Complete anterior segment reconstruction: Corneal transplantation and implantation of an iris prosthesis and IOL in a single surgery

Purpose: Patients who have suffered an ocular trauma may present with varying degrees of injury to the anterior segment. In this retrospective interventional case series, we report the outcome of seven patients who underwent complete anterior segment reconstruction in a single surgery. Methods: All patients with posttraumatic corneal decompensation or scar, aphakia, and iris defect underwent human donor corneal graft transplantation and implantation of an intraocular lens combined with a flexible silicone iris prosthesis. Postoperative examinations included assessment of best corrected distance visual acuity, objective refraction, and intraocular pressure. Sensitivity to glare and subjective discontent with the eye’s appearance was rated on a scale from 1 to 10, with 1 standing for low and 10 for high severity. Results: Mean best corrected distance visual acuity (BCDVA) was 1.51 ± 0.26 logMAR preoperatively and 1.29 ± 0.36 logMAR postoperatively. Mean IOP was 15.71 ± 8.94 mmHg pre-surgery and 13.57 ± 6.52 mmHg post-surgery. The mean sensitivity to glare was reduced from 7.17 ± 2.91 to 3.80 ± 3.43 and subjective cosmetic disfigurement was reduced from 5.33 ± 3.35 to 1.80 ± 1.60. Conclusions: A single surgery technique for entire anterior segment reconstruction in trauma patients can effectively reduce glare and patient discontent with the eye’s appearance.

Functional outcomes after combined iris and intraocular lens implantation in various iris and lens defects

Background To assess the functional outcomes after combined iris and intraocular lens (IOL) repair in aniridia patients. Methods Retrospective observational study in 59 aniridic and aphakic eyes for ArtificialIris (AI) and IOL reconstruction. The iris prostheses were placed together with the IOL in the capsular bag using an injection system or were fixed by transscleral suturing of the IOL and AI. The primary outcomes measured were visual acuity, contrast and glare sensitivity (Pelli-Robson chart for photopic and dark adaptometer for mesopic conditions), intraocular pressure, endothelial cell density (ECD) and patient impairment. Results Blunt trauma (37 eyes) and penetrating injuries (16 eyes) were observed more frequently than congenital aniridia (1 eye), iatrogenic causes (1 eye), aniridic state after severe iritis (2 eyes) or iris tumor (2 eyes). Monocular CDVA improved significantly (p < 0.0001) from median 0.7 logMAR (0.0–1.98) to 0.3 logMAR (− 0.08–2.0). Median pupillary area could significantly (p < 0.0001) be reduced by 79.3% from 51.27 mm2 (17.91 to 98.23) to 8.81 mm2 (4.16 to 8.84). Median ECD decreased from 2646.0 mm2 to 2497.5 mm2 (p = 0.007). Contrast and glare sensitivity improved significantly (p = 0.008) in photopic light conditions from 0.9 (0.0–1.95) to 1.35 (0.0–1.8). Patients reported to be highly satisfied with the functional improvement. Conclusion The flexible ArtificialIris seems to be a safe and effective iris prosthesis in combination with an IOL having functionally and cosmetically exceptional reconstruction options.

Implantation of ArtificialIris, a CustomFlex® iris prosthesis, in a trauma patient with an Artisan lens

Purpose: To evaluate probable complications of ArtificialIris implantation with iris-fixated intraocular lens. Method: Development of photophobia, glare, and psychological strain during face-to-face communication in a 23-year-old man with a widespread traumatic iris defect terminate to make a decision for performing implantation an ArtificialIris (HumanOptics, Erlangen, Germany) under the remnant iris without removing the patient’s existing Artisan lens. Results: Without any intraoperative or postoperative complications, the patient’s visual acuity increased by one line, the endothelial cell loss was comparable with the cell loss associated with standard cataract surgery, and the anterior chamber depth and anterior chamber anatomy did not change. At the final follow-up examination, the mean intraocular pressure (IOP) did not differ from baseline, and we achieved high level of patient satisfaction and subjective vision improvement. We discuss the particular importance of considering the patient’s expectations, the appropriate measurements, ways to perfect color evaluation, and the types of ArtificialIris products. Conclusion: The implantation of the ArtificialIris in patients with aphakic iris-supported lenses (i.e., preexisting Artisan lenses) is a feasible approach and a useful option for patients with thin irises and iris hypoplasia who are at risk of subluxation or the dislocation of the PCIOL as well as those with sclerally fixed PCIOLs.

Challenges and Complication Management in Novel Artificial Iris Implantation

Purpose. Evaluation of postoperative artificial iris prosthesis-related complications. Design. Retrospective cohort study. Methods. Fifty-one consecutive patients underwent pupillary reconstruction using an artificial iris implant made from silicone between 2011 and 2015. Quantity and quality of complications were subclassified into three groups including mild, moderate, and severe complications. Their management and the learning curve were evaluated. Results. In total, 13 (25.5%) of 51 included artificial iris implantations showed unexpected events in various degrees: mild complications: recurrent bleeding (n=1, 2.0%), slight but stable iris deviation (n=1, 2.0%), capsular fibrosis (n=2, 3.9%); moderate complications: suture cutting through the residual iris (n=1, 2.0%), glaucoma (n=3, 5.9%), and corneal decompensation (n=3, 5.9%); severe complications: artificial iris suture loosening (n=2, 3.9%) and dislocation (n=3, 5.9%), synechiae (n=2, 3.9%), glaucoma (n=2, 3.9%), and corneal decompensation (n=5, 9.8%) with the need for surgery, cystoid macular edema (n=3, 5.9%) and retinal detachment (n=1, 2.0%). The complication rate decreased from 83.3% (5 of 6 implantations) in the first year to 13.3% (2 of 15 implantations) in the 4th year. Nineteen of 45 evaluated patients showed a significant gain in best-corrected visual acuity (BCVA) from 1.09 ± 0.56 logMAR to 0.54 ± 0.48 logMAR (p<0.001), and 13 of 45 eyes had a significant BCVA loss from 0.48 ± 0.39 logMAR to 0.93 ± 0.41 logMAR after surgery (p<0.001). Conclusions. The artificial iris is a feasible option in the treatment of iris defects with a wide spectrum of postoperative complications. The significant reduction of complications after twelve implantations implicates that the procedure is not to be recommended in low volume settings.

Iris reconstruction using artificial iris prosthesis for management of aniridia

Purpose: To discuss the limitations and benefits of the BrightOcular prosthetic artificial iris device in management of aniridia associated with aphakia or cataract. Methods: This is a retrospective study including 5 eyes of 4 patients who underwent implantation of the BrightOcular iris prosthesis (Stellar Devices) for total or partial aniridia. The cases included 2 eyes of 1 patient with congenital aniridia associated with congenital cataract and 3 eyes with traumatic aniridia: 1 with subluxated cataractous lens and 2 with aphakia. In all cases, the iris prosthesis was implanted after a 3-piece acrylic intraocular lens was implanted. We evaluated the clinical course with a minimum follow-up period of 6 months, the intraoperative and postoperative complications, and the cosmetic satisfaction of patients. Results: All patients had improved uncorrected distance visual acuity and best-corrected distance visual acuity. All patients had a transient corneal edema that resolved within the first postoperative week. Only the patient with congenital aniridia had a permanent increase in intraocular pressure and developed a band keratopathy throughout a 2-year follow-up period. The prosthesis was well-centered in all eyes except for one case that required scleral suture fixation after 3 months. All patients had a satisfactory cosmetic appearance. Conclusions: BrightOcular iris prosthesis is a safe and useful tool to correct aniridia associated with pseudophakia or aphakia. Being foldable, it is easy to be implanted through a small incision and placed in the ciliary sulcus without sutures when properly sized. Cosmetic results are satisfactory. Sizing methods should be improved.