More Related Content
Similar to IOL options in the absence of capsular support (20)
IOL options in the absence of capsular support
- 1. IOL OPTIONS IN THE ABSENCE OF CAPSULAR SUPPORT Musha Mustapha Consultant and vitreoretinal surgeon Hospital UKM 1
- 2. www.globetheme.com 2 OUTLINE 1. Options of IOL 2.Literatures 3. Sample of cases
- 3. www.globetheme.com 3 • Coloboma • Pseudoexfoliation • Marfan syndrome • Zonulysis • Capsular rupture • Endophthalmitis • Dislocated IOL • UGH syndrome Trauma Pre existing Intraoperative complications (50%)* Explantation Causes of no capsular support • Blunt trauma • Penetrating eye injury * Guell JL, Velasco F, Malecaze F et al. Secondary Artisan-Veruysise a phakic lens implantation. J cataract refract Surg.2005 (31) 2266-2271 (16 eyes 36 months follow up)
- 4. Options of IOL Anterior chamber IOL Scleral fixated IOL Iris fixated IOL 4
- 5. 1: Anterior Chamber IOL (AC IOL) 5
- 6. www.globetheme.com 1: Anterior Chamber IOL: potentially long history Chronic inflammation/ UGH Corneal decompensation Endothelial cell lost (16% at 3 years) CMO Late onset/ chronic Glaucoma ACIOL too small Pigment dispersion and corneal endothelial fair ACIOL too big Chronic iritis and CMO 6
- 7. 1: Anterior Chamber IOL: Relative Contraindications 1.Pre existing cornea dystrophy/ problem 2.Young patient < 50 years old 3.Poor endothelial cell count for various reason 4.Extensive PAS/ abnormality at the angle 5.Large eyeball 7
- 8. 2: Iris Fixated IOL Iris sutured IOL (1990s/ early 2000) 810 prolene Standard Iris Claw EC lost: 10% Retropupillary Iris Claw EC lost 5% *Gonnermann J, Amiri S, Klamann M et al. Endothelial cell loss after retropupillary iris-claw intraocular lens implantation. Klin Monatsbi Augenheikd 2014;231:784-787 (2006-2012: 62 eyes; follow up range from 13 months-78 months) • 7.78% during the first year
- 9. 2: Iris Fixated IOL: iris claw Guell JL, Velasco F, Malecaze F et al. Secondary Artisan-Veruysise aphakic lens implantation. J cataract refract Surg.2005 (31) 2266-2271 (16 eyes 36 months follow up) Vision: 20/40 or better in 37.5% Mean SE: 0.46 D Endothelial cell lost: ACIOL (16%) vs Standard iris claw (10%) Retropupillary iris claw (5.5%) 9 Standard Iris Claw EC lost: 10% Retropupillary Iris Claw EC lost 5% EC lost : ACD less than 3 mm vs more than 3.4 mm
- 10. 2: Iris Fixated IOL: Gonnermann J et al •Abnormal shape of pupil ( ovalisaton): 3.2% •Disenclavation occurs in 4.8% (enclavement site becomes atrophic) *Gonnermann J, Amiri S, Klamann M et al. Endothelial cell loss after retropupillary iris-claw intraocular lens implantation. Klin Monatsbi Augenheikd 2014;231:784-787 (2006-2012: 62 eyes; follow up range from 13 months-78 months) #Forlini M, Soliman W, Bratu A et al. Long term follow up of retropupillary iris-claw IOL implantation: a retrospective analysis. BMC ophthalmology (2015)15:143 (2 experienced surgeon Forlini M et al: *Mean IOP: 16 mmHg (follow up until 5 years) *Specific: (5%) *Dull aching pain *Severe Iridodenesis *Poor vision when leaning forward 10
- 12. www.globetheme.com 3: Scleral fixated IOL Sutured IOL Sutureless IOL ALCON CZ 70BD PMMA 10 -O / 9-0 POLYPROPYLENE (20% OF BREAKAGE AND DISLOCATED IOL AFTER 10 YEARS) AKREOS ADAPT B & L GORE TEX SUTURE 3 PIECE IOL OPTIC: ACRYLIC HAPTIC: PMMA OR PVDF (polyvinylidene fluoride) 12 4 point fixation2 point fixation
- 13. www.globetheme.com 3: Scleral fixated IOL: SUTURED 4 point fixation2 point fixation 13
- 15. www.globetheme.com 3: Scleral fixated IOL Sutured IOL Sutureless IOL ALCON CZ 70BD PMMA 10 -O / 9-0 POLYPROPYLENE (20% OF BREAKAGE AND DISLOCATED IOL AFTER 10 YEARS) AKREOS ADAPT B & L GORE TEX SUTURE 3 PIECE IOL OPTIC: ACRYLIC HAPTIC: PMMA OR PVDF (polyvinylidene fluoride) 15 4 point fixation2 point fixation
- 16. www.globetheme.com 3: Scleral fixated IOL: SUTURELESS Scleral flap: flap is sutured or glued Tunnel Transconjunctival: Yamane 16
- 17. www.globetheme.com 17 OUTLINE 1. Options of IOL 2. Literatures 3. Sample of cases
- 18. www.globetheme.com 18 ACIOL vs Scleral fixated IOL (Sutured and Sutureless) At 6 weeks ACIOL : 36% (20/60 —20/40 ) Sutured PCIOL : 40.6% Glued scleral PCIOL: 52% (20/30-20/20)
- 19. www.globetheme.com Retropupillary iris claw vs Sutureless PCIOL Kelkar AS, Kelkar JA, Kothari AA et al. Comparison of flanged intrascleral intraocular lens fixation versus iris claw intraoucular lens fixation: A retrospective study. Indian J Ophthalmol 2019Indian Journal of Ophthalmology 2019 Retropupillary (90 patients) vs SFIOL (60 patients) 28% were primary insertion 72% were secondary implantation 19
- 20. www.globetheme.com Retropupillary (90 patients) vs SFIOL (60 patients) 28% were primary insertion 72% were secondary implantation Kelkar AS, Kelkar JA, Kothari AA et al. Comparison of flanged intrascleral intraocular lens fixation versus iris claw intraoucular lens fixation: A retrospective study. Indian J Ophthalmol 2019Indian Journal of Ophthalmology 2019 20 Retropupillary iris claw vs Sutureless PCIOL
- 21. www.globetheme.com 21 OUTLINE 1. Options of IOL (4 types) 2. Literatures 3. Sample of cases
- 22. 3 November 2019 Cases Subluxated Artisan Broken iris sutured IOL Malposition of ACIOL 22
- 23. www.globetheme.com 23 Case 1: Subluxated Artisan 54 year-s old Cat op with artisan IOL implanteation 3 years ago Presented with reduce vision Focal iris atrophy (previous enclavemeny site) With disenclaved iris claw lens
- 24. www.globetheme.com 24 Case 2: malposition of the ACIOL Sutured SF IOLACIOL 2015 This is a 50 year old lady had complicated cataract surgery few years back Referred • ongoing corneal decompensation (superior) • Tilted ACIOL Vision: 6/12 Surgery: Explantation of ACIOL (with difficulty) - Implantation of posterior sutured IOL Vision: 6/12 Stable
- 25. www.globetheme.com 25 Case 3: Iris sutured IOL(Broken haptic) Anterior segment Iris Sutured IOL 24 year old female/ student Previous history of trauma 10 years ago (14 years old) - lens aspiration and IOL implantation Presented with history of fluctuation of vision Post recent shuttlecock injury. Although vision on sitting down was 6/9, Lying down: IOL was in the anterior vitreous Sutureless SF IOL Vision 6/12,6/9
- 26. Personal sharing: Start w easy cases • (GA/ non vitrectomised eyes) Avoid soft eye • (infusion/loads of Viscoelastic) Don’t be afraid to leave the eye Aphakic What is best for the patient: depends on the - availability, - Most comfortable technique for the attending surgeon Consider the patient’s age Other comorbidities: Ocular or systemic - ? endure repeated surgery - Primary or secondary IOL Be prepared to deal with unexpected challenges Plan A/Plan B/Plan C Yamane • Few similar lenses • ACIOL standby • Scleral sutured IOL: • few similar IOL power If too complex: reschedule when The surgeon is ready IOL Properly chosen IOL Properly fixated Patient well Monitored 26 SUCCESSFUL SURGERY