Eye (2005) 19, 205–209 & 2005 Nature Publishing Group All rights reserved 0950-222X/05 $30.00 www.nature.com/eye 1 2 1 2 Surgical I Mavrikakis , E Mavrikakis , PP Syam , J Bell , CLINICAL STUDY J Hickman Casey3, AG Casswell1, GP Brittain1 and management of iris C Liu1 defects with prosthetic iris devices Abstract findings that contribute to reduced visual acuity are corneal pannus and epitheliopathy, Purpose To evaluate the safety and efficacy of glaucoma, foveal and optic nerve hypoplasia, surgical implantation of prosthetic iris devices cataract, and nystagmus.1 Traumatic iris in patients with iris deficiency. deficiency is often accompanied with corneal Methods Nine patients with traumatic iris scarring, cataract, and secondary glaucoma. defects, congenital aniridia or iris coloboma, Symptoms of iris deficiency range from and surgical or optical iridectomies were decreased visual acuity and poor cosmetic included in a noncomparative case series. appearance to glare, and photophobia. Various Cataract surgery with intraocular lens and methods have been used to overcome the prosthetic iris implantation was performed in disabling effects of iris deficiency, including 10 eyes. The visual acuity, subjective degree of 2,3 eyelid surgery, coloured contact lenses, 1 glare disability, postoperative anatomic Sussex Eye Hospital corneal tattooing,4,5 and implantation of results, and intraoperative and postoperative Brighton and Sussex artificial irides.6–14 University Hospitals complications were evaluated. In 1994, Sundmacher and coauthors were the Brighton, UK Results The mean follow-up was 17.75 first to report the use of a black iris-diaphragm months (range 4–48 months). Best-corrected 2Eye Unit, Pembury Hospital posterior chamber intraocular lens (IOL) to visual acuity improved in nine of 10 eyes Royal Tunbridge Wells, UK correct congenital and traumatic aniridia.6–8 (90%) and remained unchanged in one eye. These prosthetic implants have evolved over the 3 Glare subjectively improved in four of five Department of last decade. The purpose of the study was to eyes (80%) of patients complaining of glare Ophthalmology evaluate the safety and efficacy of surgical Eastbourne District General preoperatively. All eyes achieved the desired implantation of prosthetic iris devices in Hospital, Eastbourne, UK anatomic result. Intraoperative complications patients with iris deficiency. included one anterior capsular tear. Correspondence: C Liu Postoperative complications included a short Sussex Eye Hospital period of mild postoperative anterior uveitis Materials and methods Eastern Road in four eyes. Secondary glaucoma was absent. Brighton BN2 5BF, UK Tel: þ 44 1273 606126 Conclusion In patients with iris deficiency, This was a retrospective noncomparative case series from 1998 to 2002. It includes nine Fax: þ 44 1273 693674 implantation of prosthetic iris device, and E-mail: CSCLiu@ intraocular lens implant following cataract consecutive patients (10 eyes) with iris aol.com surgery appears to be safe and effective in deficiency, who were treated at the Sussex Eye reducing glare disability and improving visual Hospital, Brighton and Sussex University Received: 4 August 2003 outcomes. Hospitals, Brighton, the Eye Unit, Pembury Accepted: 29 December 2003 Eye (2005) 19, 205–209. doi:10.1038/sj.eye.6701448 Hospital, Royal Tunbridge Wells, and the Department of Ophthalmology, Eastbourne Published online: 25 June Published online 25 June 2004 2004 District General Hospital, Eastbourne, UK. Keywords: aniridia; coloboma; cataract;glare Of the nine patients who have been studied, The authors have no six are male and three are female. The age range proprietary interest in this varied between 31 and 80 years with a mean age study. There was no of 53.8 years. Four of the iris deficiencies were financial support. Presented Introduction in part at the annual traumatic (three total and one sectorial iris loss), meeting of the Royal Iris deficiency can be congenital or traumatic. four were iatrogenic [three optical iridectomies College of Ophthalmologists The congenital iris deficiency-associated (previous treatment for congenital cataract), and Birmingham, May 2003. Prosthetic iris devices in cataract surgery I Mavrikakis et al 206 one surgical iridectomy to remove a malignant This was in the patient with congenital aniridia, whose melanoma of the iris], and two were congenital (one visual potential was limited by nystagmus. Glare aniridia and one coloboma). subjectively improved in four of five eyes (80%) of Inclusion criterion was any patient with partial or total patients complaining of glare preoperatively. In the iris deficiency, and exclusion criterion was postoperative remaining eye the degree of glare disability was the same follow-up of less than 4 months. pre- and postoperatively. No glare was reported before or Preoperative ophthalmologic assessment included after surgery in three eyes, and two patients did not Snellen best-corrected visual acuity, slit-lamp return their completed questionnaire. biomicroscopy, intraocular pressure measurement using Intraoperative complications included one anterior Goldmann applanation tonometry, gonioscopy, and capsular tear, during implantation of a 50C ring. fundoscopy following pupillary dilation when feasible. Postoperative complications included a short period of Each eye underwent cataract surgery (eight phaco, one mild postoperative anterior uveitis in four eyes. ECCE) with IOL and prosthetic iris device implantation. Secondary glaucoma was absent in all cases. Eight of 10 The visual acuity, subjective degree of glare disability, prosthetic iris devices remained well centred throughout postoperative anatomic results and intraoperative and the follow-up period. In one eye the 96G implant postoperative complications were evaluated (Table 1). migrated centrally secondary to capsular contraction In particular, the subjective degree of glare disability (Figure 4). In the eye with the anterior capsular tear, the was evaluated pre- and postoperatively with the use of a 50C rings migrated in the sulcus, and misaligning of the questionnaire that graded glare as follows: no glare, mild ring implants also occurred (Figure 5). glare, moderate glare, and severe glare. Posterior capsular opacification occurred in one eye The prosthetic iris devices used in this study are the with congenital aniridia, cataract, and posterior Morcher aniridia IOL Types 67F and 67G, the aniridia lenticonus 4.5 months postoperatively, requiring YAG ring Type 50C, and the coloboma diaphragm Type 96G laser capsulotomy. (Figure 1). Types 67F and 67G are biconvex poly(methyl methacrylate) (PMMA) IOLs with an overall (haptic) Discussion diameter of 13.5 and 12.5 mm respectively, and a diaphragm diameter of 10 mm. The periphery of the In the current literature,6–14 the most commonly used diaphragm is treated with a black co-polymer leaving a prosthetic iris devices are the ones used in our study. central 5.0 mm transparent. Namely, the Morcher aniridia IOL Types 67F and 67G, the Type 50C has an overall diameter of 10.75 mm and two aniridia ring Type 50C, and the coloboma diaphragm of these rings have to be implanted and turned against Type 96G. each other in order to produce a full iris diaphragm. Type Types 67F and 67G are used in traumatic or congenital 96G has an overall diameter of 11.0 mm. Types 67G and aniridia either in the ciliary sulcus, if there is adequate 67F have been designed to be inserted through a corneal capsular support, or trans-sclerally sutured in the incision of at least 11 mm, while Types 50C and 96G are absence of capsular support.6–13 We were the first to inserted through a small incision. report implantation of a Morcher 67G aniridia IOL within the capsular bag.14 Type 50C is also designed for endocapsular implantation in cases of traumatic or Results congenital aniridia.11,13 For a total reconstruction of the The mean follow-up was 17. 75 months (range 4–48 missing iris, two rings have to be implanted and turned months). Nine eyes underwent phacoemulsification and against each other to form a complete ring, and then an one extracapsular cataract extraction. In six eyes a 96G additional foldable lens is inserted. Type 96G is used in implant was inserted (Figure 2). Insertion of an the capsular bag in cases of sector iris defects up to additional capsular tension ring was performed in one of 901.11,13 Iris defects between 901 and 1801 could be the above eyes. Two 50C implants were used in two eyes. managed by inserting two such devices. Both the 96G and 50C implants were inserted into the Advantages of endocapsular over sulcus or trans- capsular bag through a small incision. The incision was sclerally sutured aniridia IOLs may include reduction in enlarged to accommodate endocapsular implantation of the incidence of glaucoma and improvement of the a 67G IOL in one eye (Figure 3). A 67F IOL was stability of the device, provided the capsular bag is introduced in the ciliary sulcus in the patient that intact.14 The main disadvantage of the use of a single- underwent extracapsular cataract extraction. piece iris black diaphragm and optical lens is the Best-corrected visual acuity improved in nine of 10 requirement for large incision of at least 10 mm. eyes (90%), with an average of three lines on the Snellen Moreover, they are brittle, like all blackened PMMA chart. In one eye the visual acuity remained unchanged. devices. Alternatively two capsular tension rings with Eye Table 1 Summary of diagnoses, surgery, results, and complications.