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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 680-681

An unusual complication of retropupillary iris claw intraocular lens fixation


Department of Glaucoma Services, Sankara Eye Hospital, Bengaluru, Karnataka, India

Date of Submission12-Dec-2021
Date of Acceptance23-Mar-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Roshan G Colaco
Sankara Eye Hospital, Varthur Main Road, Kundanahalli Gate, Bengaluru- 560037, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3089_21

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  Abstract 


A patient with well enclaved retropupillary iris-claw intraocular lens (IOL) presented 3 months later with spontaneous diminishing of vision to counting fingers at 3 m. On slit-lamp examination, the cornea was clear, the anterior chamber was normal in depth and the IOL was found to have rotated by 90° and was now vertical, perpendicular to the iris and pupillary plane, and the superior site of enclavation was kinked. The edge of the IOL optic was seen protruding out of the pupil; however, not touching the cornea and a fibrosed posterior capsule was noted nasally. The patient was taken for anterior vitrectomy with repositioning of the IOL. The lever effect of the remnant posterior capsule can be the cause of the tilt.

Keywords: Anterior–posterior tilt, anterior vitrectomy, remnant fibrosed capsule, retropupillary iris-claw lens


How to cite this article:
Colaco RG, Menon MG, Sajjan S. An unusual complication of retropupillary iris claw intraocular lens fixation. Indian J Ophthalmol Case Rep 2022;2:680-1

How to cite this URL:
Colaco RG, Menon MG, Sajjan S. An unusual complication of retropupillary iris claw intraocular lens fixation. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 19];2:680-1. Available from: https://www.ijoreports.in/text.asp?2022/2/3/680/351174



There is no ideal way to correct aphakia without capsular support. Various options include anterior chamber lenses, iris- or scleral-sutured lenses, and iris-claw lenses. The iris-claw lens method was invented by Worst in 1980 and the design was an anterior chamber iris-claw lens.[1] The technique of posterior fixation of iris-claw lenses was proposed by Amar[2] and later modified by Mohr et al.[3] to prevent the decrease in the endothelial cell density associated with the anterior chamber iris-claw lens.[4] Iris-claw lens implantation is not only easier and less time-consuming compared to scleral fixated lenses but also safe with fewer complications.[5] Iris-claw lens presents with unique complications such as temporary ovalization of the pupil in the initial postoperative period and disenclavation in the early and late postoperative periods. In this case report, we describe a rare late postoperative decentration and rotation of the retropupillary iris-claw lens.


  Case Report Top


A 68-year-old male patient presented to our hospital with left eye visual acuity of counting fingers at 3 m. On examination, there was a mature brown cataract with no phacodonesis. There was no previous history of trauma and no other pre-existing cause for weak zonules.

The patient was posted for small incision cataract surgery with IOL implantation. Cataract surgery was performed through the sclerocorneal tunnel. During nucleus delivery, a very large posterior capsular rupture with vitreous loss was noted extending inferiorly. Automated anterior vitrectomy was done, and because there was insufficient capsular support, a retropupillary rigid iris-claw IOL was implanted with enclavation at 12 o'clock and 6 o'clock positions. Postoperative examination on the following day showed a few striate keratopathy with a quiet anterior chamber and a well-enclaved iris-claw lens. The patient improved with postoperative topical medication with a best-corrected visual acuity (BCVA) of 6/12.

Three months later, the patient reported to us with a sudden diminution of vision for the past 7 days, with no history of trauma. There was no notable triggering event that he could recollect preceding the decrease in vision. His visual acuity was counting fingers close to face with no improvement. Slit-lamp examination showed a few Descemet folds, the anterior chamber was irregular in depth with no signs of iritis or hyphema. The iris-claw lens was found to have rotated by 90° and was now vertical, perpendicular to the iris and pupillary plane, and the superior site of enclavation was kinked. The edge of the IOL optic was seen protruding out of the pupil but not touching the cornea and fibrosed remnant posterior capsule was noted nasally [Figure 1]. The intraocular pressure was 30 mmHg as noted on Tonopen.
Figure 1: Anterior–posterior tilting of the iris-claw lens

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The patient was started on anti-glaucoma medications and was planned for repositioning of the iris-claw lens with anterior vitrectomy. There was no vitreous in the anterior chamber and when the fibrosed remnant capsule was cut using a vitrectomy cutter the intraocular lens moved back to its original position with minimal tapping of the lens. There was no evident disenclavation or damage to the haptics as well. He was prescribed a tapering dose of antibiotic steroid topical drops and hypertonic saline.

He was examined a week after the surgery, which revealed a well-positioned iris-claw lens with few striate keratopathy [Figure 2]. The intraocular pressure was 19 mmHg. Postoperative medications were continued along with topical anti-glaucoma medications. At the last follow-up 2 months after the procedure, his final BVCA was 6/12 with well-controlled intraocular pressure.
Figure 2: Postoperative stable iris-claw lens

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  Discussion Top


Retropupillary iris-claw lens implantation is considered a safe and effective method of visual rehabilitation in patients without capsule support. This surgical procedure has the advantages of posterior chamber implantation with a low intraoperative and postoperative risk profile. Disenclavation of the haptics is a known complication of the retropupillary iris-claw lens. Two retrospective studies, where an average of 5 years of the follow-up period was taken, showed a disenclavation occurrence rate of 1.3% and 2.0%, respectively.[6],[7] Causes for disenclavation can be insufficient primary enclavation, as well as trauma.[8] The atrophy of the iris at sites of enclavation has been reported in up to 24% of retropupillary iris-claw implantations, which can also cause disenclavation. Kim et al. identified 22 dislocations in 225 cases of retropupillary iris-claw implantation (9.8%) after an average of 90 days postoperatively.[8] Other complications include dislocation of the iris-claw lens in the vitreous, pupillary distortions, cystoid macular edema, and endothelial cell loss.

Tilting of the iris-claw IOL, as in this case, has only been reported only once to the best of our knowledge.[9] It was an early postoperative complication presenting within 3 weeks of the surgery and it was assumed that the vitreous pushing from behind resulted in the tilting. The main reason we attribute this tilt is to the lever effect of the remnant posterior capsule. There was fibrosis at the edge of the posterior capsule, which pushed one side of the iris-claw lens anteriorly resulting in the tilting in the anterior–posterior direction. This along with the kinking of the iris at the enclavation site would have resulted in the IOL staying in the position perpendicular to the plane of the pupil and it only assumed its original position when the lever effect was removed following the cutting of the fibrosed edge posterior capsule. Forlini et al.[6] in his study has advocated that any capsular remnants should be removed before IOL implantation due to the risk of IOL instability from postoperative capsule fibrosis.


  Conclusion Top


We report this case to educate upon a very rare late complication of retropupillary iris-claw lens. Adequate anterior vitrectomy, complete removal of the posterior capsule remnant will go a long way in preventing this rare tilting of the retropupillary iris-claw lens.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Worst JG. Indomethacin and CME. J Am Intraocul Implant Soc 1980;6:51-2.  Back to cited text no. 1
    
2.
Amar L. Posterior chamber iris claw lens. J Am Intraocul Implant Soc J 1980;6:279.  Back to cited text no. 2
    
3.
Mohr A, Hengerer F, Eckardt C. Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation techniques. Ophthalmologe 2002;99:580-3.  Back to cited text no. 3
    
4.
Koss MJ, Kohnen T. Intraocular architecture of secondary implanted anterior chamber iris-claw lenses in aphakic eyes evaluated with anterior segment optical coherence tomography. Br J Ophthalmol 2009;93:1301-6.  Back to cited text no. 4
    
5.
Jing W, Guanlu L, Qianyin Z, Shuyi L, Fengying H, Jian L, et al. Iris-claw intraocular lens and scleral-fixated posterior chamber intraocular lens implantations in correcting aphakia: Ameta-analysis. InvestOphthalmolVis Sci 2017;58:3530-6.  Back to cited text no. 5
    
6.
Forlini M, Soliman W, Bratu A, Rossini P, Cavallini GM, Forlini C. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: A retrospective analysis cataract and refractive surgery.BMC Ophthalmol 2015;15:143.  Back to cited text no. 6
    
7.
Toro MD, Longo A, Avitabile T, Nowomiejska K, Gagliano C, Tripodi S, et al. Five-year follow-up of secondary iris-claw intraocular lens implantation for the treatment of aphakia: Anterior chamber versus retropupillary implantation. PLoS One 2019;14e0214140.  Back to cited text no. 7
    
8.
Kim MS, Park SJ, Joo K, Kang HG, Kim M, Woo SJ. Single-haptic dislocation of retropupillary iris-claw intraocular lens: Outcomes of reenclavation. Ophthalmic Surg Lasers Imaging Retina 2020;51:384-90.  Back to cited text no. 8
    
9.
Chandrashekharan S, Sabnis SV, Rengappa R. Postoperative tilting of a well-enclaved retropupillary iris claw intraocular lens: A rare complication. TNOA J Ophthalmic Sci Res 2020;58:40.  Back to cited text no. 9
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