Iris Repair after Long-Term Complications of Angle-Supported Phakic Intraocular Lenses

doi:10.4236/ojoph.2012.22010

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Open Journal of Ophthalmology, 2012, 2, 40-43

http://dx.doi.org/10.4236/ojoph.2012.22010 Published Online May 2012 (http://www.SciRP.org/journal/ojoph)

Iris Repair after Long-Term Complications of

Angle-Supported Phakic Intraocular Lenses

Camille Budo

Ophthalmology Polyclinic Sint-Truiden, Sint-Truiden, Belgium.

Email: camille[email protected]

Received January 17th, 2012; revised February 20th, 2012; accepted March 9th, 2012

ABSTRACT

We report the case of a high myopic patient who had been implanted with angle-supported phakic intraocular lenses

(pIOL) in 1990 and who subsequently and gradually developed complications in both eyes including endothelial cell

loss, chronic glaucoma, cataract, pupil ovalization and severe iris atrophy. The patient was impaired by photophobia,

glare, halo, loss in visual acuity and concerned about the cosmetically deforming aspect of her eyes. Cataract surgery

was performed after explantation of the pIOL followed by combined implantation of a standard IOL in the capsular bag

and a Dr. Schmidt artificial iris in the sulcus. There were no intraoperative and postoperative complications except slight

bilateral corneal oedema which resolved completely within 1 month after surgery. Uncorrected and corrected visual

acuity improved progressively to reach 0.3 and 0.6 at the last follow-up visit (±1 year), respectively. The patient was

very satisfied with the functional and aesthetical outcomes.

Keywords: Artificial Iris; Prosthetic Iris; Angle-Supported Phakic Intraocular Lens

1. Introduction

Patients with iris defects, either from congenital, trau-

matic or other causes, are often significantly incapaci-

tated by varying amounts of visual disability including

photophobia, glare, reduced visual acuity, loss of contrast

sensitivity and depth of focus. In addition, patients, par-

ticularly those with large iris damages, are likely to ex-

perience substantial psychological distress from the un-

aesthetic appearance of their eyes. In many cases, a sur-

gical intervention is the only treatment option to address

the functional problems caused by iris damage. Simple

suture repair to create a new pupillary aperture is usually

the preferred approach when the quality and amount of

the remaining iris tissue is sufficient to ensure a success-

ful outcome. However, in more complex cases, an iris

prosthesis is necessary.

Iris implants have been available since 1991 and many

studies have shown their efficacy to resolve the visual

symptoms associated with iris defects [1-6]. However,

most implant models have substantial limitations; in par-

ticular most require large incisions for implantation and

do not restore the original appearance of the iris. In the

past few years, though, valuable progress has been made

in this field with the introduction on the European market

of an iris prosthesis manufactured by Dr. Schmidt In-

traoculalinsen GmbH/HumanOptics AG (Germany) which

offers some features not available in the other models.

This device is a foldable prosthesis that can be inserted in

the sulcus through a small incision (≤3.2 mm) and cus-

tom-made for each patient to match the patient’s natural

iris colour.

We report the functional and aesthetic outcomes in a

patient who had a Dr. Schmidt iris prosthesis implantation

in both eyes to repair an extensive iris atrophy following

angle-supported phakic IOL (pIOL) implantation. Iris

reconstruction was combined with pIOL explantation,

cataract removal with capsular bag IOL implantation.

2. Case Report

A 35 year-old woman presented to the University Clinic

of Maastricht in August 2002 complaining of decrease in

visual acuity, photophobia and disturbing glare and halo.

The patient had a history of high myopia in both eyes

which was treated with anterior chamber angle-supported

pIOL in 1990 (Morcher type 54; power pIOLs-22 D). A

review of her medical records indicated an uncorrected

distance visual acuity (UDVA) following treatment of

0.7 (20/29) in the right eye and 0.8 (20/25) in the left eye.

Eight years later (1998), the patient had gradually

developed chronic glaucoma associated with iris defor-

mation in both eyes. Her glaucoma was controlled with

topical β-blockers i.e. Timolol (Timoptol, MSD, Belgium)

and Travoprost (Travatan, Alcon, Belgium).

At her first visit to the clinic in 2002, a slit lamp ex-

Iris Repair after Long-Term Complications of Angle-Supported Phakic Intraocular Lenses 41

amination revealed pupil ovalization and iris atrophy.

The UDVA had decreased to 0.6 (20/40) in the right eye

(–4.75 - 0.75 × 72˚) and to 0.2 (20/100) in the left eye

(–4.00 - 2.00 × 156˚). Endothelial cell density was about

1100 cells/mm2 in the right eye and 2300 cells/mm2 in

the left eye. Intraocular pressure (IOP) was 18 mmHg in

the right eye and 22 mmHg in the left eye. Two further

examinations took place until January 2003. Although

the patient was informed of her serious condition, she

didn’t consult again until August 2009 when she com-

plained of worsening visual symptoms and further iris

deformation (see Figure 1(A)). Upon examination, UDVA

was 0.5 (20/40) in her right eye and 0.3 (20/70) in her

left eye. Endothelial cell density had remained approxi-

mately the same in the right eye (1008 cells/mm2) but

had significantly decreased in her left eye (1662 cells/

mm2). There was evidence of nuclear cataract and in-

crease of IOP in both eyes (OD: 23 mmHg; OS: 27

mmHg). Together we decided upon explantation of the

pIOL followed by simultaneous phacoemulsification,

capsular bag IOL implantation and iris reconstruction in

both eyes. In this case, due to the extent of iris damage

and poor quality of the remaining tissue, simple suturing

was not an option and we opted for an artificial iris im-

plant from Dr. Schmidt Intraocularlinsen. This foldable

prosthesis is made of a pigmented, biocompatible sili-

cone elastomer with a diameter of 12.80 mm and a fixed

pupillary aperture of 3.35 mm. It is available in two ver-

sions; one containing a polymer fiber meshwork that

allows the device to be sutured, and one without the

meshwork for sutureless fixation. Both versions can be

folded and implanted into the ciliary sulcus through a

mini incision. The device is custom-made with hand-

crafted adjustment of the colour to mimic patient’s origi-

nal iris colour. For this patient, two customized fibre-free

artificial iris were manufactured based on a photograph

of the patient’s residual iris. The sulcus size was esti-

mated by measuring the limbus size (white to white di-

ameter) and by adding 0.5 mm. Surgery was scheduled

for her left eye in March 2010. The second surgery took

place in September 2010.

Surgeries were performed under general anaesthesia.

The surgery procedure consisted of explantation of the

pIOL via a limbal incision of approximately 6.5 mm,

followed by phacoemulsification, irrigation/aspiration

and implantation of an AcrySof MN60MA IOL (OS:-4D;

OD:-5D) in the capsular bag (Alcon, Belgium). Calcula-

tion of the IOL power was performed using the standard

SRK-T formula, and preoperative axial length and kera-

tometry were performed using ultrasound. In the final

surgical step, the iris prosthesis was inserted into the an-

terior chamber with a folding forceps through the same

incision as that used for the pIOL explantation and the

standard IOL implantation and then positioned under the

natural iris remnants into the sulcus. The corneal wound

was then sutured with 9-0 nylon sutures, which were

removed 6 weeks after the surgery. There were no intra-

operative complications. The patient was followed-up

very closely during the first month and then approxi-

mately on a monthly basis thereafter. Follow-up was 14

months for the left eye and 10 months for the right eye.

Two weeks after the surgery, CDVA was 0.3 in the

left eye (+1.50 - 6.50 × 163˚) and 0.45 in the right eye

(–1.50 - 3.00 × 10˚). The iris prostheses were well posi-

tioned and covered the entire iris defect. There was no

rise in IOP and values were within normal range (OD: 21

mmHg; OS: 20 mmHg). Endothelial cell density was

1446 cells/mm2 in the left eye and 584 cells/mm2 in the

right eye and no corneal decompensation occurred. There

were no postoperative complications except a small cor-

neal oedema in both eyes which had resolved within a

month post-surgery. At the 6-month follow-up visit,

CDVA had improved to 0.6 (20/33) in the left eye (–1.00

- 1.00 × 12˚) and had remained at 0.45 in the right eye

(–2.50 - 2.75 × 17˚). At the 10-month visit, an IOP spike

occurred in the left eye (33 mmHg) requiring an increase

in antiglaucoma medications i.e. Acetazolamide (Diamox,

Goldshield Pharmaceuticals Ltd, UK), Dorzolamide/

Timolol (Cosopt, MSD, Belgium), Latanoprost (Xalatan,

Pfizer, Belgium) and Brinzolamide/Timolol (Azarga,

Alcon, Belgium). At the most recent follow-up visit

(June 2011), the CDVA had improved to 0.6 (20/33) in

the right eye and had remained stable in the left eye (0.6).

IOP was normal in both eyes (OS: 17 mmHg; OD: 14

mmHg). The patient was delighted with the results. Her

visual symptoms had resolved and she was very satisfied

with the cosmetic appearance of her eyes (see Figure

1(B), Figur e 2 ).

3. Discussion

In the 1990s, there have been an increasing number of

reports of short and long-term complications associated

with angle-supported anterior chamber pIOLs including

Figure 1. (A) Pupil ovalization (orange arrow) and large iris

defect (red arrow) in the patient’s left eye following im-

plantation with an angle-supported phakic IOL (Morcher

type 54); (B) The left eye two months postoperatively. The

Dr. Schmidt Artificial iris has created a round pseudopupil

(white arrow).

Iris Repair after Long-Term Complications of Angle-Supported Phakic Intraocular Lenses

Figure 2. Appearance of the right and left eyes one year

postoperatively. The Dr. Schmidt Artificial iris was posi-

tioned into the sulcus under the natural iris remnants (ar-

rows). Note the excellent cosmetic match between the pros-

thesis and the color of the patient’s native iris.

corneal endothelial cells loss, pupil ovalization, iris at-

rophy, glaucoma, and chronic anterior uveitis [7]. If to-

day most early designs have been abandoned, surgeons

still are facing late implant-related complications as re-

ported here with the myopic Morcher type 54 pIOL. The

patient was impaired by photophobia, glare, halo and loss

in visual acuity and was seriously distressed due to the

cosmetically deforming aspect of her eyes. The man-

agement of this case was challenging due to the poor

preoperative status of the corneal endothelium that would

be further affected by another surgery, the presence of

glaucoma and cataract, and also because the iris defect

was so severe that implantation of an iris prosthesis was

necessary. Furthermore, besides all the functional aspects,

aesthetic issues had to be considered. Thus, we selected

the Dr. Schmidt iris prosthesis that could address both

aspects. Our patient was managed by explantation of the

pIOL combined with cataract extraction and simultane-

ous implantation of a standard IOL in the bag and an

artificial iris in the sulcus.

One of the most attractive aspects of the Dr. Schmidt

artificial iris is its flexibility and foldability that allow

insertion through a sutureless small incision, thus mini-

mizing potential surgically induced astigmatism. In our

case though, because a large incision was required for the

pIOL explantation, we used the same incision for im-

plantation of the prosthesis and the standard IOL. The

surgery was uneventful and no serious complications

such as irritation, inflammation and corneal decompen-

sation occurred during the one year postoperative period.

In spite of the patient’s preoperative advanced glaucoma,

only one eye required an increase in antiglaucoma medi-

cations 10-month postoperatively. At the last visit, there

was no significant change in the manifest cylinder and

both eyes had reached UDVA of 0.3 and CDVA of 0.6; a

very satisfactory outcome considering the patient pre-

existing ocular comorbidity. The patient also reported a

significant improvement in the quality of vision due to

the disappearance of photic disturbances.

The primary function of iris prostheses is to minimize

visual disturbances by providing an artificial pupil which

limits the amount of light entering the eye, to promote

depth of focus and to limit spherical and chromatic aber-

rations associated with large pupil sizes. The Dr. Schmidt

artificial iris was designed with a small fixed aperture of

3.35 mm, thereby reducing maximally the symptoms of

glare and daytime photophobia. We have also found the

size to be adequate for examination of the peripheral ret-

ina. In addition to significant visual disabilities, patients

with iris defects usually suffer of psychological and so-

cial disabilities because of the disfigured appearance of

their eyes. Besides its functional role, the Dr. Schmidt

artificial iris offers the advantage of reproducing a pa-

tient’s original iris appearance due to the flexibility of its

silicone material and colour customization. Our patient

was very pleased in the cosmetic appearance of her eyes

and has returned to a normal social life.

In summary, despite our patient pre-existing ocular

comorbidity, implantation of a Dr. Schmidt artificial iris

proved to be a safe and effective method to improve vis-

ual quality and quality of life. This device represents a

significant aesthetic improvement over other artificial iris

devices that are currently available on the market.

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