Intraocular Lens Implantation In Case of Absent Capsular Support

Abstract

Intraocular lens (IOL) implantation in eyes with inadequate capsular support has undergone extensive modifications. Various surgical techniques, IOL types and management protocols have been studied and reported . With growing surgical modifications and technological advances, operative complications have been reduced to a great extent in cataract surgery. However, lens implantation in the presence of a posterior capsular rupture is still challenging. The posterior capsule is an essential physical barrier to the normal lens. After cataract surgery, capsular support is crucial for maintaining the normal anatomical position and the ‘barrier’ effect for the IOL. In the presence of little or no capsular support, the surgeon has the following options for lens implantation: an angle-supported or iris-fixated anterior chamber IOL, a PCIOL over residual capsule, an iris-sutured PCIOL, or a transsclerally sutured PCIOL. Each of these are different with regards to technical difficulty, potential postoperative problems and complications. Before the early 1980s, for aphakia ACIOLs were the implants of choice among surgeons because of ease of Summary - 86 - insertion and relatively short operating time. In the mid- 1980s, however, it became evident that the rigid closedloop ACIOLs were associated with complications, including irreversible endothelial loss leading to pseudophakic bullous keratopathy, intractable inflammatory sequelae with or without cystoid macular edema, angle structure damage, formation of peripheral anterior synechiae, fibrosis of haptics into the angle, pupillary block with increased intraocular pressure, iris chafe, and hyphema. Partly in response to these problems, PCIOL implantation techniques became increasingly popular. Today, considerable controversy remains over the relative efficacy and safety of the different implantation approaches when capsular support is minimal or absent. ACIOL implantation is coming back into favor among some surgeons, thanks to improved, open-loop ACIOL designs and re-emergence of the iris-fixated claw IOL. Nevertheless, concern remains that ACIOLs are more damaging to the corneal endothelium than PCIOLs. Iris-fixated claw intraocular lens The Artisan lens , a modification of the Worst Iris Claw lens. Because of the apparently low complication rate associated with this lens, it is also beginning to play a role Summary - 87 - in the correction of aphakia. Early results for the correction of aphakia are promising However, the posterior chamber IOL (PCIOL) namely, the iris-sutured or transsclerally sutured PCIOL offers numerous advantages for certain patients. By virtue of their anatomic location in the eye, capsular-supported or sutured PCIOLs are appropriate for patients with glaucoma, diabetes, cornea guttata or low endothelial cell count, peripheral anterior synechiae, or known or suspected cystoid macular edema. They may also be appropriate when the patient with aphakia is young and has a relatively long life expectancy. The sutured PCIOL procedure specifically, the transsclerally sutured PCIOL procedure is far from benign, however, and surgical expertise is an important consideration.