SURGICAL TECHNIQUE A New Technique for Treating Posttraumatic Aniridia With Aphakia First Results of Haptic Fixation of a Foldable Intraocular Lens on a Foldable and Custom-Tailored Iris Prosthesis Martin S. Spitzer, MD; Efdal Yoeruek, MD; Martin A. Leitritz, MD; Peter Szurman, MD; Karl U. Bartz-Schmidt, MD e describe a new surgical technique for treating traumatic aniridia with aphakia and its results in a small consecutive case series. We attached a 3-piece acrylic intraocular lens through the haptics to a customized silicone iris prosthesis. The combined implant was inserted through a 5-mm incision and fixated with a trans- Wscleral suture in the ciliary sulcus using a knotless technique (Z suture). In all patients, the com- bined implant stayed firmly fixed within the sulcus and showed a stable and centered position with- out any tilt or torque during follow-up. Thus, managing posttraumatic aniridia with aphakia by means of haptic fixation of a foldable intraocular lens on a custom-tailored iris prosthesis is a prom- ising approach for visual rehabilitation and cosmetic improvement. Arch Ophthalmol. 2012;130(6):771-775 Posttraumatic aniridia with aphakia often results. Other options, such as an iris re- causes significant debilitating glare, photo- construction lens consisting of a custom- phobia, and loss of vision in affected pa- made polymethylmethacrylate IOL with a tients.1,2 Management options include the polymethylmethacrylateirisdiaphragm(Ar- fitting of contact lenses with an artificial iris tisan;Ophtec,Inc),areonlysuitableforcases peripheral pigmentation painted on it,3 cor- of partial aniridia with enough iris tissue neal tattooing,4,5 and the implantation of a left for enclavation of the haptic portions.12 prosthetic iris intraocular lens (IOL). Iris Devices such as the endocapsular ring print contact lenses, however, need peri- (Morcher GmbH) require capsular support, odic replacement, may be difficult to fit in which often is absent after severe anterior eyes with posttraumatic anterior segment segment trauma.13 changes, and often are difficult for elderly Customized silicone iris prostheses that people to handle. Corneal tattooing can ad- can be implanted through a small incision dress only the symptoms of aniridia, such have recently become available (Dr Schmidt as glare and photophobia, but not the de- Intraocularlinsen GmbH, distributed by Hu- creased visual acuity caused by aphakia. manOptics AG). This iris prosthesis not only Thus, a permanent surgical solution decreasesglaresymptomsinaniridiabutalso would be desirable in many patients. Ide- provides excellent cosmetic outcomes.14-17 ally, a prosthetic iris IOL would completely However, the iris prosthesis cannot correct replace the missing iris for its full periph- foraphakia.Inthispatientseries,wedescribe eral extension along 360°. Unfortunately, a new surgical technique for treating trau- current large-diameter iris IOLs suitable for matic aniridia with aphakia and the lack of sulcus fixation have a diameter of 9.0 to 10.0 capsular support by using haptic fixation of mm and thus require a large incision.6-11 an IOL on a foldable, custom-tailored iris Moreover, the iris color of these prosthe- prosthesis and its outcome. ses is black or—with the exception of the rigidirisprosthesis(MorcherGmbH)—only METHODS available in a limited number of colors and cannot be customized for optimal cosmetic PATIENTS Author Affiliations: Department of Ophthalmology, University Eye Hospital We included 4 patients with traumatic aphakia Tübingen, Centre of Ophthalmology, Eberhard-Karls University Tübingen, and aniridia. All patients underwent primary Tübingen, Germany. wound closure as soon as possible, with addi- ARCH OPHTHALMOL / VOL 130 (NO. 6), JUNE 2012 WWW.ARCHOPHTHALMOL.COM 771 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 1. Patients Characteristics Time From Trauma Patient to Iris No./Sex/ Prosthesis–IOL Age, y Type of Trauma VA at Presentation Ocular Procedures for Trauma Repair Implantation, mo 1/M/72 Globe rupture with loss of iris, lens, and Light perception Wound closure and PPV with silicone oil 4 vitreous; vitreous hemorrhage for retinal detachment; silicone oil removal 2 mo later 2/M/39 Severe corneal laceration with lens and Hand movements Wound closure; lens removal and 6.5 iris loss anterior vitrectomy 4 d later 3/M/78 Globe rupture with loss of iris and IOL Light perception Wound closure (patient developed 11 postoperative chronic CME) 4/M/56 Penetrating injury with corneal Hand movements Wound closure; PPV 3 d later 10 laceration, partial iris loss, and loss of (pronounced corneal scar) lens, vitreous, and choroid Abbreviations: CME, cystoid macular edema; IOL, intraocular lens; PPV, pars plana vitrectomy; VA, visual acuity. A B C D Figure 1. First stage of implantation with iris prosthesis and intraocular lens (IOL). A, Two small stab incisions using a 0.9-mm microsurgical blade are created about 1 mm apart, passing through the back of the customized iris prosthesis (2 incisions at the 0° position and 2 at the 180° position). B, The haptics of a 3-piece IOL are docked inside the tip of a 28-gauge hollow needle and pulled through the small previously created tunnel in the iris prosthesis. C, Because of the high elasticity and stability of the iris prosthesis, the haptics are tightly attached to the back of the artificial iris. D, The haptics are slightly bent by using a needle holder to decrease the maximum diameter of the combined implant. Intraoperative video frames of this technique are found in the eFigure. tional secondary procedures (eg, pars haptics of the IOL extended over the edges Usingapush-pullhook,the2sutureswere plana vitrectomy for internal reconstruc- of the prosthesis. Thus, the haptics were pulled out through the superior tunnel tion) a few days later if needed. The pa- slightly bent with the use of a needle (Figure 2). The sutures were cut, and tient characteristics are given in Table 1. holder to decrease the maximum diam- we ensured throughout the next steps that Patient 1 required pars plana vitrectomy eter of the combined implant (Figure 1C the resulting 4 free ends were attached with silicone oil filling. The patient sub- and D) (intraoperative video frames are to the corresponding quadrant of the iris sequently developed secondary glau- found in the eFigure, http://www prosthesis. The free suture ends were coma that required silicone oil removal. .archophthalmol.com). pulled through the iris prosthesis along The conjunctiva was opened circum- a loop that was created with an additional SURGICAL TECHNIQUE ferentially at the limbus, and an infusion polypropylene suture. Thereafter, the su- cannula was positioned in the pars plana tures could be firmly tied to the iris Iris prostheses custom tailored to the color inthetemporalinferiorquadrant.Remain- prosthesis–IOLimplant.Theimplantthen of the patients’ fellow iris were obtained ing anterior vitreous was removed by vi- was partially folded using IOL implan- (Dr Schmidt Intraocularlinsen GmbH). trectomy when necessary. A superior cor- tation forceps and introduced through the On 2 pair of opposite sides, 2 small stab neoscleral tunnel approximately 5 mm tunnel incision (Figure 3). incisions using a 0.9-mm microsurgical in length was created. For correct suture The prosthesis was centered and fix- blade were created about 1 mm apart and placement (each 90° apart), we used a ated to the sclera using a Z-suture tech- passing through the back of the custom- radial marker for keratoplasty. Corre- nique with 5 passes for external fixa- ized iris prosthesis (2 incisions at the 0° sponding marks were made on the iris tion of a transscleral polypropylene 20 and 2 at the 180° positions). The haptics prosthesis. Two scleral needles with a suture as reported previously. Fi- of a 3-piece IOL (Tecnis ZA9003, Ab- double-armed 10-0 polypropylene suture nally, the sutures were simply cut at the bott Medical Optics) were docked inside (Prolene; Ethicon, Inc) were passed level of the sclera and left without any the tip of a 28-gauge hollow needle and obliquely through the sclera approxi- knot (Figure 4). pulled through the small previously cre- mately 1.2 mm posterior to the limbus ated tunnel in the iris prosthesis from the outside inward in an ab externo RESULTS (Figure 1A and B). Owing to the high technique and docked inside the tip of a elasticity and stability of the iris prosthe- 28-gauge hollow needle that had been sis, the haptics were tightly attached to the passed through the ciliary sulcus on the In all patients, the combined im- back of the artificial iris. However, the opposite side as described previously.18,19 plant stayed firmly fixed within the ARCH OPHTHALMOL / VOL 130 (NO. 6), JUNE 2012 WWW.ARCHOPHTHALMOL.COM 772 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 A B C D Figure 2. Suturing technique for placement of the iris prosthesis. A, Two scleral needles with a double-armed 10-0 polypropylene suture are passed obliquely through the sclera approximately 1.2 mm posterior to the limbus from the outside inward in an ab externo technique. B and C, The sutures are docked inside the tip of a 28-gauge hollow needle, which has been passed through the ciliary sulcus on the opposite side. D, Using a push-pull hook, the 2 sutures are pulled out through the superior tunnel. A B C D E F Figure 3. Securing the ends of the sutures. A, The sutures are cut. B, The resulting 4 free ends are attached to the corresponding quadrant of the iris prosthesis. C and D, The free suture ends are pulled through the iris prosthesis along a loop that has been created with an additional polypropylene suture. E, Thereafter, the sutures can be firmly tied to the combined iris prosthesis–intraocular lens implant.