Clarifying the methods of fixation of intraocular lenses

Abstract

We have read the article by Fiorentzis et al. (2017) with an interest; however, we believe that some comments and discussion is required. The authors present a review article on the methods of intraocular lens (IOL) fixation in trauma eyes.The authors describe different surgical methods for placing IOL in the sulcus in eyes with the presence of capsular bag support. This approach is presented as leading to complications, such as pigment dispersion, uveitis-glaucoma-hyphema syndrome, and recurrent vitreous hemorrhage. The reference analysis reveals that these complications arise from sulcus placement single-piece acrylic IOL. With that, the reader is not informed about such a significant issue as the recommended IOL types in this specific clinical situation. The ASCRS Cataract Clinical Committee has presented a statement (Chang et al., 2009) that sulcus placement of intraocular lenses designed solely for the capsular bag is associated with complications and is contraindicated. The use of 3-piece IOLs with angulated haptics was recommended with capturing the optic within a well-centered capsulorhexis whose diameter must be slightly smaller than that of the optic. Lacking optic capture with a capsulorhexis, the overall haptic diameter must be sufficiently long to avoid lateral subluxation within the sulcus space. Such dedicated foldable lenses with a 13.5 mm overall length are currently available commercially.With that, the authors claim that in aphakic eyes fixation of the iris-claw lens behind the iris should be preferred. We believe that both anterior and posterior iris-fixation can be considered. De Silva et al. (2011) have conducted a study on anterior iris-fixation of iris-claw IOLs revealing good visual outcome and safety for a wide range of indications including aphakia. The most common complications were wound leakage and lens dislocation, due to slippage of one of the iris-claw haptics. Thus, the correct implantation technique was found to be critical in avoiding postoperative IOL subluxation. These problems are likewise reported after retropupillary implantation, and lens repositioning in these cases can be more challenging. We ought to mention that in the majority of cases, iris-claw IOL implantation requires a 5-6 mm incision with subsequent suturing, however it was recently shown that sutureless approach is also possible (Choragiewicz et al., 2016).Finally, the authors state that in aphakic eyes with cystoid macula edema the patient should preferably receive a posterior chamber (PC) IOL rather than an anterior chamber (AC) IOL. Furthermore, implantation of ACIOLs in aphakic eyes is claimed to be associated with cystoid macular edema, ovalization of the pupil, secondary glaucoma, and vitreous herniation anterior to the optic, or epithelial invasion. We should emphasize that with the development of open-loop haptic ACIOLs have significantly improved their safety profile. Chan et al. (2015) have reported no long-term differences in the visual outcomes after primary open-loop ACIOL or secondary scleral-fi...

Current Developments in Corneal Topography and Tomography

“…Visualizing the anterior chamber morphology is critical to establish the long-term safety of phakic IOLs. One of the most threatened potential complications of any type of anterior segment surgery, and particularly after anterior chamber and iris-fixated IOLs, is accelerated endothelial cell loss [49,50]. This risk has been shown to be negatively correlated with the anterior chamber depth, and the position of these IOLs in the anterior chamber is one of the main safety parameters in both preoperative screening and follow-up [51].…”