 ± 0.216 for retropupillary implantation).

Several studies demonstrated the effectiveness of IC-IOL implantation for eyes without adequate capsular support with improvement of UDVA and CDVA.Güell et al.[13] evaluated 16 consecutive eyes of 14 patients with aphakia who were subjected to iris-supported Artisan–Verisyse IOL implantation for aphakia correction. They reported that preoperative Best Spectacle Corrected Visual Acuity (BSCVA) was 20/40 or better in five (31.25%) eyes and postoperatively in six (37.5%) eyes. Postoperative UDVA was equal to or better than preoperative BSCVA in 50% of eyes (eight of 16 eyes) at 36-month follow-up.

Schallenberg et al.[10] studied 31 eyes of 31 patients who underwent an Artisan aphakic IOL implantation. They reported that the mean best-corrected visual acuity postoperatively was 0.64 logarithm of the minimum angle of resolution (logMAR) and varied from 0 logMAR to 3 logMAR. Some patients had a low visual acuity preoperatively because of preoperative eye pathologies. In 22 patients the visual acuity improved, in two patients the visual acuity remained unchanged, and seven patients showed a decreased visual acuity.

Choragiewicz et al.[14] studied 47 eyes that underwent sutureless IC lens implantation. They reported that the mean preoperative CDVA was 0.25 (SD, 0.21) and the final mean CDVA was 0.46 (SD, 0.27), and this improvement was found to be statistically significant.

Rabie et al.[15] retrospectively analyzed 12 eyes of nine patients with lens subluxation owing to Marfan syndrome who underwent crystalline lens removal and Artisan IOL (Ophtec, Groningen, the Netherlands) implantation. They reported that the mean UDVA improved significantly from 1.3 ± 0.5 logMAR preoperatively to 0.4 ± 0.1 logMAR at final follow-up visit (P = 0.002). Mean BCVA showed a significant improvement from 0.5 ± 0.3 logMAR at the baseline to 0.2 ± 0.2 logMAR postoperatively (P = 0.006).

Kelkar et al.[16] retrospectively analyzed 104 eyes of 102 patients with poor capsular support that underwent IC-IOL retrofixation with intravitreal triamcinolone acetonide. They reported that the final mean best-corrected logMAR visual acuity improved from 1.36 ± 0.64 preoperatively to 0.36 ± 0.32 at 1-year follow-up.

Rastogi et al.[17]performed pars plana lensectomy-vitrectomy with implantation of the IC-IOL in the retropupillary position as a primary procedure for 14 eyes of children between the ages of 8–17 years with lens subluxations of more than seven clock hours. They reported that the all patients had an increase in the postoperative BCVA with a mean of 0.351 ± 0.154 logMAR units which was statistically significant as compared with the preoperative value of 0.771 ± 0.132 logMAR units (P = 0.003).

Hernández Martínez and Almeida González[18]evaluated the outcomes of IC-IOL implantations performed by the same surgeon on 75 patients between 2011 and 2017. The postoperative UDVA and CDVA were significantly better than the preoperative acuities (P < 0.001). The UDVA was 20/40 or better in 41.7% of patients and had the CDVA 20/40 or better in 68.1% of patients.

On the contrary, Jayamadhury et al.[19] studied 61 aphakic eyes of 61 patients, who were rehabilitated with retropupillary fixation of an IC lens. They reported that the mean preoperative uncorrected visual acuity was 1.66 ± 0.3 logMAR and postoperative acuity at 1 year was 0.53 ± 0.5 logMAR, with statistically significant improvement (P = 0.00001). Preoperative distant best-corrected visual acuity was 0.30 ± 0.48 logMAR and postoperative acuity at 1 year was 0.27 ± 0.46 logMAR, but the difference was not statistically significant (P = 0.07).

Only a few studies compared the outcomes of the two locations for IC-IOL implantation (AC versus retropupillary), and all of them showed no significant difference between the two techniques. Hazar et al.[20] studied 90 aphakic eyes with insufficient capsular support following previous cataract surgery that were divided into three groups based on the secondary IOL implantation procedure: AC iris-fixated IOL (AC-IFIOL), retropupillary iris-fixated IOL (RP-IFIOL), and scleral-fixated posterior chamber IOL (SF-PCIOL). They reported that a final CDVA of 20/40 or better was achieved in 22 (62.9%) eyes implanted with an AC-IFIOL, in 12 (50%) eyes with an RP-IFIOL, and 18 (58.1%) eyes with an SF-PCIOL. Mean baseline and postoperative CDVA values at each follow-up visit were not significantly different between the three groups. There were no significant differences between the three groups preoperatively and at each of the postoperative visits.

Helvaci et al.[21] studied 40 eyes of 40 aphakic patients that were divided into two groups: group 1 received AC Artisan IOL implantation, and group 2 received retropupillary Artisan IOL implantation. They reported that each of the two groups obtained a significant improvement in postoperative CDVA compared with preoperatively (P < 0.05), with no significant difference between the two fixation techniques.

Peralba et al.[1] studied 95 eyes of 95 patients who had IC-IOL implantation. Fifty-seven patients had prepupillary implantation and 38 patients had retropupillary implantation. They reported that the CDVA improved significantly in both groups and there were no differences between them.

In our study, there was no statistically significant difference between preoperative and postoperative IOP, nor between postoperative IOP following AC versus retropupillary fixation of the IC lens. Transient IOP elevation occurred in three (25%) cases and was controlled with topical antiglaucoma medications. Rastogi et al.[17] reported similar results, with no statistically significant difference between the mean preoperative IOP and the mean postoperative IOP at the end of the 6-month follow-up. Only one (7.14%) eye had an acute IOP spike, which was controlled within a week with topical timolol 0.5% and oral acetazolamide.

The incidence of transient IOP elevation was also reported by Schallenberg et al.[10]in only one (3.03%) patient, Jare et al.[22] in three (2.78%) eyes, and Kelkar et al.[16] in seven (6.73%) eyes. Helvaci et al.[21]reported that four (20%) patients in group 1 (AC-IC-IOL) and five (25%) patients in group 2 (RPIC-IOL) had significant but nonpermanent increase at IOP values.

Other postoperative complications that occurred in our study included corneal edema (four cases –33.3%), and AC reaction (three cases –25%). Vitreous hemorrhage occurred in one (8.3%) case. All these complications were temporary and managed medically, with no need for surgical intervention. Pupillary ovalization and distortion was seen in two (16.7%) cases. One (8.3%) case showed post-traumatic IOL disenclavation and displacement that occurred 6 months postoperatively. Surgical re-enclavation was performed successfully. We did not encounter any cases of cystoid macular edema, retinal detachment, or endophthalmitis in our study. There was no statistically significant difference between the AC and retropupillary groups regarding the incidence of postoperative complications.

Although most were transient with no long-term effects, the incidence of postoperative complications in our study was relatively high as compared with other studies. This might be related to the small sample size, particularly when compared with retrospective studies with much greater number of cases. The learning curve of the surgical procedure may cause higher incidence of complications in the early portion of the series and would be more obvious with small sample size. Hernández Martínez and Almeida González[18]reported that ovalization of the pupil occurred in 11.8% of cases, but during the first half of the series only and that was attributed to the learning curve during which the correct distance between the claws of the haptics was not respected.


  Conclusion Top


Aphakic IC-IOL is an effective option for visual rehabilitation in eyes with inadequate capsular support that provides a good visual outcome and high safety profile. Both AC and retropupillary fixation can achieve a satisfactory outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Peralba RT, Lamas-Francis D, Sarandeses-Diez T, Martínez- Pérez L, Rodríguez-Ares T. Iris-claw intraocular lens for aphakia: can location influence the final outcomes? J Cataract Refract Surg 2018; 44:818–826.  Back to cited text no. 1
    
2.
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Moschos MM, Nitoda E. The correction of aphakia using anterior chamber intraocular lens. In Vivo 2016; 30:733–738.  Back to cited text no. 4
    
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Güell JL, Verdaguer P, Elies D, Gris O, Manero F, Mateu-Figueras G, et al. Secondary iris-claw anterior chamber lens implantation in patients with aphakia without capsular support. Br J Ophthalmol 2014; 98:658–663.  Back to cited text no. 5
    
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Jing W, Guanlu L, Qianyin Z, Shuyi L, Fengying H, Jian L, et al. Iris-claw intraocular lens and scleral-fixated posterior chamber intraocular lens implantations in correcting aphakia: a meta-analysis. Invest Ophthalmol Vis Sci 2017; 58:3530–3536.  Back to cited text no. 6
    
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Teichman JC, Ahmed IIK. Improved technique with the Artisan aphakic IOL. Rev Ophthalmol 2007; 14:59.  Back to cited text no. 7
    
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Forlini M, Soliman W, Bratu A, Rossini P, Cavallini G, Mand Forlini C. Long-term follow up of retro-pupillary iris-claw intraocular lens implantation: a retrospective analysis. BMC Ophthalmol 2015; 15:143.  Back to cited text no. 8
    
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Dick HB, Augustin AJ. Lens implant selection with absence of capsular support. Curr Opin Ophthalmol 2001; 12:47–57.  Back to cited text no. 9
    
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Schallenberg M, Dekowski D, Hahn A, Laube T, Steuhl KP, Meller D. Aphakia correction with retro-pupillary fixated iris-claw lens (Artisan) – long-term results. Clin Ophthalmol 2014; 8:137–141.  Back to cited text no. 10
    
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Hsing YE, Lee GA. Retro-pupillary iris claw intraocular lens for aphakia. Clin Exp Ophthalmol. 2012; 40:849–854.  Back to cited text no. 11
    
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Faria MY, Ferreira NP, Pinto JM, Sousa DC, Leal I, Neto E, et al. Retro-pupillary iris claw intraocular lens implantation in aphakia for dislocated intraocular lens. Int Med Case Rep J 2016; 9:261–265.  Back to cited text no. 12
    
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Güell JL, Velasco F, Malecaze F, Vazquez M, Gris O, Manero F. Secondary Artisan–Verysise aphakic lens implantation. J Cataract Refract Surg 2005; 31:2266–2271.  Back to cited text no. 13
    
14.
Choragiewicz T, Rejdak R, Grzybowski A, Nowomiejska K, Moneta-Wielgoś J, Ozimek M, et al. Outcomes of sutureless iris-claw lens implantation. J Ophthalmol 2016; 2016:7013709.  Back to cited text no. 14
    
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Rabie HM, Malekifar P, Javadi MA, Roshandel D, Esfandiari H. Visual outcomes after lensectomy and iris claw artisan intraocular lens implantation in patients with Marfan syndrome. Int Ophthalmol 2017; 37:1025–1030.  Back to cited text no. 15
    
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Kelkar A, Shah R, Vasavda V, Kelkar J, Kelkar S. Primary iris claw IOL retrofixation with intravitreal triamcinolone acetonide in cases of inadequate capsular support. Int Ophthalmol 2018; 38:111–117.  Back to cited text no. 16
    
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Rastogi A, Goray A, Thacker P, Kamlesh, Babita. Assessment of the safety and efficacy of primary retropupillary fixation of iris-claw intraocular lenses in children with large lens subluxations. Ophthalmol 2018; 38:1985–1992.  Back to cited text no. 17
    
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Hernández Martínez A, Almeida González CV. Iris-claw intraocular lens implantation: efficiency and safety according to technique. J Cataract Refract Surg 2018; 44:1186–1191.  Back to cited text no. 18
    
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Jayamadhury G, Potti S, Kumar KV, Kumar RM, Divyansh Mishra KC, Nambula SR. Retropupillary fixation of iris-claw lens in visual rehabilitation of aphakic eyes. Indian J Ophthalmol 2016; 64:743–746.  Back to cited text no. 19
    
20.
Hazar L, Kara N, Bozkurt E, Ozgurhan EB, Demirok A. Intraocular lens implantation procedures in aphakic eyes with insufficient capsular support associated with previous cataract surgery. J Refract Surg 2013; 29:685–691.  Back to cited text no. 20
    
21.
Helvaci S, Demirduzen S, Oksuz H. Iris-claw intraocular lens implantation: anterior chamber versus retropupillary implantation. Indian J Ophthalmol 2016; 64:45–49.  Back to cited text no. 21
    
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Jare NM, Kesari AG, Gadkari SS, Deshpande MD. The posterior iris-claw lens outcome study: 6-month follow-up. Indian J Ophthalmol 2016; 64:878–883.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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[TAG2]
[TAG3]
[TAG4]