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Video Report

Posterior fixation of Artisan lens in Bullous Keratopathy

Department of Ophthalmology, Poitiers University Hospital, 86021 Poitiers, Cedex, France

Correspondence: Paul L Dighiero
Email: pauldighiero{at}aol.com or p.dighiero{at}chu-poitiers.fr C.H.U Jean Bernard, 2 rue de la Milétrie – BP 577 - 86021, Poitiers, Cedex, France Tel: +33 5 49 44 43 17; Fax: +33 5 49 44 46 68.

Date of acceptance: 15th June 2006

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Introduction

During cataract surgery, in the event of major capsular tear, leaving no sufficient capsular bag remnants for sulcus implantation, the intraocular lens (IOL) has to be sutured to the sclera or fixed in the anterior chamber [1]. Anterior chamber IOLs with irido-corneal angle fixation are inevitably leading to endothelial cells loss and bullous keratopathy. Next generation refractive iris-fixated anterior chamber single piece polymethyl methacrylate IOLs such as Artisan, maintain sufficient space between them and the endothelium in order not to harm it in phakic and aphakic eyes with genuine uncut corneas [2]. In our experience we found that such IOL was not as satisfactory when used combined with penetrating keratoplasty (when rendered necessary by bullous keratopathy). We present a surgical technique more respectful of the anterior segment anatomy, clipping the Artisan IOL under the iris instead as over it as previously described.

Case Report

Eight years ago, an 85 year old female patient who had undergone cataract surgery OD that complicated with major capsular tear, leaving no sufficient capsular bag remnants for sulcus implantation. She was then implanted with an angle supported IOL. She complicated in 2005 with pseudophakic bullous keratopathy. On presentation, she was in pain due to multiple epithelial bubbles, and her visual acuity was limited to 20/418. The cornea was opalescent and barely made possible the observation of the anterior chamber IOL, nor the iris anatomy. Intraocular pressure was noted 18 mmHg. She underwent a combined surgery associating penetrating keratoplasty and posterior Artisan IOL Implantation (Video Clip).

Pain relief was obtained shortly after surgery. 6 months later she had recovered 20/66 best corrected visual acuity. IOP was stable (17 mmHg) and graft cell density was measured 1475 with a contact specular microscope (EM-1000, Tomey) and remained stable after one year.

Surgical Techniques

Patients undergo corneal trephination with the Hanna trephine. A graft diameter of 8.25 mm is chosen (8 mm for the recipient bed).The recipient’s corneal button is finally cut out with scissors. The removal of the formerly implanted angle-supported IOL is followed by systematic complementary anterior vitrectomy (that will help vaulting of the lens) and eventually synechiolysis of the angle or iridoplasty to center the pupil if needed. After the intracameral injection of acetylcholine (to constrict the pupil to facilitate centering), the Artisan® IOL is implanted in a reverse position, vaulting it away from the iris in order to avoid rubbing of the lens against the iris (Figure 1). The lens is rotated into the following position: haptics at 3 and 9 o'clock. The IOL is enclosed, entrapping a fraction of the mid-peripheral iris within the haptics whilst firmly holding with the ARTISAN implantation forceps. The donor's corneal button is sutured to the recipient bed with 10-0 nylon sutures. Patient will receive postoperatively topical dexamethasone 0.1% 4 times a day for 1 month after surgery that will be tapered over the following 4 to 6 months.

Figure 1:
(A): Presentation of the Artisan intraocular lens flipped upside down (PMMA with a convex concave profile)
(B): The lens is inserted with forceps after an intracamerular injection of acetylcholine
(C): While the Artisan is maintained horizontally with forceps, centered over the pupil, with the haptics positioned at 3 and 9 o'clock, the iris is entrapped using a Sinskey-type manipulating instrumed.
(D): The donor's corneal button is then sutured with10-0 nylon sutures (Alcon) 

Comment

Due to the lack of a better technique, patients who develop bullous keratopathy following cataract surgery with anterior chamber angle-supported IOL implantation require penetrating keratoplasty. The first steps of this procedure give the surgeon access to the anterior segment via the open-sky approach, facilitating IOL explantation, anterior vitrectomy, synechiolysis, pupilloplasty and IOL implantation. Once the former IOL has been removed, aphakia may be corrected postoperatively by a gas permeable contact lens that will help correct keratoplasty induced astigmatism. In our experience, older patients deal with difficulties with contact lenses care and permanent lens wear being not advisable on a corneal graft. Recently developed angle-supported IOLs seem less harmful to the corneal endothelium than their predecessors but are still not ideal [1]. Their iridocorneal angle fixation inevitably leads to endothelial cell loss and bullous keratopathy. Transcleral sulcus sutured IOLs, complicate with chronic inflammation, IOL-iris contact, pigment dispersion, high aqueous flare, vitreous incarceration and BCVA loss due to cystoid macular edema [1]. Current-generation refractive iris-fixated anterior chamber IOLs, such as Artisan®, clawed onto the mid-peripheral iris, leave enough space between themselves and the endothelium to avoid harming the endothelium in phakic and aphakic eyes with genuine uncut corneas [2]. They have previously been used with anterior clipping in combination with keratoplasty for the surgical management of aphakic bullous keratopathy [3]. When clipped over the iris the Artisan® IOL closes the iridocorneal and the anterior chamber becomes shallow. These findings are best seen in UBM. This led us to implant the Artisan® device behind the iris in order to best preserve anterior chamber anatomy. Adding +2 to the A constant of the Verisyze lens calculation is necessary, as well as performing anterior vitrectomy prior to IOL implantation. This new surgical technique is a safe and easy alternative in older patients who can’t manage with contact lenses and in who we want to avoid a new angle supported IOL implantation.

References

• Dadeya S, Kamlesh, Kumari Sodhi P: Secondary intraocular lens (IOL) implantation: anterior chamber versus scleral fixation long-term comparative evaluation. Eur J Ophthalmol. 2003; 13: 627-33
• Budo C, Hessloehl JC, Izak M, et al.: Multicenter study of the Artisan phakic intraocular lens. J Cataract Refract Surg. 2000; 26: 1163-71.
• Kanellopoulos AJ: Penetrating keratoplasty and Artisan iris-fixated intraocular lens implantation in the management of aphakic bullous keratopathy. Cornea. 2004; 23: 220-4.