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University Eye University Eye University Eye University Eye University Eye University Eye University Eye University Eye ClinicClinicClinicClinicClinicClinicClinicClinic

Paracelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University Salzburg

Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.--------Prof. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther Grabner

University Eye University Eye University Eye University Eye University Eye University Eye University Eye University Eye ClinicClinicClinicClinicClinicClinicClinicClinic

Paracelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University SalzburgParacelsus Medical University Salzburg

Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.Chairman: Prim. Univ.--------Prof. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther GrabnerProf. Dr. Günther Grabner

AphakiaAphakia

� Aphakia = absence of natural crystalline lens

� Western World: very uncommon

� Phako / ECCE with IOL-implantation

in the capsular bag

� Aphakia = absence of natural crystalline lens

� Western World: very uncommon

� Phako / ECCE with IOL-implantation

in the capsular bag

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� Reasons

� After complicated cataract surgery

� Post-traumatic dislocation of crystalline lens

� Capsular loss

� Ectopia lentis

� Marfan syndrome, Weill-Marhesani syndrome, hyperlysinaemia,

homocystinuria, sulfite oxidase deficiency, Ehlers-Danlos syndrome

� Reasons

� After complicated cataract surgery

� Post-traumatic dislocation of crystalline lens

� Capsular loss

� Ectopia lentis

� Marfan syndrome, Weill-Marhesani syndrome, hyperlysinaemia,

homocystinuria, sulfite oxidase deficiency, Ehlers-Danlos syndrome

Conservative Correction ?Conservative Correction ?

� Spectacles

� Reduced peripheral vision

� Ring scotoma (prismatic effect)

� „Jack in the box“

� Aniseokonia

� Spectacles

� Reduced peripheral vision

� Ring scotoma (prismatic effect)

� „Jack in the box“

� Aniseokonia

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� Aniseokonia

� Contact lenses

� Fitting, removal, cleaning…

� Aniseokonia

� Contact lenses

� Fitting, removal, cleaning…

Surgical CorrectionSurgical Correction

� Angle supported AC-IOL

� Endothelial cell loss (1 year: 6-45%)

� Pseudophakic bullous keratopathy (PBK)

� UGH-syndrome

� Scleral fixation of PC-IOL

� Choroidal haemorrhage

� Angle supported AC-IOL

� Endothelial cell loss (1 year: 6-45%)

� Pseudophakic bullous keratopathy (PBK)

� UGH-syndrome

� Scleral fixation of PC-IOL

� Choroidal haemorrhage

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� Choroidal haemorrhage

� Retinal detachment

� Vitreous incarceration

� Chronic inflammation

� IOL-iris contact

� IOL decentration

� Pigmentary dispersion

� High aqueous flare

� CME

� Choroidal haemorrhage

� Retinal detachment

� Vitreous incarceration

� Chronic inflammation

� IOL-iris contact

� IOL decentration

� Pigmentary dispersion

� High aqueous flare

� CME

Surgical CorrectionSurgical Correction

� Iris-Claw aphakic IOL

� Best choice for primary or secondary implantation in aphakic eyes

� Safer then open-loop-angle supported AC-IOLs

� Surgery easier, shorter and safer then sclera sutured IOLs

� Some cases of PBK

� Iris-Claw aphakic IOL

� Best choice for primary or secondary implantation in aphakic eyes

� Safer then open-loop-angle supported AC-IOLs

� Surgery easier, shorter and safer then sclera sutured IOLs

� Some cases of PBK

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� Some cases of PBK

� Endothelial cell loss – caused by surgical trauma ?

� Some cases of PBK

� Endothelial cell loss – caused by surgical trauma ?

Prof. Jan Worst Model 205T Worst Iris Claw® Lens

Model 205Y or VRSA54 ARTISAN™ VERISYSE ™

Aphakia Lens

1978 1986

Verisyse® AphakiaVerisyse® Aphakia

� VRSA54 Verisyse

� Primary or secondary implantation after ICCE, ECCE and Phaco

� Dioptric power: +2,0 D to +30,0 D (14.5 to 24.5 in 0.5 D steps)

� VRSA54 Verisyse

� Primary or secondary implantation after ICCE, ECCE and Phaco

� Dioptric power: +2,0 D to +30,0 D (14.5 to 24.5 in 0.5 D steps)

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

(14.5 to 24.5 in 0.5 D steps)

� Optical Diameter: 5.0 mm

� Overall Diameter: 8.5 mm

� Biconvex design

� A-constant:

�115 for AC implantation

�116.8 for retropupillary implantation (ULIB)

(14.5 to 24.5 in 0.5 D steps)

� Optical Diameter: 5.0 mm

� Overall Diameter: 8.5 mm

� Biconvex design

� A-constant:

�115 for AC implantation

�116.8 for retropupillary implantation (ULIB)

University Eye Clinic Salzburg 1996 – 2010

Aphakic Iris claw IOL

FrequencyFrequency

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� 1996 – 2005: 78 = 8 / year

� 2006 – 2009: 50 = 14 / year

� 2009 – 2010: 22 = 22 / year

� 1996 – 2005: 78 = 8 / year

� 2006 – 2009: 50 = 14 / year

� 2009 – 2010: 22 = 22 / year

Total 150150150150

SUBLUXATED lenses 82

� Primary surgery (Marfan´s syndrome) 25

FrequencyFrequency

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� Posttraumatic 25

� Spontaneous IOL dislocation (PEX) 32

Positioning of Verisyse® AphakiaPositioning of Verisyse® Aphakia

� Anterior� Anterior

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� Posterior

� Risk of endothelial cell loss decreases

� AC is deeper

� Distance from haptics to endothelium is larger

� Irido-corneal angle is wider

� Posterior

� Risk of endothelial cell loss decreases

� AC is deeper

� Distance from haptics to endothelium is larger

� Irido-corneal angle is wider

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

Advantages

� Very safe for corneal endothelium

� Produces less glare

� Only a very small ↑ of HOA1

Advantages

� Very safe for corneal endothelium

� Produces less glare

� Only a very small ↑ of HOA1

Posterior approachPosterior approach

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� Only a very small ↑ of HOA1

� „Physiological“ space for an IOL is behind the iris

� Only a very small ↑ of HOA1

� „Physiological“ space for an IOL is behind the iris

1 Kaymak C, Mester U. paper at ESCRS-Meeting, Lissabon 2005.

Disadvantages

� Extensive anterior vitrectomy required

� Special intruments are useful in order to avoid IOL-

drop into the vitreous cavity during implantation

Disadvantages

� Extensive anterior vitrectomy required

� Special intruments are useful in order to avoid IOL-

drop into the vitreous cavity during implantation

Posterior approachPosterior approach

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

drop into the vitreous cavity during implantationdrop into the vitreous cavity during implantation

Sekundo, Eur J Ophthalmol 2008

Special Special instrumentsinstruments usefullusefull toto avoidavoid a a tiltingtilting ofof thethe IOL IOL duringduring implantationimplantation procedureprocedure

Posterior approachPosterior approach

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� Mohr et al. Ophthalmologe 2002

� 48 aphakic cases

� 2/48 reversible CME

� Wolter-Roessler et al. Klin Monatsbl Augenheilkd. 2008

� 48 aphakic cases, 14 Months

� 2/48 reversible CME

� 2/48 traumatic haptic dislocation

� Mohr et al. Ophthalmologe 2002

� 48 aphakic cases

� 2/48 reversible CME

� Wolter-Roessler et al. Klin Monatsbl Augenheilkd. 2008

� 48 aphakic cases, 14 Months

� 2/48 reversible CME

� 2/48 traumatic haptic dislocation

Posterior approachPosterior approach

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

� 2/48 traumatic haptic dislocation

� 1/48 retinal detachment

� 1/48 pupillary block > iridectomy mandatory

� Hara et al. J Refract Surg. 2011

� 11 eyes retropupillary Verisyse

� No complications

� 21 eyes transscleral sutured IOL

� 5/21 ciliary choroidal body haemmorhage

� 1/21 CME

� 1/21 IOL dislocation

� 2/48 traumatic haptic dislocation

� 1/48 retinal detachment

� 1/48 pupillary block > iridectomy mandatory

� Hara et al. J Refract Surg. 2011

� 11 eyes retropupillary Verisyse

� No complications

� 21 eyes transscleral sutured IOL

� 5/21 ciliary choroidal body haemmorhage

� 1/21 CME

� 1/21 IOL dislocation

Anterior chamber IOL´s� Angle-supported

� Iris-claw

Anterior chamber IOL´s� Angle-supported

� Iris-claw

Posterior chamber IOL´s

� Sclera-fixated� Iris-sutured

Posterior chamber IOL´s

� Sclera-fixated� Iris-sutured

Posteriorly

enclavated

Iris-claw lens

� VERY FEW COMPARATIVE LONG-TERM studies� Need for a prospective, long-term (multi-center) study

ConclusionConclusion

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at

Decision tree for the very different clinical situations

University Eye Clinic Salzburg Paracelsus Medical University alois@dexl.at 16