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| CASE REPORT |
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| Year : 2022 | Volume
: 4
| Issue : 1 | Page : 30 |
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Iris claw to the rescue - A case series
Soumya Ramani, Rachana Kotian
Department of Ophthalmology, M.S Ramaiah Medical College Hospital, Bangalore, Karnataka, India
| Date of Submission | 15-Mar-2022 |
| Date of Decision | 25-Mar-2022 |
| Date of Acceptance | 28-Mar-2022 |
| Date of Web Publication | 23-Jun-2022 |
Correspondence Address:
Rachana Kotian
MS Ramaiah Medical College Hospital, MSR Nagar, Bangalore - 560 054, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/pajo.pajo_20_22
The utility of retropupillary (RP) iris-fixated lenses, even when the iris support is deemed inadequate is portrayed in this case series. The case series emphasizes iris-claw lens as an effective alternative in cases where there is a disfigurement of the iris with meticulous surgical skills. A 58-year-old with diminution of vision in the right eye for 6 months had a vision of 6/60, iris coloboma inferiorly with zonule loss and cataractous lens. Manual small-incision cataract surgery (M-SICS) was performed with placement of iris-claw lens despite the presence of iris disfiguration. A 62-year-old male with diminution of vision in the left eye had a vision of counting fingers at 1 m. On slit-lamp examination, iris atrophy, an oval-shaped pupil with a maximum of 5 mm eccentric dilation, cataractous lens inferiorly subluxated and partially absorbed, a breach in the anterior capsule, and vitreous strands were noted in the anterior chamber. M-SICS with iris-claw lens was then performed. A 3-year-old female child with a history of trauma to the left eye had a vision of perception of light only. On anterior segment evaluation, she had radial, full-thickness corneoscleral tear with iris plugging the wound, iris trauma, and traumatic immature cataract. Left eye corneal tear repair with cataract extraction and iris-claw insertion was performed. Postoperative vision on follow-up after a month was 6/12p in all three cases. Iris claw lens being readily available, and surgical technique of insertion being easy and quick, serves as one of the effective alternatives for the intraocular lens in difficult situations.
Keywords: Coloboma, iris claw, trauma
How to cite this article:
Ramani S, Kotian R. Iris claw to the rescue - A case series. Pan Am J Ophthalmol 2022;4:30 |
| Introduction | |  |
Aphakia without adequate posterior capsular support is a commonly encountered condition in association with intraoperative complications during cataract surgery, ocular trauma, and dislocation of lens due to various reasons. There are many options and surgical procedures to correct the condition which includes spectacle use, contact lens use, and primary or secondary intraocular lens (IOL) implantation with the use of various type of lens-angle-supported anterior chamber IOLs (ACIOLs), scleral supported, and RP iris fixated IOLs. The surgical procedure adopted is individualized as it depends on ocular factors like capsular support or condition of iris and on the surgeon's skill. For the implantation of a RP iris-claw lens, the presence of adequate iris support is important. When there is damage to the iris either due to trauma or a congenital defect, the insertion of an iris-supported lens becomes difficult and its stability comes into question. However, a RP iris-claw lens require to be enclavated in the midperiphery. Therefore, iris support that allows for the aforementioned enclavation should be sufficient. In this case series, we discuss three such cases where RP iris-claw lenses were inserted in situations where “adequate” iris support did not exist [Figure 1] and [Figure 2]. | Figure 2: Post op image of case 3 showing adherent leucomatous grade opacity due to scarring along the apposed corneal tear wound, peaked pupil with iris claw lens in situ
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| Case Report | | |
All the three cases underwent detailed ophthalmic examination after detailed history was elicited. Visual acuity was examined using a Snellen chart. Where possible, best-corrected visual acuity was ascertained. The anterior segment was examined using slit-lamp biomicroscopy. Dilated fundus examination was done using slit-lamp biomicroscopy with 90D lens.
Cases
Case 1
A 58-year-old patient had a diminution of vision in the right eye. The vision was 6/60. There was an iris coloboma and zonular dehiscence from 5 to 7 o' clock hours inferiorly and a cataractous lens.
Manual small-incision cataract surgery (M-SICS) was done. The surgery was carefully executed ensuring no intraoperative complications due to the preexisting iris coloboma and zonular loss. Iris-claw lens was placed.
On postoperative day 1, day 7, and day 30, the visual acuity was found to be 6/12p on each of these visits.
Case 2
A 62-year-old male with diminution of vision in the left eye had a vision of counting fingers (CF) at 1 m on examination. On slit-lamp examination, the iris was atrophic along 1 o'clock–2 o'clock with oval-shaped pupil with a maximum of 5 mm eccentric dilation. Lens of the left eye was cataractous, subluxated inferiorly, and partially absorbed. In addition to this, a breach in the anterior capsule was seen superiorly. A few vitreous strands were noted in the AC. Intracapsular cataract extraction with scleral fixation of IOL (SFIOL) placement was planned. Intraoperatively, following lens delivery, a large paracentral posterior capsular tear was noted almost 4 mm in diameter. Anterior vitrectomy was performed. An iris-claw lens was then placed and the wound was secured with a suture. Postoperatively, the patients vision improved to 6/12 parts.
Case 3
A 3-year-old female child with a history of trauma to the left eye with scissors 5 days ago had of perception of light only. Anterior segment evaluation revealed radial full-thickness corneal tear extending paracentrally at 10 o'clock to the limbus at 5 o'clock and to the sclera with iris plugging the wound with suspected iris trauma. In addition, an associated traumatic cataract was also noted. Left eye corneal tear repair with cataract extraction and lens insertion under general anesthesia was planned. Careful B-scan of the left eye was also done which showed normal posterior segment. Left eye corneal tear repair with cataract extraction and iris-claw insertion was performed. The iris adherence to the corneal wound was released. However, residual iris adherence was still noted adjacent to the wound. On follow-up after a month, vision improved to CF 3 m and anterior segment examination showed well-apposed wound with sutures in situ, iris-claw in place, but with posterior capsular opacification. The child was then taken up for corneal tear suture removal and membranotomy. Follow-up after 5 days revealed improvement in the vision– CF >3m. On subsequent follow-up, vision improved further to 6/12p, with the anterior segment showing adherent leucomatous grade opacity due to scarring along the apposed corneal tear wound, peaked pupil, and AC irregular depth.
| Discussion | | |
The best method for achieving adequate visual rehabilitation in cases without capsular support for IOL has always been a topic of interest. With various options available for rehabilitation like AC lens, scleral fixated lens, and RP iris-fixated lenses.
Iris-claw lens can be placed anteriorly or RP area. RP placement is preferred due to the risk of endothelial cells' damage and the development of secondary glaucoma in the latter.[1] It also shortens and simplifies the procedure in comparison to attaching the lens to the sclera.[2] RP iris-claw IOL combines the ease of ACIOL implantation with the advantages of posterior chamber IOL (PCIOL) location in terms of optics and physiology.
RP fixation of iris-claw lens involves the fixation arms (haptics) being attached to the midperiphery of the iris which represents the immobile iris stroma along horizontal position with enclavation site at 3 o'clock‒9 o'clock positions. Our case series included a case of iris coloboma with zonular loss and associated cataract, a case of full thickness radial corneal tear with iris plugging and traumatic cataract and also a case of iris atrophy, eccentric pupil with subluxated cataractous lens. In all these cases, RP iris-claw lens was used. Intraoperatively, manipulations in the technique of iris-claw insertion were introduced so as to make sure the centration and the contouring of the iris stroma were achieved despite the irregular pupil. Intraoperatively, iris enclavation was ensured that the sites did not overlie the area of iris defect to avoid insufficient enclavation and chances of luxation of the claws leading to subluxation of the IOL.
In case 1 of iris coloboma and zonular loss, the vision of 6/12p was attained with RP iris-claw with an added advantage of surgical simplicity and shorter duration of surgery. This is in contrast to the surgical techniques explained by Ogawa et al.[3] wherein IOL placed after primary closure of iris coloboma at the time of cataract surgery has been advised. The literature on surgical measures for cataractous lens associated with iris coloboma evaluates and compares the functional outcome between phacoemulsification and M-SICS.[4] However, the type of IOL has not been elucidated in the literature.
In general, RP iris-fixated lenses have a better outcome than SFIOLS.[5],[6],[7] However, there are no studies that describe RPIOLs in iris trauma. In our series, RP iris-claw was placed in a case of nonwell dilating and a focally atrophied iris resulting in a vision of 6/12p.
In case 3, RP iris-claw lens has been placed for traumatic pediatric cataract. The postoperative vision on follow-up improved to 6/12p. Kavitha et al.[8] concluded that iris-claw lens is an alternative to PCIOL in the treatment of traumatic pediatric cataract. However, RPIOL in trauma to iris has not been described.
Iris claw lens being readily available, and surgical technique of insertion being easy and quick, serves as one of the effective alternatives for the intraocular lens in difficult situations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Chen Y, Liu Q, Xue C, Huang Z, Chen Y. Three-year follow-up of secondary anterior iris fixation of an aphakic intraocular lens to correct aphakia. J Cataract Refract Surg 2012;38:1595-601.  |
| 2. | Menezo JL, Martinez MC, Cisneros AL. Iris-fixated Worst claw versus sulcus-fixated posterior chamber lenses in the absence of capsular support. J Cataract Refract Surg 1996;22:1476-84. |
| 3. | Ogawa GS. Reply: Congenital iris coloboma repair with excision of colobomatous sphincter muscle. J Cataract Refract Surg 2021;47:831. |
| 4. | Kohli G, Shah C, Sen A, Joshi R, Sood D, Patidar N, et al. Cataract surgery in eyes with associated coloboma: Predictors of outcome and safety of different surgical techniques. Indian J Ophthalmol 2021;69:937-45. [ PUBMED] [Full text] |
| 5. | Kang HG, Jun JW, Choi EY, Byeon SH, Kim SS, Koh HJ, et al. Comparison of long-term surgical outcomes for scleral-fixated versus retropupillary iris-claw intraocular lens. Clin Exp Ophthalmol 2021;49:686-95. |
| 6. | Hara S, Borkenstein AF, Ehmer A, Auffarth GU. Retropupillary fixation of iris-claw intraocular lens versus transscleral suturing fixation for aphakic eyes without capsular support. J Refract Surg 2011;27:729-35. |
| 7. | Vounotrypidis E, Schuster I, Mackert MJ, Kook D, Priglinger S, Wolf A. Secondary intraocular lens implantation: A large retrospective analysis. Graefes Arch Clin Exp Ophthalmol 2019;257:125-34. |
| 8. | Kavitha V, Balasubramanian P, Heralgi MM. Iris-claw versus posterior chamber fixation intraocular lens implantation in pediatric traumatic cataract. Taiwan J Ophthalmol 2016;6:69-74. [ PUBMED] [Full text] |
[Figure 1], [Figure 2]
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