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SECONDARY INTRAOCULAR LENS IMPLANTATION

IN APHAKIC EYE

DESTY RIA TIFFANI

M. HIDAYAT
ARDIZAL RAHMAN

STAGE III
CATARACT AND REFRACTIVE SURGERY SUBDIVISION

OPHTHALMOLOGY DEPARTMENT M.DJAMIL GENERAL HOSPITAL

MEDICAL FACULTY ANDALAS UNIVERSITY

2018
 CHAPTER I

INTRODUCTION

Intraocular lens (IOL) implantation can be performed as a primary or

secondary procedure. Primary implantation is planned in most cases and secondary
implantation is done at another surgery or at a time remote from the initial cataract
extraction. In some conditions, the IOL implantation is not possible due to the type of
cataract (such as traumatic cataracts with lens subluxation, cataracts in
pseudoexfoliative syndrome with zonular dehiscence) or to systemic and congenital
disorders characterized by weakness of zonules. 1,2

Secondary IOL implantation is defined as insertion of an IOL into an eye,

which is rendered aphakic by prior cataract extraction by any method or by an
exchange IOL that is a special case of secondary intraocular lens implantation.
Secondary IOL implantation is a relatively safe procedure and can give great benefit
particularly to the monocular aphakic patient. In general, there are several alternatives
in secondary IOL implantation which is positioned either in anterior chamber (AC) or
posterior (PC). If capsular support is available, standard PC lenses placed in the
ciliary sulcus or, preferably, in the capsular bag are the standard of care. If capsular
support is absent, the decision is more controversial. Debate continues regarding
which of several methods of secondary IOL implantation is superior for eyes lacking
sufficient capsular support because of the limited number of studies available and the
lack of controlled studies with long-term follow-up. 3,4,5

Benefits and risks must be considered from each of the procedure so that
secondary IOL implantation could be a reasonable means of improving the functional
acuity in selected aphakic patients. This paper will further discuss about the pre
operative assessment of the eye, classification, surgical techniques, and complications
of various methods of secondary IOL implantation in aphakic eye.

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 CHAPTER II

PREOPERATIVE ASSESSMENT OF SECONDARY IOL IMPLANTATION

Secondary IOL implantation refers to IOL insertion at a time remote from the
initial cataract extraction and is performed when primary implantation failed due to
intraoperative complications (such as rupture of the posterior capsule, accidental
aspiration of the capsular bag, etc.) or when cataract extraction was done without lens
implantation at the first instance. Some important issues in secondary IOL
implantation are the location of new IOL placement and the method of fixation in that
location. There are several alternatives for secondary IOL implantation which
depends on preoperative status of the eye. Those lenses are devided into anterior
chamber IOL and posterior chamber IOL : 3,4

1. Angle-supported AC IOL
2. Iris Claw AC IOL
3. Standard capsular bag PC IOL
4. Sulcus placement PC IOL.
5. Peripheral iris suture-fixated PC IOL.
6. Transscleral-fixated PC IOL.

Traditionally, most patients who required secondary IOL implantation are

either elderly aphakes who had previously undergone intracapsular cataract
extraction, or aphakes who had lensectomy during early childhood for congenital
cataracts. Individuals also may be left aphakic after complicated cataract surgery,
lensectomy after trauma, or removal of a dislocated crystalline lens. Monocular
aphakic spectacle correction is generally not acceptable because it induces
anisometropia, creating an image size disparity as great as 25–30%. Thus for these
patients, secondary implantation of an IOL generally is recommended when
traditional spectacle or contact lens correction of aphakia is unsuccessful. 3,5,6

3
 There are several issues to consider when deciding which type of IOL to use
for a secondary implantation. Secondary IOL implantation after an ICCE must be
either placed in the anterior chamber, sutured to the iris, or sutured in the posterior
chamber because of the lack of posterior capsular support. After an ECCE that has
left a posterior capsule, the surgeon can, theoretically, implant a PC IOL. However,
even in the rare instances in which the posterior capsule is open, without fused walls,
it is always necessary to have ciliary sulcus placement of secondary posterior
chamber lenses because capsular bag fixation is practically impossible. 1,4

It is important to evaluate some key features of the eye before placing an IOL
into an aphakic eye. Evaluation may include a complete eye examination. Best
corrected visual acuity, the cornea, anterior chamber angle, iris and pupil, posterior
capsule adequacy, posterior segment, and intraocular pressure should be evaluated
carefully before secondary IOL implantation. Gonioscopy, biometry, and endothelial
cell counts should also be done before surgery.3,5,6

Preoperative vision may act as a significant predictor factor of visual

outcome. Meanwhile, the presence of pre-existing corneal astigmatism can be
reduced by making wound incision site centered on the steep corneal meridian in
order to use the natural flattening along the meridian of the incision. The health of
endothelial corneal cell is also one to be considered before a secondary lens
implantation because it can precipitate corneal decompensation. Using a high-
magnification slit lamp, or if needed, with a specular microscope, the eye can be
examined to assess the health of the corneal endothelial cells. Endothelial counts of
fewer than 1000 cells/mm2 are a contraindication, because any procedure on the eye
can cause loss of endothelial cells, and if there is a critically low number of cells
preoperatively, a secondary lens implantation could precipitate corneal
decompensation.4,5

Anterior chamber angle should be evaluated using gonioscopy to assess any

peripheral anterior synechiae, recession, and or neovascularization or if an anterior

4
chamber IOL implantation is possible. Since the footplates of an anterior chamber
lens rest in the recess of an open angle, areas of peripheral anterior synechiae should
be noted and avoided as sites of implantation. Iris and pupil have to be assessed
carefully. The previous iridectomy should be kept away from the path of lens
insertion. 3,4,6

The choice of IOL must be determined by the knowledge of the remaining

capsular support and iridocapsular adhesions. The capsular remnant provides an
excellent support, although it may remain adherent to the posterior surface of the iris,
the remnant may be used to reconstruct the ciliary sulcus and provide adequate
support for a posterior chamber IOL. High-frequency ultrasound such as ultrasound
biomicroscopy, can provide detailed information regarding capsular remnants, sulcus
support, and iridocapsular adhesions. 4,7

The presence of vitreous in the anterior chamber requires a vitrectomy, an

additional surgical step that is often necessary. Macula and peripheral retina is
examined using biomicroscopy and indirect ophthalmoscopy. Although a healthy
macula helps predict a good postoperative visual prognosis, preexisting CME with
fluctuating vision may increase postoperatively, leading to deterioration of visual
acuity. 3,8

Intraocular pressure (IOP) measurement is important, especially if low, which

may indicate the presence of a leaky cataract wound, a retinal detachment, or a
choroidal detachment. On the other hand, a high IOP or a history thereof may
necessitate a glaucoma work-up. If the patient has a high cup-to-disk ratio with
advanced visual field changes, the surgeon should carefully weigh the benefits versus
the risks of secondary lens implantation. Biometric measurements of axial length and
corneal curvature are necessary for determining the IOL power calculation 4,8,9

5
 CHAPTER III

CLASSIFICATION OF SECONDARY IOL IMPLANTATION

3.1. Anterior Chamber IOL

An anterior chamber IOL has an optic that rests in the anterior chamber and
haptics that rest and fixate in the anterior chamber angle. Gonioscopy is especially
important and valuable to evaluate the anterior chamber angles if an anterior chamber
IOL is contemplated. Because the footplates of an anterior chamber lens rest in the
recess of an open angle, areas of peripheral anterior synechiae should be noted and
avoided as sites of implantation. 3,4 `

3.1.1. Angle-Supported Anterior Chamber IOL

The main advantages of an AC IOL for secondary implantation are the

relative ease, faster, and minimally traumatic nature of the surgical procedure, which
may reduce intraoperative complications. Older anterior chamber lens designs have a
problematic track record. The original rigid designs and second-generation, flexible,
closed-loop haptic designs caused many complications, including erosion into the
angle, pain, corneal edema; iris/pupil distortion, peripheral anterior synechia (PAS);
uveitis, glaucoma, and hyphema (UGH) syndrome; and cystoid macular edema
(CME). 3,5,10

Those original designs have since been replaced by lenses with flexible, open-
loop haptics (Kelman multiflex style) that have proved to be safer and have produced
better long-term visual outcomes. Three-point and four-point flexible Kelman style
anterior chamber IOLs are the most frequently used anterior chamber lenses for
secondary implants (Fig. 1). 5,11

6
 Figure 1. Kelman AC IOL with flexible 4-point fixation. 5

Despite the flexibility of the multiflex haptics, lens sizing is critical for safe
AC IOL implantation. Many surgeons use the rule of measuring the horizontal
“white-to-white plus one” millimeter (1 mm greater than the measurement of the
corneoscleral junction from 3 to 9 o’clock horizontally) to determine overall AC IOL
diameter. A lens that is too large or implanted in the iris root may cause ocular
discomfort, angle erosion and peripheral anterior synechia. A lens that is too small
will not fixate and may move back and forth, predisposing the patient to progressive
endothelial cell loss and uveitis. 4,9

In an eye with free vitreous in the anterior chamber, an anterior vitrectomy is

often necessary before secondary IOL insertion. Some surgeons avoid vitrectomies by
using a plastic sheets glide to push back loose vitreous during insertion of the anterior
chamber IOL. In an eye that has an anterior chamber free from vitreous, the surgical
technique employed for a secondary anterior chamber IOL insertion is the same as
that used for the primary insertion, except that the surgeon may select a temporal
incision to avoid any conjunctival fibrosis from the previous surgery.3,9

After selecting an appropriate sized AC IOL, secondary AC IOL implantation

proceeds by making a 5.5-mm temporal incision at the limbus. The need for an
anterior vitrectomy must be determined which is always required if there is vitreous
anterior to the plane of the iris. After an adequate vitrectomy is performed, a rapidly
acting miotic agent is injected intracamerally followed by viscoelastic material to
ensure a deep anterior chamber during the subsequent anterior chamber IOL

7
implantation (Fig. 2a). When the anterior hyaloid face is intact but prolapsing into the
anterior chamber, it can usually be pushed posteriorly by a bolus of sodium
hyaluronate. 3,8,9

Once the IOL is already inserted, it can be rotated as necessary to avoid haptic
contact with any pre-existing PAS or the iridectomy (to prevent haptic migration
through it) and until the desired lens position in the angle is achieved correctly. This
is accomplished by gently retracting the distal haptic, rotating the lens, and then
releasing the haptic. This process is repeated as necessary for either haptic until the
desired lens position is achieved. If not already present, a peripheral iridectomy is
made to eliminate the risk of pupillary block. The peripheral iridectomy is typically
made superiorly, far from the lens haptic to minimize haptic prolapse throught
iridectomy. The anterior chamber intraocular lens is released and allowed to slide into
its appropriate anatomic position (Fig 2b). After proper IOL positioning is ensured,
the wound is sutured, the viscoelastic is manually removed and replaced with
balanced salt solution, and the conjunctiva is closed (Fig. 2c).4, 9

a b c

Figure 2. AC IOL implantation. a. AC IOL insertion through temporal incision. b. A peripheral

iridectomy is made to eliminate the risk of pupillary block. c. The anterior chamber in its appropriate
anatomic position. 4, 9

3.1.2. Iris Claw Anterior Chamber IOL

In order to move the IOL further away from the endothelium and to avoid
damage to angle structures, Worst proposed an alternative design for the anterior
chamber intraocular lens in 1977 termed the “iris claw” lens. In this design, the lens is

8
fixated anterior to the iris plane by two diametrically opposing haptic claws that
incarcerate a portion of mid-peripheral iris, where the iris is less vascularized and less
reactive. One of the latest versions of the iris-fixated AC IOL designed is the Artisan
aphakic IOL, which have a substantially different lens design than previous
generations and is associated with fewer complications (Fig. 3).9,13

Figure 3. a. Artisan lens. b Properly positioned Artisan lens.13

Originally used to correct aphakia following cataract surgery, Worst later

modified the iris claw lens into a negative powered biconcave design to correct
myopia in phakic patients. Since then, this model has been employed and was
renamed the Artisan myopia lens by the manufacturer. Currently, the Artisan is a non-
foldable PMMA lens capable of ultraviolet filtration and has different models that are
also available for the correction of myopia and hyperopia.13

Iris-claw lens is easy to place and associated with a good visual outcome and
a low incidence of intraoperative and postoperative complications. Artisan aphakic
IOL has been largely used in adult cataract surgery. To ensure proper horizontal
alignment of the lens claws for reliable lens centration, a laser mark can be
preoperatively applied to the iris at the sites where the claws should be anchored,
usually 4 mm off center horizontally at each side of the pupil. 4,14

Worst iris-supported claw lens insertion proceeds by making a 5.5 mm

corneoscleral incision, open the anterior chamber and inject acetylcholine to narrow
the pupil maximally. Protect the corneal endothelium from injury during lens
implantation by filling the anterior chamber with a high-molecular weight

9
viscoelastic substance, such as sodium hyaluronate (Fig. 4a). After inserting the IOL,
center it, and place the haptics over the laser marks. Place the claws directly over the
laser spots and clip the lens to the iris fold. Anchor the second haptic in the same
manner (Fig. 4b).4,14

After the lens is properly positioned (Fig. 4c), create a superior peripheral
iridectomy then suturing the corneal wound with interrupted 10-0 nylon sutures
Thoroughly irrigate and aspirate the sodium hyaluronate. 4,9,14

Figure 4. Worst iris-claw lens implantation. a. Inserting worst iris-supported claw lens
insertion through a 5.5 mm corneoscleral incision. b. Placing the haptics over the laser
marks. c. Properly positioned iris-claw lens. 4,14

3.2. Posterior Chamber Intraocular Lenses (PC IOL)

3.2.1. Capsular Bag Posterior Chamber IOL

If sufficient capsular support exists, in-the-bag placement often can be

achieved. This is accomplished by reopening the capsular bag and inserting a one-
piece polymethylmethacrylate (PMMA) lens or, if possible, a foldable lens through a
small, clear corneal incision. 9,15

First, the capsular anatomy is inspected, both visually and tactilely, to assess
its integrity. This is initially accomplished by retracting the iris 360 degrees and
determining the extent of intact capsule and zonules. A viscoelastic then is injected to
gently tease open the fused leaflets of the anterior and posterior capsule. Much of this

10
dissection can be performed passively, because the capillary action of the viscoelastic
filling the bag usually separates the capsular surfaces. If resistance is encountered,
careful manipulation with a spatula or microhook may be necessary. If the capsule
cannot be safely reopened, it is best to desist and place a large foldable or one-piece
PMMA IOL in the ciliary sulcus. Once the lens is positioned within the capsular bag,
its centration and stability should be assessed. 9, 15

3.2.2. Sulcus Placement Posterior Chamber IOL

Secondary PC IOLs are often placed in the unsutured ciliary sulcus because
the capsular bag is usually collapsed and fibrotic at the time of secondary IOL
implantation. The capsular remnants should be thoroughly inspected before lens
insertion. Synechiae between the posterior iris and the capsule are often present and
may lead to decentration or even impede insertion of the loops of the PC IOL. A
viscoelastic device is injected between the iris and anterior capsule; any residual
adhesions are bluntly dissected with the cannula or a spatula, taking care not to tear
the posterior capsule or disinsert the zonules (Fig. 5a). 4,16, 18

The optimal lens for secure sulcus fixation is a large optic (6.5 mm or more),
one-piece polymethyl methacrylate (PMMA) IOL with an overall diameter of 13.5 to
14 mm. However, a foldable IOL with a 6-mm optic and 13-mm overall length allows
insertion through a smaller wound. The IOL power should be reduced by 0.5 to 1.0 D
for sulcus-positioned versus capsular bag PC IOL. The lens can be inserted to the
posterior chamber between the iris and the capsule through a 6-7 mm limbal insicion
(Fig. 5b). Insert the lens into the posterior chamber between the iris and the capsule.
(Fig.5c). 4,16,18

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 Figure 5. PC IOL insertion in the ciliary sulcus. a. Separate any adhesions between the iris
and the capsule. b. Insert the lens into the posterior chamber between the iris and capsule. c.
Retract the iris while the proximal loop is placed in the posterior chamber.4

3.2.3. Peripheral Iris Suture-Fixated Posterior Chamber IOL

In the eye without an intact posterior capsule, however, a PC IOL can be

inserted only if it is sutured to either the iris or the sclera. Peripheral iris suture
fixation of the haptics of a PC IOL is commonly referred to as “McCannel suturing”.
McCannel sutures are a convenient and efficient method, using long needles to pass
sutures through the iris and around elements of the IOL, for the stabilization or
secondary implantation of PC IOL in the absence of adequate capsular support. Some
surgeons advocate these techniques over transscleral suturing in all cases. Others
reserve peripheral iris suture fixation for particular indications. These include
glaucoma patients for whom an AC IOL is thought inadvisable or anatomically
impossible and patients in whom the conjunctiva needs to be preserved for possible
future filtration surgery or where a filtering bleb is already present and must be
protected. 3,17

IOL is inserted through main wound (12 o’clock preferred). Size of main
wound will depend on choice of foldable or nonfoldable IOL. As soon as the lens is
placed into the ciliary sulcus, an intracameral miotic agent (Miochol) is administered
so that the IOL optic can be captured through the pupillary space. Iris capture of the
optic stabilizes the lens and enables better visualization of the haptics, while the

12
haptics remain in the posterior chamber and will be outlined against the posterior
surface of the iris.3,17

A single armed 10–0 polypropylene suture is passed through peripheral

cornea, iris, under the haptic and back through iris and peripheral cornea. A key in
obtaining a round central pupil is to keep the length of the iris suture pass as short as
possible and as peripheral as possible. Long suture passes bunch up iris tissue.
Nonperipheral suture passes inhibit free movement of the pupil. Both errors result in
distorted, nonreactive pupils. The surgical technique of McCannel iris suture fixation
PC IOL is shown in figure 6. 3,17,18

Figure 6. McCannel iris suture fixation of a PC IOL. a, Microhook are introduced through two
paracentesis openings and used to elevate the optic above the iris plane, capturing the optic in the pupil
while the haptics remain in the posterior chamber. b, A 10-0 polypropylene suture on a fine long
needle is passed through the paracentesis, penetrates the iris in the periphery just in front of the haptic,
which is indenting the iris stroma, exits the iris as soon as possible after the haptic, and then is driven
up through the peripheral clear cornea. c, Same maneuver is performed under the opposite haptic. d,
With both needles remaining in place behind the haptics, the successful capture of the haptics and
acceptable location of the IOL in the pupil are verified. E, Sutures are tied and cut inside the eye then,
microhook presses the intraocular lens (IOL) optic posteriorly back into the posterior chamber. F,
Pupil is round, and the IOL is well centered.3

3.2.4. Transscleral Fixated Posterior Chamber IOL

The sulcus location is the most closely normal anatomic position of the
crystalline lens. The goal of scleral fixated PC IOL is to have the haptics resting in

13
the ciliary sulcus. Anatomic studies have shown that the ciliary sulcus is 0.83 mm
posterior to the limbus in the vertical meridian and only 0.46 mm posterior to the
limbus in the horizontal meridian. Because of their anatomic location, scleral-fixated
PC IOL have a theoretic advantage over other IOL's with regard to complications..3,9

Advantages of transscleral fixated IOL include the elimination of corneal and

angle trauma associated with anterior chamber lenses, decreased risk of pupillary
block and secondary glaucoma, and little or no IOL contact with the iris, thereby
decreasing the risk of iritis and pigment dispersion. Important disadvantages to this
type of lens fixation need to be considered. Compared with AC IOL and iris-sutured
PC IOL, the procedure is technically more difficult, requiring longer surgical time
and a thorough anterior vitrectomy, both of which might increase the risk of
intraoperative and postoperative complications. 9, 11

Many different alternatives have been presented in the literature for placement
of transscleral-fixated PC lenses, either sutured or sutureless. Scleral-sutured lenses
can be sutured by passing the suture needle from the inside to the outside of the eye
(ab interno) and have the advantage of being faster (fig. 7), or by passing the needles
from the outside to inside of the eye (ab externo) that allows more precise needle
placement (fig. 8).9,11

(a) (b) (c) (d)

Figure 7. Technique for the ab interno approach. a. The long needles are passed under the iris, aiming
for the inferior ciliary sulcus. Two needle passes are made for each haptic approximately 0.75 mm
posterior to the limbus under previously dissected scleral flaps . b. A second pair of short needle passes
is made under the superior iris for the suture to be tied to the second haptic. c. Girth hitch can be used
to attach the polypropylene suture loop to IOL haptic. This technique is more rapid than tying the
suture to the haptic. The suture can be attached to the IOL haptics before the transscleral needle passes,

14
but the surgeon must avoid tangling the long sutures. d. After exiting the eye under the previously
dissected scleral flaps, the sutures are tied securing the IOL into position. Appropriate suture tension is
important to avoid lens decentration. 3,9

(a) (b)

(c) (d)

Figure 8. Technique for the ab externo approach. a. The long, straight solid needle is passed through
the scleral flap approximately 0.75 mm posterior to the limbus. Inside the eye, the needle should exit at
the ciliary sulcus. A second hollow needle is passed from the opposite side of the eye. b. Solid needle
is “docked” inside the tip of the hollow needle, which has been passed through ciliary sulcus on the
opposite side. After docking, the pair of needles are withdrawn together from the eye, with the solid
needle inside the hollow needle. C. A hook is used to pull the suture out through a superior limbal
wound so that it can be tied to the IOL. D. Suture is cut, and each end is tied to IOL haptic. After the
IOL is placed into position, the scleral sutures must be anchored to the sclera. 3,9

The recent sutureless technique for transcleral-fixated IOL gaining more

attraction is the the glue-assisted intrascleral fixation PC IOL or “glued IOL” for
shortened term. In glue assisted intrascleral fixation differs, two partial scleral
thickness flaps are made 180 degrees apart and scleral pockets are made at the edge
of the flap base, parallel to the sclerotomy wound. The haptics are tucked in the
scleral pockets and the flaps are then adhered to the base with the help of tissue fibrin

15
glue. The glue has two main components that occur naturally in the blood : fibrinogen
and thrombin, which are kept separate before use. The glue also helps in sealing the
sclerotomy site which would otherwise act as a filtration site and cause hypotony.
The surgical proceduresof glued IOL is shown in figure 9.19

(a) (b) (c)

(d) (e) (f)

Figure 9. Procedures of glued IOL. a. Create two partial scleral thickness limbus based flaps about 2.5
mm × 2.5 mm, at 3 and 9’o clock position (180° opposite to each other) and sclerotomy done with a 22
G needle about 1 mm behind the limbus underneath the flap. b. A three-piece foldable IOL is then
injected into the eye and a glued IOL forcep, which is an end-opening forcep, introduced from the
sclerotomy site and the tip of the leading haptic is grasped, pulled and externalized beneath the flap. c.
Externalization of the trailing haptic from the other sclerotomy site. d. Two scleral pockets were
created with a 26 G needle in alignment with the sclerotomy wound along the edge of the scleral flap.
e. The haptics were tucked into the scleral pockets. f. The glue (one drop of fibrinogen preparation
followed by a drop of thrombin) was applied under the scleral flap after drying the area and pressed for
nearly one minute and followed by sealing the conjungtiva with the glue. 19

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 CHAPTER IV

COMPLICATION OF SECONDARY IOL IMPLANTATION

4.1. Complications of Secondary Anterior Chamber IOL Implantation

Complications of secondary AC IOL mostly occur because the haptics are

close to the iris root, the trabecular meshwork, and the corneal endothelium. The
major problems arise from inflammation, rise in IOP, and hemorrhaging; this triad is
sometimes referred to as the UGH syndrome (uveitis, glaucoma, hyphema). The
complication rate is greatest when the IOL haptics are not positioned properly and
rest on the iris or endothelium, leading to iris tuck or endothelial decompensation.
Constant contact between the iris and the pseudophakos causes an inflammatory
response, which may lead to uveitis and hyphema. The incidence of this complication
can be decreased by carefully sizing the secondary implants so that they are neither
too large and erosive nor too small and excessively mobile. Acute or chronic
glaucoma can develop after inadequate iridectomies. In addition, chronic
inflammation can lead to decreased trabecular filtration, resulting in an increased
IOP. Modern AC IOL have a greatly decreased incidence of postoperative pain and a
decreased incidence of UGH syndrome associated with the older, rigid closed-loop
designs. 3,4,20

A secondary AC IOL may cause corneal endothelial decompensation much

more easily than a primarily placed lens because it is inserted into an eye that has
already experienced trauma to the corneal endothelium. A decrease in the number of
normally functioning endothelial cells beyond the critical number needed to maintain
corneal clarity is the cause of corneal endothelial decompensation. Several factors can
contribute to the evolution of corneal endothelial decompensation, including
endothelial cell loss at the time of surgery, IOL subluxation with permanent or
intermittent endothelial touch, secondary glaucoma, and chronic iritis. With this risk

17
in mind, patient selection is important because a patient with extremely damaged
corneal endothelium could either undergo a secondary lens implantation or a
combined lens implantation and penetrating keratoplasty. 4,9,11

Centering of the IOL optic is technically more difficult when the lens is iris
fixated. Even if the lens is properly centered intraoperatively, decentration may occur,
and the lens may luxate either spontaneously or secondary to trauma if the fixation
bite is too shallow. By adjusting the manipulation procedure and ensuring enough iris
tissue clamped, the complication can be avoided. The size of clamped iris tissue
should be 1.5-2 mm to ensure the IOL fixation and decrease the incidence of lens
dislocation. 9,14

4.2. Complications of Secondary Posterior Chamber IOL Implantation

Iris-sutured IOL may encounter complications such as iris chafe, chronic

inflammation or intraocular hemorrhage. Placing sutures in the iris tissue together
with an IOL close to its posterior surface might cause chronic inflammation because
of the motility of the iris tissues rubbing against the sutured lens (iris chafe). The two
important factors affecting the likelihood of iris chafe are suture location and
tightness of the suture. The central iris is most mobile, therefore, central suture
placement will result in excessive inflammation. Excessively tight sutures or
excessively large bites of iris may also cause peaking of the pupil or bunching of the
iris. 4,17

There may be a tendency toward an increased risk of unusual but serious

complications with scleral-sutured PC IOL. These serious complications include
retinal detachment, hemorrhagic choroidal detachment, and later lens dislocation.
Greater overall complication is found to be related with scleral-sutured PC IOL.
Schein et al also found a greater overall rate of complications with scleral-sutured PC
IOL compared with iris-sutured PC IOL. 3,18

18
 The most common postoperative complication after scleral-sutured PC IOL
implantation is persistent CME especially in scleral-sutured PC IOL. There also
appears to be a slightly greater risk of retinal detachment with scleral-sutured PC
lenses which reported to had a 2.7–5.4% risk of retinal detachment. The poor
positioning of the haptics with sutured PC lenses rather than in the ciliary sulcus may
increase the risk of retinal detachment. Also, transscleral sutures ought to increase the
risk of choroidal hemorrhage or effusion particularly in longer time of surgery. 9, 21

Lens decentration is found in 5–10% of patients after scleral-sutured PC lens

implantation. Proper polypropylene suture placement and tension are important in
avoiding this complication. The high incidence of erosion of the sutures through the
conjunctiva prompted surgeons to place these knots under scleral flaps. Because
suture-related endophthalmitis has been reported, it is recommended that all exposed
sutures be treated either with cautery or with free scleral grafts. The incidence of
endophthalmitis was four times higher after secondary IOL implantation than after
3, 22
cataract extraction with or without IOL implantation.

Bleeding in the form of vitreous hemorrhage or hyphema should be

anticipated with scleral-sutured lenses because of the proximity of the needle path to
the ciliary body. Proper passage of the needles through the ciliary sulcus rather than
the pars plicata may help to prevent this complication. Vitreous hemorrhage, if it
occurs, is usually self-limited and spontaneously clears. 3, 12.

19
 CHAPTER V

CONCLUSION

1. Secondary IOL implantation is an alternative procedure for patients left aphakic by

previous or complicated cataract surgery, with consideration that monocular
aphakic spectacle correction is generally not acceptable.
2. Secondary IOL implantation has several alternatives in which the lens is either
positioned in anterior chamber or posterior chamber thus allowing one to
individualize the approach for each case.
3. The presence or absent of posterior capsular support clearly defines the choice of
secondary IOL implantation, complete eye examination is mandatory before
selecting the best fit IOL.
4. Complication of AC IOL is mostly related with haptics position which is close to
iris root, trabecular meshwork, and corneal endothelium, meanwhile the
complication of PC IOL is related with its location in the posterior surface of the
iris and the ciliary body.

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