surgical correction of aphakia
TRANSCRIPT
![Page 1: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/1.jpg)
Surgical Correction of AphakiaDr. Howard V. Gimbel MD MPH
Professor and ChairDept. of OphthalmologyLoma Linda University
Loma Linda, CA
Medical DirectorGimbel Eye Centre
Calgary, AB
Fall 2008 Optometry SymposiumLoma Linda University
Department of Ophthalmology
![Page 2: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/2.jpg)
I have no financial interests
![Page 3: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/3.jpg)
Surgical Correction of AphakiaOutline:I Background and history of IOLsII Correction of Aphakia in eyes with no capsular supportIII Correction of Aphakia in eyes with partial capsular support
![Page 4: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/4.jpg)
Surgical Correction of Aphakia
I. Brief History of Cataract Surgery and IOLs1949-70s early pioneers
• Harold Ridley (UK)• Edward Epstein (South Africa) • Warren Reese (USA)• Peter Choyce (UK)• Cornelius Binkhorst (Holland) • Jan Worst (Holland) • Benedetto Strampelli (Italy) • Joachin Barraquer (Spain)• Svystoslav Fydorov (Soviet Union)
![Page 5: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/5.jpg)
Surgical Correction of Aphakia
Early adapters of IOLs in Cataract Surgery
1980s
many more innovators and lens designs
![Page 6: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/6.jpg)
The Earliest IOLs
• Were used used with intra-capsular surgery leaving no capsular support
• Using angle support
• Or iris support
![Page 7: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/7.jpg)
Second Generation IOLs
• Were designed for extra-capsular surgery
• First using a combination of iris and capsular support
• Or only iris support
• Then only capsule support
![Page 8: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/8.jpg)
Two Loop Irido-capsular IOL
![Page 9: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/9.jpg)
IOL Loop Sutured to Iris
Suture
![Page 10: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/10.jpg)
IOL Loop Sutured to Capsule
Suture to capsule
![Page 11: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/11.jpg)
Belt and suspenders fixation
Upper loop also stitched to the capsuleLower loop between capsules
![Page 12: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/12.jpg)
Surgical Correction of Aphakia
Part II Correction of Aphakia in eyes with no capsular support
![Page 13: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/13.jpg)
Intra-capsular Cataract Extraction
Lens removed in one piece, including the lens capsule
Surgical Correction of Aphakia
![Page 14: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/14.jpg)
Surgical Options Options for correction of Aphakia in eyes
with no capsular support
• Epikeratophakia
• Iris supported IOLs
• Angle supported IOLs
• Scleral supported IOLs
• Capsule supported IOLs
![Page 15: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/15.jpg)
Surgical Correction of Aphakia
Epikeratophakia• Used as a surgical option by some for the correction of pediatric aphakia secondary to removal of congenital cataract• Greenbaum A, Kaiserman I, Avni I. Cornea. 2007 Dec;26(10):1210-2. Long-term
reversibility of epikeratophakia.
Instrument
Graft
![Page 16: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/16.jpg)
Surgical Correction of Aphakia
Graft
![Page 17: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/17.jpg)
Surgical Correction of Aphakia
Iris Claw Fixated IOL• Artisan Phakic IOL (Verisyse IOL, AMO, Netherlands)
Condon GP, Masket S, Kranemann C, et al. Small-incision iris fixation of foldable intraocular lenses in the absence of capsule support. Ophthalmology 2007;114:1311-1318
Worst JG, Massaro RG, Ludwig HH. The introduction of an artificial lens into the eye using Binkhorst’s technique. Ophthalmologica 1972;164(5):387-391.
![Page 18: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/18.jpg)
Surgical Correction of Aphakia
![Page 19: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/19.jpg)
Surgical Correction of Aphakia
Iris Claw Fixated IOL•Artisan Phakic IOL (Verisyse IOL, AMO, Netherlands)
•The safety and efficacy of Artisan phakic IOL implants have been reported recently in several studies
Reported problem: disenclavation
Repositioning or re-enclavation has been successfull
• Guell JL, Velasco F, Malecaze F, et al. Secondary Artisan-Verysise aphakic lens implantation. J Cataract Refract Surg 2005;31:2266-2271
• Ioannidis A, Nartey I, Little BC: Traumatic dislocation and successful re-enclavation of an Artisan phakic IOL with analysis of the endothelium. J Refract Surg. 22(1):102-3, 2006
![Page 20: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/20.jpg)
Angle supported IOLs
Surgical Correction of Aphakia
Pre-op: specular microscopy Gonioscopy to rule out anterior synechia
![Page 21: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/21.jpg)
Surgical Correction of Aphakia
Gonioscopy at surgery to confirm loop placement
![Page 22: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/22.jpg)
Surgical Correction of Aphakia
![Page 23: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/23.jpg)
Iris-Sutured PC-IOL
Surgical Correction of Aphakia
![Page 24: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/24.jpg)
Scleral Supported IOLs
• PC IOLs sutured to the sclera through sulcus
• Widely used technique if there is no capsule or only sections of peripheral capsule
• No endothelial risk
• Low risk of iris chaffing
• Some risk of suture breaking
• Some risk of suture erosion
![Page 25: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/25.jpg)
Modified Haptics
![Page 26: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/26.jpg)
Scleral-Sutured PC-IOL
Surgical Correction of Aphakia
diagram
![Page 27: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/27.jpg)
2003 AAO Report: IOL Implantation in the Absence of Capsular Support
• Open-loop AC IOLs
• Scleral-sutured PC IOLs
• Iris-sutured PC IOLs
-all are safe and effective in correcting aphakia in eyes without capsular support
![Page 28: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/28.jpg)
2005 ASCRS-ESCRS Report:AC-IOL and Sutured PC-IOL in eyes with
poor capsular support
•Findings suggest no significant differences in outcome exist between AC-IOL and sutured PC-IOL in the absence of capsular support
KE Donaldson, JJ Gorscak, DL Budenz,WJ Feuer, MS Benz, RK Forster. JCRS 2005, 31:5,904-909.
![Page 29: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/29.jpg)
Surgical Correction of Aphakia
•Part III. Intraocular Lens Implantation when there is adequate Capsular Support
• Simple sulcus placement
• In the re-opened bag
• Optic Capture through opening in the membrane
• Capsule Membrane Suture to fix the IOL to the capsule
![Page 30: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/30.jpg)
Extra-capsular Cataract Extraction
Surgical Correction of Aphakia
Capsular Support
![Page 31: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/31.jpg)
Extra-capsular Cataract Extraction
Surgical Correction of Aphakia
Maintains a ciliary sulcus with zonular attachments to a fused anterior and posterior capsular for:
a) Simple sulcus IOL support
b) Optic capture by an opening in the membrane
c) Suture fixation to the membrane
![Page 32: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/32.jpg)
Transillumination defects
from mobile sulcus placed IOL
Simple Sulcus placement has its issues
![Page 33: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/33.jpg)
Surgical Correction of Aphakia
IOL stabilized by Optic Capture after Soemmering’s Ring emptied
![Page 34: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/34.jpg)
Surgical Correction of Aphakia
In-the-bag placement
• Possible especially when done soon after original surgery
Examples: primary surgery aborted due to high vitreous pressure and iris prolapse
• Late Soemmering’s ring evacuation and IOL placement in the newly opened peripheral bag
![Page 35: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/35.jpg)
Surgical Correction of Aphakia
![Page 36: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/36.jpg)
Surgical Correction of Aphakia
Capsule remnant used for fixation by using an existing or new opening in the central part of the capsule
MOC (pushing optic through the opening and leaving the haptics in front of the opening to grasp “capture” the lens)
Membrane Optic Capture (MOC)
![Page 37: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/37.jpg)
- Optic Capture by Capsular Membrane
- haptics in sulcus
IOL Optic Capture
Optic behind the Membrane
Surgical Correction of Aphakia
![Page 38: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/38.jpg)
Surgical Correction of AphakiaCapsule Membrane Suture (CMS)
Fixation of IOL
![Page 39: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/39.jpg)
Suturing of IOLs haptics to capsular membrane is used for capsule fixation when optic capture cannot be used
As in this case with extensive fibrosis of the capsular membrane.
Surgical Correction of Aphakia
![Page 40: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/40.jpg)
Insurance suture to capsule
Binkhorst two loop Irido-capsular IOL
IOL Sutured to the Capsuleis like “coming full circle”
Surgical Correction of Aphakia
![Page 41: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/41.jpg)
Gimbel HV et al. Capsular Membrane Suture Fixation of Sulcus IOLs. Clinical and Surgical Ophthalmology vol. 26:2, 2008, pp. 42-47.
Capsular Membrane Suture (CMS) Fixation
Surgical Correction of Aphakia
![Page 42: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/42.jpg)
Surgical Correction of Aphakia
![Page 43: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/43.jpg)
Summary• Many Options for correcting Aphakia:
• Epikeratophakia
• Angle supported IOLs
• Iris supported IOLs
• Scleral supported IOLs
• Capsule supported IOLs
![Page 44: Surgical Correction of Aphakia](https://reader030.vdocument.in/reader030/viewer/2022020203/587c7e591a28abd1378b474b/html5/thumbnails/44.jpg)
Summary• Choice of Option depends on anatomical situation and
age of the patient
• Epikeratophakia-used by some in pediatrics
• Angle supported IOLs low risk in elderly
• Iris supported IOL option may be considered
• Scleral supported IOLs very popular
• Capsule supported IOLs preferred whenever possible