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SURGICAL TECHNIQUE
Year : 2018  |  Volume : 66  |  Issue : 11  |  Page : 1609-1610

Phacoemulsification in phakic iris-claw lens with cataract


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

Date of Submission20-Mar-2018
Date of Acceptance09-Jul-2018
Date of Web Publication25-Oct-2018

Correspondence Address:
Dr. Manish Mahabir
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, Room 490, Fourth Floor, AIIMS, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_423_18

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  Abstract 


In this new technique of cataract surgery in patients with iris-fixated phakic intraocular lens with cataract, phakic IOL is explanted at the end of surgery. Phakic IOL remains stable and securely enclaved to the iris during phacoemulsification which is performed through a small 2.2 mm incision. Endothelial protection is provided by viscodispersive OVD above the phakic IOL and space for surgery is created by high molecular weight viscocohesive OVD beneath the phakic IOL. This technique provides significant advantages from the previously described techniques in terms of chamber stability, endothelial protection, iris trauma and surgical ease.

Keywords: Artisan, iris-claw, phacoemulsification, phakic


How to cite this article:
Khokhar S, Mahabir M. Phacoemulsification in phakic iris-claw lens with cataract. Indian J Ophthalmol 2018;66:1609-10

How to cite this URL:
Khokhar S, Mahabir M. Phacoemulsification in phakic iris-claw lens with cataract. Indian J Ophthalmol [serial online] 2018 [cited 2024 Mar 28];66:1609-10. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?2018/66/11/1609/244057



Phakic intraocular lenses (PIOL) are being used for high refractive error.[1],[2],[3],[4],[5] In 2004, Food and Drug Administration approved the Artisan lens for correcting moderate to severe myopia ranging from- 5.00 to- 20.00 dioptres. Patients who have undergone iris-fixated lens in the past are now coming for cataract surgery. Since these Artisan PIOL are made of rigid polymethylmethacrylate, they require a large incision for removal. Foldable Artiflex lenses were introduced in the market in 2005.[6],[7],[8],[9]

Various surgeons have described different techniques for removal of these lenses during cataract surgery. In 1997, Menezo et al.[10] and in 2009 de Vries et al.[11] performed phacoemulsification after explanting PIOL. In 2016, Kaur et al.[12] used femto-assisted cataract surgery. We describe a novel technique in which we perform phacoemulsification with foldable lens implantation in the bag while phakic lens is still enclaved to the iris. The 2.2-mm incision is enlarged to 6 mm to remove phakic lens. Incision is sutured at the end of surgery [Video 1].





  Surgical Technique Top


Three incisions were made: two side ports at 11'o and 2'o clock using micro vitreo-retinal blade and one main incision with 2.2-mm blade. Side ports were used to disenclave the lens at the end of surgery and perform bimanual irrigation and aspiration. After making side ports, viscodispersive ophthalmic viscosurgical device (OVD) Viscoat® (Alcon, Hünenberg, Switzerland) was injected on top of the PIOL for endothelial protection. High-molecular-weight viscocohesive OVD Healon GV® (Abbott Laboratories, Lake Bluff, IL, USA) was injected under the PIOL, and over the cataractous lens, to create space. A needle cystitome was used to create a central continuous curvilinear capsulorhexis [Figure 1]a. Phacoemulsification was performed using Centurion® Vision System (Alcon) with the following settings: intraocular pressure of 55 mmHg, aspiration flow rate of 55 ccs/min, vacuum of 450 mmHg, and torsional phacoemulsification power ranging from 20 to 60 with intelligent phacoemulsification setting enabled [Figure 1]b. Irrigation and aspiration was performed with a coaxial system for cortex removal [Figure 1]c. Anterior chamber was formed with a dispersive OVD whenever the chamber became shallow. In our case [Figure 2], AcrySof® IQ Monofocal IOL (Alcon) was implanted in the bag [Figure 1]d and [Figure 1]e. We injected intracameral acetylcholine (Myochol; Ciba Vision, Duluth, GA, USA) to constrict the pupil. With the OVD in the anterior chamber, the phakic lens was disenclaved from two side ports [Figure 1]f. The main incision was enlarged from 2.2 to 6 mm to remove the phakic lens [Figure 1]g. The main incision was secured with one 10-0 monofilament suture. Irrigation and aspiration was performed using bimanual to remove the residual viscoelastic [Figure 1]h. Side ports were hydrated to stabilize the anterior chamber [Figure 1]i.
Figure 1: Intraoperative (a) Anterior capsulorhexis. (b) Phacoemulsification. (c) Irrigation and aspiration. (d) Intraocular lens insertion in bag. (e) Both phakic and pseudophakic intraocular lens. (f) Disenclaving haptic. (g) Phakic intraocular lens removal. (h) Irrigation and aspiration. (i) End of surgery

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Figure 2: Preoperative (a) diffuse illumination on slit lamp. (b) Cross-sectional view on slit lamp

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Preoperative best-corrected visual acuity was 0.5 LogMAR unit, while postoperatively day 1, it was 0.3 LogMAR unit, associated with few Descemet's folds and a tight suture. The preoperative specular count was 1053 cells/mm2. At 6 months postoperatively, it was recorded as 1027 cells/mm2. There was no postoperative iris atrophy, pupil deformity, or prolonged inflammation.


  Discussion Top


Our technique has some benefits as we performed phacoemulsification and IOL insertion in the bag through the 2.2-mm incision using standard technique maintaining a stable anterior chamber throughout the procedure. Performing cataract surgery after phakic lens removal and incision closure with a suture which we did earlier had two major issues; first, the iris gets irritated during disenclaving causing pupil to constrict causing problems during the procedure. Second, there were higher anterior chamber fluctuations as these eyes were highly myopic. We even tried putting tight suture to stabilize anterior chamber, but that leads to striations on the cornea leading to loss of chamber clarity. PIOL explant at the end of the surgery does away all these problems.

The usage of viscocodispersive OVD above and viscocohesive OVD below the phakic lens provides a shell for endothelial protection and creates space between the crystalline and phakic lens. Since the phakic lens was well enclaved and sandwiched between OVDs, it did not flutter during the entire surgical procedure, especially phacoemulsification and cortical aspiration. The disenclavation of haptic before phacoemulsification will cause the lens to move around and cause pupillary constriction as well as endothelial touch. Disenclaving only one haptic as described by Kaur et al. will keep the lens fixed on one side and the disenclaved side may lead to movement of the lens during phacoemulsification and cortical aspiration and might lead to iris trauma or endothelial damage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fechner PU, van der Heijde GL, Worst JG. The correction of myopia by lens implantation into phakic eyes. Am J Ophthalmol 1989;107:659-63.  Back to cited text no. 1
    
2.
Fechner PU, Strobel J, Wichmann W. Correction of myopia by implantation of a concave worst-iris claw lens into phakic eyes. Refract Corneal Surg 1991;7:286-98.  Back to cited text no. 2
    
3.
Fechner PU, Singh D, Wulff K. Iris-claw lens in phakic eyes to correct hyperopia: Preliminary study. J Cataract Refract Surg 1998;24:48-56.  Back to cited text no. 3
    
4.
Budo C, Hessloehl JC, Izak M, Luyten GP, Menezo JL, Sener BA, et al. Multicenter study of the artisan phakic intraocular lens. J Cataract Refract Surg 2000;26:1163-71.  Back to cited text no. 4
    
5.
Pop M, Payette Y. Initial results of endothelial cell counts after artisan lens for phakic eyes: An evaluation of the United States food and drug administration ophtec study. Ophthalmology 2004;111:309-17.  Back to cited text no. 5
    
6.
Alió JL, Mulet ME, Shalaby AM. Artisan phakic iris claw intraocular lens for high primary and secondary hyperopia. J Refract Surg 2002;18:697-707.  Back to cited text no. 6
    
7.
Moshirfar M, Mifflin M, Wong G, Chang JC. Cataract surgery following phakic intraocular lens implantation. Curr Opin Ophthalmol 2010;21:39-44.  Back to cited text no. 7
    
8.
Chen LJ, Chang YJ, Kuo JC, Rajagopal R, Azar DT. Metaanalysis of cataract development after phakic intraocular lens surgery. J Cataract Refract Surg 2008;34:1181-200.  Back to cited text no. 8
    
9.
Lovisolo CF, Reinstein DZ. Phakic intraocular lenses. Surv Ophthalmol 2005;50:549-87.  Back to cited text no. 9
    
10.
Menezo JL, Cisneros AL, Rodriguez-Salvador V. Removal of age-related cataract and iris claw phakic intraocular lens. J Refract Surg 1997;13:589-90.  Back to cited text no. 10
    
11.
de Vries NE, Tahzib NG, Budo CJ, Webers CA, de Boer R, Hendrikse F, et al. Results of cataract surgery after implantation of an iris-fixated phakic intraocular lens. J Cataract Refract Surg 2009;35:121-6.  Back to cited text no. 11
    
12.
Kaur M, Sahu S, Sharma N, Titiyal JS. Femtosecond laser-assisted cataract surgery in phakic intraocular lens with cataract. J Refract Surg 2016;32:131-4.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]


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