|Year : 2020 | Volume
| Issue : 1 | Page : 25-34
The use of iris claw intraocular lens in aphakic eyes with inadequate capsular support and in phakic eyes for correction of high refractive errors
Abdel-Khalik I El-Saadany, Hany A Khairy, Ghada Z Rajab, Ahmed M.S Fayed
Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||26-Feb-2019|
|Date of Decision||09-Aug-2019|
|Date of Acceptance||12-Dec-2019|
|Date of Web Publication||28-Feb-2020|
Ahmed M.S Fayed
Department of Ophthalmology, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia 51132
Source of Support: None, Conflict of Interest: None
Background Iris-claw intraocular lens (IOL) implantation is effective for correction of aphakia in the absence of capsular support. Iris claw phakic IOLs lack potential size-related complications that may occur with other phakic IOLs.
Objective The aim of this study was to evaluate the technique, efficacy, and safety of iris claw IOL implantation.
Patients and methods Patients with inadequate capsular support underwent aphakic iris-claw IOL implantation using two techniques: anterior chamber and retro-pupillary fixation of iris-claw lens. Phakic iris claw IOLs were implanted for myopic patients with high refractive errors or with thin or suspicious corneas. Eyes were evaluated for uncorrected and corrected distance visual acuity, refraction, intraocular pressure, and any postoperative complications.
Results The study included 17 eyes. Group I included 12 eyes that underwent aphakic iris-claw lens implantation. Indications for surgery were surgical aphakia (n=8), lens dislocation (n=1), and lens subluxation (n=3). Eight eyes had pre-pupillary lens implantation and four eyes underwent retro-pupillary implantation. Group II included five eyes that underwent phakic iris-claw lens implantation. The final postoperative unaided visual acuity was 0.13±0.067 in group I and 0.22±0.076 in group, II, whereas the corrected visual acuity was 0.28±0.193 in group I and 0.34±0.114 in group II. The visual acuity improved significantly compared with the preoperative values (P=0.003 and 0.003, respectively, in group I and P=0.041 and 0.042, respectively, in group II). Postoperative complications included corneal edema, intraocular pressure elevation, inflammatory reaction, pupil ovalization, vitreous hemorrhage, and lens disenclavation.
Conclusion Aphakic iris-claw IOL implantation is an effective option for visual rehabilitation in eyes with inadequate capsular support. Phakic iris-claw lens implantation is useful for correction of high refractive errors with high efficacy and safety.
Keywords: aphakia, iris-claw lens, lens dislocation, lens subluxation, phakic intraocular lens
|How to cite this article:|
El-Saadany AKI, Khairy HA, Rajab GZ, Fayed AM. The use of iris claw intraocular lens in aphakic eyes with inadequate capsular support and in phakic eyes for correction of high refractive errors. Delta J Ophthalmol 2020;21:25-34
|How to cite this URL:|
El-Saadany AKI, Khairy HA, Rajab GZ, Fayed AM. The use of iris claw intraocular lens in aphakic eyes with inadequate capsular support and in phakic eyes for correction of high refractive errors. Delta J Ophthalmol [serial online] 2020 [cited 2021 Dec 3];21:25-34. Available from: http://www.djo.eg.net/text.asp?2020/21/1/25/279715
| Introduction|| |
In 1978, Jan Worst developed an iris claw intraocular lens (IOL) for the correction of aphakia following cataract surgery . There have been significant modifications to the original design. Later, the great success and safety of this implant led Jan Worst and Paul Fechner to modify the iris-claw IOL for use in phakic eyes, and they implanted the first iris-claw phakic intraocular lens (pIOL) in 1986 .
Iris-claw IOL implantation is an effective method for correction of aphakia in the absence of capsular support. Several studies have demonstrated that it has several advantages and fewer complications, with its easy placement and good visual outcome, when compared with the trans-scleral sutured posterior chamber intraocular lenses (PC-IOLs) and angle supported anterior chamber intraocular lenses (AC-IOLs). Being fixated to the mid-peripheral iris, in a location away from the anterior chamber (AC) angle, it is less likely to damage the angle structures. The optic vaults away from the iris to reduce the risk of pupillary 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 . Furthermore, retropupillary implantation is possible, allowing the iris to act as a barrier protecting the corneal endothelium from damage by the IOL and preserving the anatomy of the anterior segment .
Phakic iris-claw intraocular lenses (pICIOLs) are a useful option for the correction of high refractive errors, where laser refractive surgery is not suitable. Advantages include precise and stable refractive outcome, reversibility, preservation of accommodation, a wide refractive error treatment range, and infrequent complications .
The aim of this study was to evaluate the visual outcome and the safety profile of the two types of iris-claw IOLs: aphakic iris-claw lenses in eyes with inadequate capsular or zonular support and phakic iris-claw lenses in patients seeking refractive surgery.
| Patients and methods|| |
This is a descriptive case series study. The patients were selected from the Ophthalmology Outpatient Clinic of Menoufia University Hospital between May 2015 and May 2017. A written informed consent for participation in the study and for publication of data was obtained from all patients before enrollment in the study. The study was approved by the Ethics Committee of Human Rights, Faculty of Medicine, Menoufia University, and was carried out in accordance with the tenets of the World Medical Association’s declaration of Helsinki.
The study was performed on two groups. In group I, aphakic iris claw intraocular lenses (Verisyse Aphakic IOL VRSA54; Abbot, Chicago, Illinois, USA) were used for patients who had insufficient capsular or zonular support for conventional IOL implantation. In group II, pICIOLs (Verisyse Phakic IOL VRSM50; Abbot) were implanted for patients seeking refractive surgery who were not good candidates for corneal refractive surgery owing to high refractive error with thin or suspicious corneas.
The inclusion criteria for group I were aphakia with insufficient capsular or zonular support following complicated cataract surgery with posterior capsule rupture or significant zonular dehiscence, congenital or traumatic lens subluxation, and anterior or posterior lens dislocation. For group II, the inclusion criteria included myopia with spherical equivalent (SE) between −10 and −25 D in patients with an age greater than 18 years and stable refraction for at least 1 year.
In both groups, 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; 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 AC depth measured from the corneal epithelium to the anterior surface of the crystalline lens less than 3.2 mm. Additional exclusion criteria for pICIOLs included high preoperative intraocular pressure (IOP) (>21 mmHg), glaucoma, cataract, keratoconus, uveitis, and angle abnormalities detected by gonioscopy.
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 unaided and best-corrected distance visual acuity using Landolt’s broken ring chart, 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, and fundus examination with indirect ophthalmoscope. Visual acuity values were expressed as decimal values for statistical analysis.
For aphakic iris-claw IOL, the lens power to be implanted was calculated with Saunders, Retzlaf, and Kraff (SRK-II) formula using A-constant of 115 for AC iris claw intraocular lens (IC-IOL) implantation and 117 for retro-pupillary IC-IOL implantation. Manual keratometry was performed using manual keratometer (Javal Schiotz, Köniz, Switzerland). The axial length and AC depth were measured by A-scan ultrasonography (Sonomed, Escalon 300 A PACSCAN, New York, New York, USA). For phakic iris-claw IOL, the dioptric power of the IOLs was calculated according to the manufacturer’s guidance by considering refraction, keratometry, and AC depth.
The surgical procedure involved 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 and injection of intra-cameral acetylcholine chloride 1% (Carbakol USP 0.01; Tarun Enterprises, New Delhi, India), followed by a cohesive viscoelastic agent (Optiflex Sodium Hyaluronata Ophthalmic Solution 1.4%; Moss Vision Inc. Ltd, London, UK) into the AC. Then the IOL was inserted vertically into the AC. The IOL was rotated such that the claw haptics were oriented 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. The procedure was completed with creation of a superior peripheral iridectomy and suturing the large corneal wound with 10–0 nylon suture. Steroid and antibiotic eye-drops were prescribed for 1 month.
For retropupillary fixation of aphakic IC-IOL, the surgical procedure was performed in the same manner, except that the two side ports were made at 3 and 9 o’clock positions. The iris-claw IOL was introduced inverted into the AC vertically followed by rotating it horizontally or otherwise according to the amount of iris tissue present. The lens was held with a fixation forceps through the corneoscleral tunnel and slipped through the pupillary area. The IOL was re-centered behind the iris plane and then lifted against the iris plane in such a way that the haptics become apparent through the iris stroma. This was followed by enclavation of the mid-peripheral iris between the claw haptics with a small spatula by applying gentle pressure.
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.
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: unaided and best-corrected distance visual acuity, manifest refraction, complete slit-lamp examination, Goldmann applanation tonometry, fundus examination with indirect ophthalmoscope, 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.
The database was prepared using EXCEL software, Microsoft office 2013 version (Microsoft Corporation, Redmond, Washington, United States). All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) program version 20 (IBM, Armonk, New York, USA) on a personal computer. Quantitative data were expressed as mean±SD. Qualitative data were expressed as numbers and percentages. Wilcoxon 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 or equal to 0.05 was considered statistically significant.
| Results|| |
The study included 17 eyes of 15 patients. The patients were divided into two groups according to the type of iris-claw IOL to be implanted. Group I patients underwent aphakic iris-claw IOL implantation. This group included 12 eyes of 11 patients, comprising seven (63.63%) males and four (36.36%) females. Their age ranged from 10 to 70 years, with a mean of 46.42±24.55 years. Group II patients underwent phakic iris-claw IOL implantation. This group included five eyes of four patients, comprising two (50%) males and two (50%) females. Their age ranged from 22 to 37 years, with a mean of 27.4±7.47 years ([Table 1]).
Among patients of group I, the indications of surgery were as follows: eight (66.67%) eyes had inadequate capsular support after cataract surgery and underwent secondary implantation of aphakic iris-claw IOL, two (16.67%) eyes of the same patient had congenital lens subluxation owing to Marfan’s syndrome, and one (8.33%) eye had traumatic lens subluxation. The three eyes underwent lensectomy with aphakic iris-claw IOL implantation. One (8.33%) eye had congenital posterior lens dislocation and underwent pars plana vitrectomy with lensectomy and aphakic iris-claw IOL implantation. In eight (66.67%) eyes, iris-claw IOL was implanted in the AC, and the remaining four (33.33%) eyes underwent retropupillary fixation of iris-claw IOL based on surgeon’s preference. [Figure 1] shows a case on the first postoperative day following AC aphakic iris-claw IOL implantation. [Figure 2] shows a case on the first postoperative day following retropupillary aphakic iris-claw IOL implantation. All members of group II had high myopia outside the range of corneal laser refractive surgery and underwent phakic iris-claw IOL implantation. [Figure 3] shows a case on the first postoperative day following pICIOL implantation.
|Figure 1 Anterior chamber aphakic iris-claw intraocular lens − first day postoperatively.|
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|Figure 2 Retropupillary aphakic iris-claw intraocular lens − first day postoperatively.|
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In group I, the preoperative unaided visual acuity (UAVA) ranged from 0.01 to 0.05 decimal, with a mean of 0.023±0.026. The preoperative best-corrected visual acuity (BCVA) ranged from 0.015 to 0.2 decimal, with a mean of 0.11±0.084. The preoperative SE of refractive error in the aphakic eyes ranged from +9.25 to +14 D, with a mean of +10.86±1.48 D, whereas in eyes with lens subluxation, the SE ranged from −7.75 to −23.75 D, with a mean of −16.33±8.064 D. The preoperative IOP ranged from 6 to 30 mmHg, with a mean of 14.67±5.99 mmHg.
In group II, the preoperative UAVA ranged from 0.015 to 0.1 decimal, with a mean of 0.073±0.039. The preoperative BCVA ranged from 0.1 to 0.2 decimal, with a mean of 0.14±0.042. The preoperative SE ranged from −15 to −27 D, with a mean of −20.5±4.899 D. The preoperative IOP ranged from 12 to 16 mmHg, with a mean of 13.8±1.483 mmHg.
In group 1, 6 months postoperatively, the final UAVA ranged from 0.01 to 0.2 decimal with a mean of 0.13±0.067, which is significantly better than the preoperative UAVA (P=0.003). The final BCVA, 6s month postoperatively, ranged from 0.1 to 0.6 decimal, with a mean of 0.28±0.193, which is significantly better than the preoperative BCVA (P=0.003). The final BCVA was better than the preoperative value in 11 (91.67%) eyes and was unchanged in one (8.33%) eye. Worsening of the final BCVA did not occur in any case ([Table 2]).
|Table 2 Preoperative and postoperative unaided and best-corrected visual acuity, refraction, and intraocular pressure in group I|
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Regarding the SE of refractive error, refraction could not be performed in the early postoperative period in all cases owing to corneal edema or inflammatory reaction in some cases. Therefore, it was reported after one month and after six months. After 6 months postoperatively, the SE ranged from −1.50 to +11.5 D, with a mean of +0.58±3.662 D, in group I, with no statistically significant difference between it and the preoperative SE (P=0.238). Considering only the aphakic eyes that underwent secondary IC-IOL implantation, the SE ranged from −1.75 to +2 D, with a mean of −0.61±1.17 D, which is significantly less than the preoperative SE (P=0.008). However, in the eyes that had lens subluxation and underwent lensectomy with IC-IOL implantation, it ranged from −1 to +11.5 D, with a mean of +4.17±6.53 D. This wide range was caused by one extreme case (+11.5 D) that was caused by the incidence of traumatic IOL disenclavation and displacement in this eye 6 months postoperatively with subsequent increase in the SE of the refractive error.
The final postoperative IOP, 6 months postoperatively, in group I 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 3] shows comparison between postoperative data following the two locations of iris-claw aphakic IOL implantation in group I. There was no statistically significant difference regarding postoperative uncorrected or BCVA, refraction, or IOP between the two techniques.
|Table 3 Postoperative unaided, best-corrected visual acuity, refraction, and intraocular pressure after anterior chamber versus retropupillary fixation of iris-claw intraocular lens|
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[Table 4] shows comparison between preoperative and postoperative data in group II. After 6 months postoperatively, the final UAVA ranged from 0.15 to 0.3 decimal, with a mean of 0.22±0.076, which is significantly better than the preoperative UAVA (P=0.041). The final BCVA, 6 months postoperatively, ranged from 0.2 to 0.5 decimal, with a mean of 0.34±0.114, which is significantly better than the preoperative BCVA (P=0.042). All five eyes in group II showed improvement of the final BCVA compared with the preoperative values. The final SE, 6 month postoperatively, ranged from −0.5 to −5 D, with a mean of −2.4±1.737 D, which is significantly less than the preoperative SE (P=0.042). The final postoperative IOP, 6 month postoperatively, ranged from 10 to 14 mmHg, with a mean of 11.8±1.789 mmHg. There was no statistically significant difference between preoperative and postoperative IOP at any of the postoperative visits.
|Table 4 Preoperative and postoperative unaided and best-corrected visual acuity, refraction, and intraocular pressure in group II|
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There was no statistically significant difference between the two groups regarding the final UAVA (P=0.08186) or BCVA (P=0.36812). The final postoperative SE of refractive error in group II was significantly less than that in group I (P=0.0394). There was no statistically significant difference in the postoperative IOP between groups I and II at any of the postoperative visits ([Table 5]).
|Table 5 Comparison between postoperative unaided, best-corrected visual acuity, refraction, and intraocular pressure in groups I and II|
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[Table 6] shows the postoperative complications in the two study groups. In group I, 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 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. In group II, one (20%) eye showed mild corneal edema, one (20%) eye had transient IOP elevation, and one (20%) eye showed pupillary distortion. There was no statistically significant difference regarding the incidence of postoperative complications between AC and retropupillary fixation of the iris-claw aphakic IOL at any of the postoperative visits ([Table 7]).
|Table 7 Postoperative complications after anterior chamber versus retropupillary fixation of iris-claw intraocular lens|
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| Discussion|| |
Iris-claw IOL implantation is an effective method for correction of aphakia in the absence of capsular support. Several studies have demonstrated that 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 . Furthermore, iris claw phakic IOLs lack potential size-related complications such as crystalline lens and peripheral corneal contact, which may occur with posterior chamber or angle-supported phakic IOLs .
In this study, the mean UAVA significantly improved from the first postoperative day in both groups. There was no statistically significant difference between the mean postoperative BCVA and the mean preoperative BCVA within both groups on the first postoperative day. This can be explained by the transient postoperative corneal edema or intraocular inflammation that can limit the BCVA in the early postoperative period. Visual recovery occurred in the subsequent visits, and the mean postoperative BCVA was significantly better than the preoperative value at one and six months postoperatively. The final mean BCVA was 0.28±0.193 in group I and 0.34±0.114 in group II.
Within group I, there was no statistically significant difference between UAVA and BCVA following AC and retropupillary fixation of aphakic iris-claw IOL at any of the postoperative visits. To our knowledge, six studies have compared the results of iris-claw IOL implantation considering pre-pupillary or retropupillary location ,,,,,. They all reported that the visual acuity improved significantly in both fixation techniques and that there were no statistically significant differences between them.
There are, however, other articles that do not compare both locations, utilizing only one of the two techniques of iris-claw aphakic IOL implantation and demonstrating the efficacy of both fixation techniques in improving visual acuity postoperatively. Regarding authors who studied AC implantation, Güell et al.  reported that the mean logarithm of the minimum angle of resolution (logMAR) preoperative best-spectacle corrected visual acuity was 0.67±0.53 and significantly improved one year postoperatively to 0.52±0.46 and remained stable up to 5 years. Rabie et al.  reported that the mean UCVA improved significantly from 1.3±0.5 logMAR preoperatively to 0.4±0.1 logMAR at the final follow-up visit. Mean BCVA showed a significant improvement from 0.5±0.3 logMAR at baseline to 0.2±0.2 logMAR postoperatively.
Regarding authors who studied the retropupillary implantation, Jayamadhury et al.  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. Preoperative distant BCVA 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. Kelkar et al.  reported that although the mean postoperative day1 logMAR BCVA did not differ significantly from the mean preoperative value, significant improvement in postoperative logMAR BCVA as compared with mean preoperative logMAR vision was noted from the first postoperative week follow-up and thereafter. Rastogi et al.  reported that all patients had an increase in the postoperative BCVA with a mean of 0.351±0.154 log MAR units, which was statistically significant as compared with the preoperative value of 0.771±0.132 log MAR units.
Several studies reported the efficacy of iris-claw phakic IOL implantation in improving visual acuity postoperatively. Moshirfar et al.  reported that 6 months postoperatively, the UCVA was better than 20/40 in 83% of eyes and better than 20/25 in 32%. Titiyal et al.  reported that the mean CDVA improved from 6/10 preoperatively to 6/7 postoperatively and the mean UDVA from 6/319 to 6/9.
In group I, the final BCVA was better than the preoperative value in 11 (91.67%) eyes and was unchanged in one eye (8.33%). Worsening of the final BCVA did not occur in any case in the current study. Schallenberg et al.  reported that in 71% of eyes the visual acuity improved, in 6.5% of eyes the visual acuity remained unchanged, and 22.5% of eyes showed a decreased visual acuity. Lett and Chaudhuri  reported that at final follow-up, 65.6% of eyes achieved BCVA better than that measured preoperatively and 31.3% of eyes matched their preoperative BCVA. Only one eye (0.03%) attained a final BCVA worse than preoperatively, owing to nonarteritic anterior ischemic optic neuropathy.
In the current study, all five eyes in group II showed improvement of the final BCVA compared with the preoperative values. Karimian et al.  reported that the rate of at least one line improvement in BCVA postoperatively was 75% in the Artisan group. In addition, more than one line of improvement occurred in 25% of eyes. Three (7.5%) eyes experienced more than one Snellen’s line decrease in BCVA, and one (2.5%) eye demonstrated more than two lines of decreased vision. Yaşa et al.  reported that 75% of patients gained one or more lines and 45% of patients gained two or more lines of CDVA. No patient lost two or more lines of CDVA.
In the present study, the SE of refractive error decreased postoperatively, approaching emmetropia, in all cases, but there was no statistically significant difference between the mean preoperative and postoperative SE in group I. This can be explained by the great variation in preoperative SE according to the indication of surgery. When we considered only the aphakic eyes that underwent secondary iris-claw IOL implantation (excluding eyes that had lens subluxation), the postoperative SE was significantly less than preoperatively.
In group I, the mean postoperative SE changed from −0.44±1.42 D (range from −2.25 to +2 D) at 1 month to +0.58±3.662 D (range from −1.50 to +11.5 D) at 6 months. This change was caused by the incidence of traumatic IOL disenclavation and displacement in one eye 6 months postoperatively with subsequent increase in SE. There was no statistically significant difference between postoperative SE following AC versus retropupillary implantation of iris-claw IOL. These results are comparable to those found in literature. Schallenberg et al.  reported a mean preoperative SE refraction of 5.01±6.21 D. This refraction decreased to a mean SE of −0.43±1.93 D postoperatively. Rabie et al.  reported that SE changed significantly from −11.38±1.99 D preoperatively to −0.45±1.65 D postoperatively. Rastogi et al.  reported that the mean postoperative SE was −0.303±1.233 D, and the mean astigmatism was −2.07±0.91 D at the end of 6 months.
In group II, the final mean SE at 6 months was −2.4±1.737 D (range from −0.5 to −5 D). Although it is significantly less than the preoperative SE (P=0.042), it was significantly higher than in group I (P=0. 0394). This is because we were aiming for myopia in one patient in group II rather than emmetropia to avoid significant anisometropia. This patient had previous angle-fixed phakic IOL implantation in the fellow eye several years before and that eye had myopia and myopic astigmatism with SE of −7.5 D. Yaşa et al.  reported that the mean preoperative SE was −11.6±3.6 D. SE significantly decreased postoperatively, and there was no difference between the postoperative visits at 6 months, 1 year, and 2 years. Mean SE was −0.85±0.57 D at 2 years. Bouheraoua et al.  reported that the mean preoperative SE of −13±4.10 D decreased postoperatively to a final SE of −0.75±0.74 D at 5 years.
In this study, there was no statistically significant difference between preoperative and postoperative IOP, nor between postoperative IOP following AC and retropupillary fixation of the iris-claw lens. Transient IOP elevation occurred in three (25%) cases in group I and in one (20%) case in Group II. In all cases, IOP was controlled with topical antiglaucoma medications. Rastogi et al.  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.  in only one (3.03%) patient, Jare et al.  in three (2.78%) eyes, and Kelkar et al.  in seven (6.73%) eyes. Helvaci et al.  reported that four (20%) patients in group 1 (AC-ICIOL) and five (25%) patients in group 2 (RPIC-IOL) had significant but nonpermanent increase of IOP values. Titiyal et al.  reported increased IOP in five (5.88%) eyes following iris-claw phakic IOL implantation, which responded well to topical antiglaucoma therapy. Yaşa et al.  reported elevated IOP in two (3.23%) eyes at the 1-month postoperative visit. They considered these increases to be steroid induced. The IOP returned to its baseline levels after cessation of steroid use.
Other postoperative complications that occurred in the present study included corneal edema, AC reaction, pupillary ovalization and distortion and vitreous hemorrhage. All these complications were temporary and were managed medically with no need for surgical intervention. One (8.3%) eye in group I 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. There was no statistically significant difference between the AC and retropupillary groups regarding the incidence of postoperative complications.
Although most complications that we encountered were transient with no long-term effects, the incidence of postoperative complications in the present 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 have contributed to the higher incidence of complications in the early portion of the series and that would be more obvious with small sample size. Martínez and González  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|| |
Aphakic iris claw IOL is an effective option for visual rehabilitation in eyes with inadequate capsular or zonular support that provides a good visual outcome and high safety profile. Both AC and retropupillary fixation can achieve a satisfactory outcome. pICIOL is a useful option for correction of high refractive errors where laser refractive surgery is not suitable, and it provides the advantages of precise and stable refractive outcome, reversibility, preservation of accommodation, a wide refractive error treatment range, and infrequent complications.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]