Laboratory science

Br J Ophthalmol: first published as 10.1136/bjophthalmol-2014-305364 on 1 July 2014. Downloaded from http://bjo.bmj.com/ on January 8, 2020 at AAO/BJO. Protected by copyright.
Morphologic alterations on posterior iris-claw
intraocular lenses after traumatic disenclavation
Tobias Brockmann, Johannes Gonnermann, Claudia Brockmann, Necip Torun,
Antonia M Joussen, Eckart Bertelmann

Department of Ophthalmology, ABSTRACT iris-claw implantation.13–15 Thereby, a disenclava-

Charité—University Medicine Aims To analyse morphologic alterations on posterior tion might occur spontaneously because of insuffi-
Berlin, Berlin, Germany
iris-claw intraocular lenses (IOL) after dislocation due to cient tissue grasping, or despite adequate
Correspondence to traumatic disenclavation. enclavation after significant trauma.16 17 Because of
Dr Tobias Brockmann, Methods Seven dislocated iris-claw IOLs were included potential complications, such as rhegmatogenous
Department of Ophthalmology, in this observational study. Five posterior iris-claw IOLs retinal detachment and vitreous haemorrhage, a
Charité—University Medicine
were explanted after traumatic disenclavation and dislocated posterior iris-claw IOL requires replace-
Berlin, Augustenburger Platz 1,
Berlin 13353, Germany; tobias. compared to two iris-claw IOLs with a history of ment9 17 18 or re-enclavation.11 12 In this regard,
[email protected] spontaneous disenclavation. One original aphakic iris- the long-term endothelial cell loss, as a measure for
claw IOL served as control. All IOLs underwent perioperative trauma, after re-enclavation, and after
Received 7 April 2014 standardised examinations using light microscopy. uneventful implantation, was found to be compar-
Revised 22 May 2014
Accepted 3 June 2014 Results All traumatically disenclaved iris-claw haptics able.19 Even though, re-enclavation is considered to
Published Online First presented decentred and twisted fixation arms. The be the less hazardous,20 the procedure may be tech-
1 July 2014 average decentration on iris-claw haptics measured nically difficult and does not ensure against further
23±11 mm in the surface plane and 103±43 mm on the dislocation, especially in cases of structurally
edge profile; the axial twist of the fixation arms damaged haptics.21 In this regard, potential defects
measured five angular degrees. Traumatically affected on the IOL cannot be evaluated adequately intrao-
haptics were tilted (3/5) or did not provide an adequate peratively, and the extent of posttraumatic deform-
closure (2/5), so that a reliable fixation on the iris stroma ation in iris-claw IOLs has not been investigated so
was not ensured. Morphologic alterations were far. Therefore, this study has been initiated to
significantly different after traumatic and spontaneous investigate morphologic alterations on haptics of
disenclavation. Spontaneously disenclaved IOLs and the posterior iris-claw IOLs after traumatic
original IOL demonstrated symmetric haptics with disenclavation.
centred iris-claws and a sufficient closure.
Conclusions Traumatically dislocated iris-claw IOLs METHODS
presented considerable alterations on the affected Eight monofocal iris-claw IOLs were investigated
haptics, which might not guarantee a reliable re- morphologically. Seven explanted iris-claw IOLs
enclavation. Therefore, we suggest an IOL replacement, from seven consecutive patients who underwent an
instead of reenclavation, in cases of traumatic iris-claw IOL exchange or explantation between January
disenclavation. 2013 and March 2014 were included in this case
series. During that observational period, overall 99
eyes of 93 patients underwent a retropupillar
INTRODUCTION iris-claw IOL implantation. Five (5.1%) posterior
Intraocular lens (IOL) implantation in cases of iris-claw Artisan/Verisyse IOLs were explanted after
aphakia and missing capsular support is particularly traumatic disenclavation, and two iris-claw IOLs
challenging. While several techniques have been (one PMMA Artisan/Verisyse IOL and one acrylic
described, most procedures are associated with Artiflex/Veriflex IOL) were explanted after a history
severe intraoperative and postoperative complica- of spontaneous disenclavation. One sealed original
tions.1–5 In this regard, the retropupillar ( posterior) +21.0 D Verisyse IOL (VRSA54, serial number
implantation of an iris-claw IOL is a promising ML109704) served as control.
alternative.6 7
The polymethylmethacrylate The explantation and replacement of posterior
(PMMA) Artisan/Verisyse aphakic IOL (Ophtec, iris-claw IOLs was accomplished as follows: two
Groningen, The Netherlands; Advanced Medical paracenteses were created at the 3 o’clock and 9
Optics, Santa Ana, USA) attaches to iris tissue with o’clock positions. The pupil was dilated using intra-
clips on both sides of the optic. These haptics have cameral epinephrine (diluted 1:1000) and a cohe-
fine fissures enabling an enclavation of a mid- sive ophthalmic viscosurgical device was inserted
peripheral iris stroma fold. In this position, the IOL into the anterior chamber. The disenclaved side of
is virtually immobile, does not interfere with vascu- the iris-claw IOL was luxated in the anterior
larisation or angle structures, and thereby provides chamber and the optic was held with Verisyse
favourable visual outcomes with a low complication holding forceps (Ophtec, Groningen, The
To cite: Brockmann T,
rate.8 9 However, one considerable complication Netherlands). Following this, the remaining
Gonnermann J, after posterior iris-claw IOL implantation is the dis- iris-enclavation was released from the iris-claw by
Brockmann C, et al. Br J location due to disenclavation.9 In literature, the gentle pressure on the iris-fold with an angled
Ophthalmol 2014;98: dislocation rate was reported between 0% and spatula (54270Y2A; Bausch & Lomb Storz
1303–1307. 10%,9–12 which is comparable to an anterior Ophthalmic Instruments, Rochester, USA), so that

Brockmann T, et al. Br J Ophthalmol 2014;98:1303–1307. doi:10.1136/bjophthalmol-2014-305364 1303

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Br J Ophthalmol: first published as 10.1136/bjophthalmol-2014-305364 on 1 July 2014. Downloaded from http://bjo.bmj.com/ on January 8, 2020 at AAO/BJO. Protected by copyright.
Table 1 Overview of patient characteristics
Age Time to IOL Type of iris-claw IOL
(yrs)/ Preop Type of Surgical procedure and reason explantation and reason for initial
Case gender Eye BSCVA dislocation for IOL explantation (months) implantation Ocular history

1 39/M R 20/100 Traumatic IOL replacement with a new 32 Posterior aphakic Vitrectomy after
Verisyse IOL (+17.0D) for traumatic iris-claw IOL after pseudo-phakic retinal
disenclavation after ocular contusion PCIOL dislocation detachment
(2010) (macula-detached) in 2006
2 15/M R 20/70 Traumatic IOL replacement with a new 13 Posterior aphakic Cataract surgery without
Verisyse IOL (+22.0D) for traumatic iris-claw IOL for primary IOL implantation
disenclavation correction of aphakia (2012) for congenital
(2012) cataract
3 85/M L 20/25 Traumatic IOL replacement with a new 60 Posterior aphakic Cataract surgery without
Verisyse IOL (+19.0D) for iris-claw IOL for primary IOL implantation
disenclavation after trauma by a correction of aphakia (1980)
pull cord of a window blind (2008)
4 80/M R 20/400 Traumatic IOL explantation without IOL 39 Posterior aphakic Pars-plana vitrectomy for
implantation after traumatic iris-claw IOL after macular pucker and retinal
disenclavation due to airbag phakic lens dislocation schisis
collision (2010)
5 61/M L 20/63 Traumatic IOL replacement with a new 62 Posterior aphakic Vitrectomy with IOL
Verisyse IOL (+25.0D) and iris iris-claw IOL after implantation after traumatic
reconstruction for traumatic traumatic PCIOL lens dislocation (2008)
disenclavation after fistfight dislocation (2008)
6 68/F L 20/63 Spontaneous IOL explantation followed by 244 Anterior phakic iris-claw History of spontaneous IOL
cataract surgery with IOL as refractive surgery disenclavation
phacoemulsification and IOL for myopia magna
implantation (1993)
7 39/F R 20/25 Spontaneous IOL (Artiflex/Veriflex) explantation 77 Anterior phakic iris-claw History of repeated
without reimplantation of a new IOL as refractive surgery spontaneous IOL
IOL as desired by the patient for myopia magna disenclavations
(2007)
BSCVA, best spectacle corrected visual acuity; D, diopters; F, female; L, left; M, male; (PC)IOL, (posterior chamber) intraocular lens; R, right.

the IOL could be entirely rotated into the anterior chamber. V.20.0 (IBM, Armonk, USA). Normally distributed variables
Then, a 5.5 mm sclerocorneal tunnel incision was made for IOL with equal variances were compared using the Student t test;
explantation. Intraoperative, the explanted IOL was handled variables with unequal variances were compared using the
with care to avoid mechanical manipulation. The preoperatively Welch-test for independent samples. A p value less than 0.05
disenclaved haptic was marked with a vicryl 6-0 thread and was considered as statistically significant.
placed in balanced salt solution with ofloxacine to avoid con-
tamination. Following this, acetylcholine chloride 1% was RESULTS
injected in the anterior chamber and a new Verisyse IOL was Clinical data
implanted retropupillary at a separate, unaffected enclavation Seven eyes of seven patients, as presented in table 1, underwent
site on the iris stroma as previously described.18 Individual an iris-claw IOL explantation. The mean patients’ age was
modifications of the performed surgical procedure are sum- 55±25 years (range: 15–85 years). Five patients had a posterior
marised in table 1. iris-claw IOL explantation after traumatic disenclavation, the
Postoperative ofloxacin, dexamethasone and pilocarpine average time between IOL implantation and explantation was
drops were prescribed five times daily and gradually tapered 41.2±20.4 months. In general, traumatically dislocated IOLs
over 4 weeks. were replaced by new Verisyse IOLs. In one case, the patient
For microscopic examination, explanted IOLs were rinsed refused a reimplantation because of the poor prognosis of visual
with distilled water and handled with toothless forceps to avoid acuity and high age. In all cases, surgery was uneventful.
damage. Traumatically disenclaved haptics remained untouched According to institutional guidelines, spontaneous iris-claw IOL
throughout the explanation and examination procedures, so that disenclavation is no indication for an IOL explantation; those
alterations due to intraoperative or postoperative manipulation cases usually undergo re-enclavation. Therefore, the investigated
were excluded. The IOLs were mounted flat on a glass slide. A anterior iris-claw IOLs with a history of spontaneous disenclava-
small drop of aqua was used to attach the optic to the glass tions were explanted due to other indications, such as cataract
surface to ensure positional stability during the examination. surgery and patient’s desire (cf. table 1).
Next, the setup was mounted under a light microscope (Axio
Imager.M2; Zeiss, Jena, Germany) and photographs were taken Morphologic data
at standardised magnifications of ×25. The haptic surface was Seven iris-claw IOLs were examined, light microscopic images
scanned in a plan view, while the haptic edge was scanned per- are shown in figures 1 and 2. Corresponding morphologic mea-
pendicular. Measurements were performed using image analysis surements are summarised in table 2.
software by the National Institutes of Health (ImageJ V. 1.41 for The original Verisyse IOL demonstrated symmetric haptics
Macintosh; National Institutes of Health, http://rsb.info.nih.gov/ with well centred iris-claws and a custom-fit closure, as shown
ij/). Statistical analyses were performed using SPSS software in figure 1 (Original). The mean width of the iris-claw fixation

1304 Brockmann T, et al. Br J Ophthalmol 2014;98:1303–1307. doi:10.1136/bjophthalmol-2014-305364

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Figure 1 Light microscopic images of three Artisan/Verisyse aphakic iris-claw intraocular lenses (IOL). On a new original +21.0 D Verisyse aphakic
iris-claw IOL (Original) no irregularities were revealed. Haptics appeared symmetric with centred iris-claws and a custom-fit closure. Cases 1 and 2
represent iris-claw haptics of traumatically dislocated IOLs. Traumatically affected haptics are shown in the upper images (A and B), while
intraoperatively released haptics are shown underneath (C and D). Decentrations of affected fixation arms were analysed on the haptic surface and
in the edge profile. In Case 1 the discenclaved iris-claw did not provide a tight closure, while the haptic in Case 2 was tilted. Scale bars represent
1000 mm. Cases 3 through 5 represent haptics of traumatically dislocated posterior iris-claw IOLs. In Cases 4 and 5, the affected haptics were
considerably tilted and material defects become evident on the iris-claw fissure. Scale bars represent 1000 mm.

arms measured 214±4 mm in the surface plane and 152±4 mm between traumatic and iatrogenic intraoperative disenclavation
on the edge profile. (p=0.331 and 0.337). However, spontaneously disenclaved
By contrast, traumatically disenclaved haptics of posterior iris-claw IOLs, as presented in figure 2, revealed an average
iris-claw IOLs presented a considerable deformation of the fix- decentration of 0 mm in the surface plane and 5±7 mm on the
ation arms. The average decentration measured 23±11 mm in edge profile. In this regard, the mean decentration of iris-claw
the plane and 103±43 mm on the edge profile. Of five investi- haptics was significantly smaller on the surface plane and the
gated IOLs, as shown in figure 1, two did not provide a tight edge profile after spontaneous, compared to traumatic, disencla-
closure of the iris-claw (Cases 1 and 3), while three presented a vation (p=0.011 and p=0.028).
tilting of the fixation arms (Cases 2, 4 and 5). The width of the
fixation arms on haptics after traumatic disenclavation measured DISCUSSION
218±4 mm in the plane and 173±10 mm on the edge profile. Our study on the morphology of iris-claw IOLs revealed rele-
Compared to the original Verisyse IOL, the average width of the vant alterations on affected haptics after traumatic disenclava-
iris-claw fixation arms was significantly increased on the edge tion. The fixation arms were decentred and twisted, so that a
profile after traumatic disenclavation ( p=0.002), which indi- tight closure of the iris-claws was not given. On this account,
cates a mean axial torsion of the arms by five angular degrees. we presume that a re-enclavation of those damaged haptics
Intraoperatively released iris-claw haptics were decentred by might not provide a sufficient capture of iris tissue. While the
16±11 mm in the plane and 75±45 mm on the edge profile. IOL and both haptics were affected by a traumatic impact, an
Thereby, revealed morphologic alterations were comparable iatrogenic release of the posterior iris-claw haptics might also

Brockmann T, et al. Br J Ophthalmol 2014;98:1303–1307. doi:10.1136/bjophthalmol-2014-305364 1305

 Laboratory science

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Figure 2 Light microscopic images of two phakic iris-claw intraocular lenses (IOL). Spontaneously dislocated iris-claw haptics are shown in the
upper images (A and B, respectively). The haptics were found to be symmetric with centred iris-claws and a sufficient closure. Case 7 represents a
three-piece foldable acrylic Artiflex/Veriflex IOL with polymethylmethacrylate (PMMA) haptics. Scale bars represent 1000 mm.

Table 2 Morphologic measurements on the haptics of investigated iris-claw intraocular lenses (IOL)
Decentration of fixation arms on the
Width of the iris-claw fixation arms (mm) affected haptic (mm)

Disenclaved Intraoperative released

Case Type of dislocation Plane Edge Plane Edge Plane Edge Comment

1 Traumatic 220/216 173/175 219/222 157/153 19 71 Fissure

2 Traumatic 220/220 158/162 217/219 173/173 41 131 Tilting
3 Traumatic 210/211 173/173 219/215 180/186 13 49 Fissure
4 Traumatic 219/218 168/168 218/218 171/169 26 114 Tilting
5 Traumatic 223/223 189/187 226/225 158/158 31 60 Tilting
6 Spontaneous 193/193 159/159 199/202 161/161 0 16 Fissure
7 Spontaneous 224/223 158/158 226/225 155/154 0 0 Fissure
Original 218/218 155/155 209/211 148/150 0 0 Custom-fit
Original=new sealed original +21.0 D Verisyse IOL, both haptics were unaffected.

produce morphologic alterations. On this account, the extent of JG and CB critically reviewed the study proposal and the manuscript. AMJ, NT and
deformation on traumatically disenclaved and intraoperatively EB served as scientific advisors. .
released iris-claw haptics were found to be comparable. By con- Competing interests None of the authors has competing, financial and
trast, morphologic alterations on the haptics were significantly proprietary interest in a product, or lack thereof.
different after traumatic and spontaneous disenclavation. Provenance and peer review Not commissioned; externally peer reviewed.
Spontaneously disenclaved iris-claw IOLs presented well-centred Data sharing statement Original datasets are available from the corresponding
fixation arms with a slight fissure on the disenclaved and iatro- author.
genically released haptic. Those observations support the
hypothesis that insufficient iris stroma grasping is the prior
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Brockmann T, et al. Br J Ophthalmol 2014;98:1303–1307. doi:10.1136/bjophthalmol-2014-305364 1307