Graefes Arch Clin Exp OphthalmolDOI 10.1007/s00417-012-2226-y Visual outcomes and complications following posterioriris-claw aphakic intraocular lens implantation combinedwith penetrating keratoplasty Johannes Gonnermann & Necip Torun &Matthias K. J. Klamann & Anna-Karina B. Maier &Christoph v. Sonnleithner & Antonia M. Joussen &Peter W. Rieck & Eckart Bertelmann Received: 21 August 2012 / Revised: 31 October 2012 / Accepted: 21 November 2012 # Springer-Verlag Berlin Heidelberg 2012 (4.3 %) 8 weeks after primary surgery. All grafts remained Background To evaluate the indication, visual outcome, and clear without any sign of graft rejection.
complication rate after implantation of a posterior iris-claw Conclusions Retropupillar iris-claw IOL during penetrating aphakic intraocular lens (IOL) during penetrating keratoplasty.
keratoplasty provides good visual outcomes with a favor- Methods This retrospective study comprised 23 eyes (23 able complication rate, and can be used for a wide range of patients) without adequate capsule support undergoing pos- indications in eyes without adequate capsule support.
terior iris-claw aphakic IOL implantation (Verisyse™/Artisan®) during penetrating keratoplasty between 2005 Keywords Aphakia . Bullous keratopathy . Penetrating and 2010. Mean follow-up was 18 months (range from 12 keratoplasty . Iris-claw . Retropupillar . Verisyse . Artisan to 37 months).
Results The IOLs were inserted during an IOL exchange in17 eyes and as a secondary procedure in six aphakic eyes.
Pseudophakic bullous keratopathy with corneal scar afteranterior chamber intraocular lens (ACIOL) was the main In spite of decreased usage of angle-supported anterior indication for penetrating keratoplasty in 16 eyes (69.6 %).
chamber intraocular lenses (ACIOLs) and other lens types The final corrected distance visual acuity (CDVA) in associated with pseudophakic bullous keratopathy [], per- logMAR (mean 1.0 ± 0.46) improved significantly (p < sistent corneal edema remains a significant indication for 0.05) compared to the preoperative CDVA (mean 1.8 ± full-thickness penetrating (PKP), Descemet-stripping auto- 0.73). Twenty eyes (86.9 %) had a final visual acuity in mated endothelial (DSAEK), and Descemet membrane en- logMAR better than the pre-operative CDVA. The mean dothelial keratoplasty (DMEK) [, ]. During keratoplasty, postoperative IOP 16.3 mmHg±4.0 was not significantly it is generally desirable to leave the eye pseudophakic, given (p > 0.05) higher compared to the preoperative IOP the optical advantages of intraocular lenses (IOLs).
15.6 mmHg±5.1. Complications included slight temporary Frequently, the lack of adequate capsular support com- pupil ovalization in three eyes (13.0 %) and iris-claw IOL plicates intraocular lens implantation at the time of penetrat- sublocation in three eyes (13.0 %); all IOLs could be easily ing keratoplasty. In these cases, an angle- or iris-supported repositioned. Cystoid macular edema occured in one eye (e.g. iris-claw) anterior chamber intraocular lens (ACIOL), atrans-sclerally sutured, fibrin glue-assisted sutureless or irisfixated posterior chamber intraocular lens (PCIOL) can be Johannes Gonnermann and Necip Torun are joint first authors.
implanted ]. ACIOLs can be associated with complica- J. Gonnermann (*) : N. Torun : M. K. J. Klamann : A.-K. B. Maier : tions including corneal endothelial cell loss, leading to C. v. Sonnleithner A. M. Joussen P. W. Rieck E. Bertelmann pseudophakic bullous keratopathy, iris sphincter erosion, Department of Ophthalmology, Charité, secondary glaucoma, chronic inflammation, and hyphema University Medicine Berlin, Augustenburger Platz 1, Trans-sclerally fixated IOLs are associated with disad- 13353 Berlin, Germanye-mail: johannes.gonnermann@charite.de vantages such as difficult suture technique, longer surgical Graefes Arch Clin Exp Ophthalmol time, IOL decentration, hypotony, possible intraoperative surgeon's factor A constant of 117.0 for posterior fixation.
bleeding and damage to the ciliary body The ideal IOL calculations were performed for all patients before position of the intraocular lens (IOL) remains behind the iris plane []. Therefore, retropupillar iris-claw lens implanta-tion seems to be an ideal alternative.
In the present study we describe our experience with the retropupillar Artisan® aphakia iris-claw lens during pene- All procedures were performed by two surgeons (PR, EB) using the same surgical protocol in all cases. Details of thesurgical technique have been published []. Underlocal (peribulbar) or general anaesthesia, all patients under- Patients and methods went corneal trephination after placing cohesive viscoelasticmaterial in the anterior chamber. After removal of the IOL and synechiolysis of the angle if necessary, the iris-claw IOLwas inserted with the open sky technique. Then the PC IOL All cases of Artisan®/Verisyse™ PCIOL (Ophtec BV, was rotated with a hook into a horizontal position from 3 Groningen, The Netherlands, Advanced Medical Optics, to 9 o'clock and centered behind the pupil using the Inc. (AMO), Santa Ana, CA, USA) implantation during Purkinje images in the reversed position. Acetylcholine penetrating keratoplasty in eyes with aphakic or pseudo- chloride 1 % (Miochol) was injected following IOL phakic bullous keratopathy with corneal scar over a 5-year insertion behind the pupillary plane. Enclavation of the period (December 2005–2010) at Charité University iris into the IOL claw was performed using an enclava- Hospital Berlin were identified from the operating theatre tion needle. Peripheral slit iridectomy was not performed logbook and reviewed. All patients were operated by two at all. The typically 0.25–0.5 mm oversized corneal do- experienced surgeons (PR, EB) using the same surgical nor tissue was then sutured to the host bed with double protocol in all cases. The retrospective study concerned 23 running sutures (Nylon 10–0, Nylon 11–0) and all visco- eyes of 23 patients [nine women and 14 men; mean age ± elastic material was removed. Gentamicin and predniso- standard deviation (SD), 72.3±9.0; range 54 to 84 years] lone acetate 1 % drops were prescribed after surgery and without adequate capsule support undergoing posterior iris- slowly reduced over time. All patients received topical claw aphakic IOL implantation (Verisyse™/Artisan®) dur- steroids 5 times daily after the surgery for prophylaxis of ing penetrating keratoplasty. Follow-up ranged from 12 to graft rejection and/or macular edema. Prednisolone ace- 37 months, mean 18 months.
tate drops were tapered one drop per month, and contin- The aetiology of bullous keratopathy and IOL dislocation ued once daily after. No systemic immunosuppressive was identified in each case. Pre- and postoperative evaluation agents have been used at all.
included CDVA (corrected distance visual acuity), In all cases, anterior open-sky vitrectomy was performed, Goldmann's applanation tonometry, slit-lamp examination, except for cases with a history of anterior or pars plana fundus examination, endothelial cell densitiy (ECC), number of topical antiglaucomatous drugs taken and complications.
Visual acuity was converted to logMAR values for statisticalanalysis [], which was performed using Student's t-test.
The IOLs were inserted during an IOL exchange in 17 eyes (73.9 %) and as a secondary procedure in six aphakic eyes(26.1 %) during penetrating keratoplasty (PKP).
The Verisyse™/Artisan® aphakia iris-claw lens is a PMMA Pseudophakic bullous keratopathy (PBK) with corneal scar IOL with an 8.5-mm length, a 1.04-mm maximum height, after anterior chamber intraocular lens (ACIOL) was the main and a 5.0-mm clear optical zone. In 1971, Worst presented indication for penetrating keratoplasty in 16 eyes (69.6 %).
the "Iris-Claw Lens" (a biconvex PMMA IOL fixated above Penetrating keratoplasty was combined with IOL ex- the iridal plane at the mid-periphery of the iris) at a meeting change in 14 eyes with PBK and subluxated ACIOLs in Paris. In 1986, a modified biconcave phakic version of (82.3 %), in two eyes with bullous keratopathy (Fuchs' the Artisan was first implanted by Feschner for refractive endothelial dystrophy) and subluxated PCIOLs due to surgery purposes. The aphakic model was redesigned in pseudoexfoliation syndrome (11.8 %) and in one eye 1996 (convex/concave). The optic power was calculated with subluxated PCIOL and bullous keratopathy after by using the SRK/T formula. The manufacturer's recom- multiple glaucoma surgeries due to congenital glaucoma mendation for anterior fixation is 115.0. We assumed a

Graefes Arch Clin Exp Ophthalmol Penetrating keratoplasty was combined with retropu- All eyes achieved the desired anatomic results. No intra- pillar iris-claw IOL implantation as a secondary proce- operative complications were observed. Postoperative com- dure in three aphakic eyes after trauma (50 %), in two plications are listed in Table In the early postoperative aphakic eyes with PBK after ACIOL explantation period (<1 week), three eyes (13.0 %) developed slight (33.3 %) and in one aphakic eye with culture confirmed temporary pupil ovalization, which tended to normalize over Acanthamoeba keratitis (16.7 %).
time. Three eyes (13.0 %) showed a partial dislocation of The postoperative corrected distance visual acuity (CDVA) one haptic of the Artisan®/Verisyse™ PCIOL due to loos- in logMAR (mean 1.0±0.46) of all eyes at last follow-up ening of the enclavation in median 2 weeks postoperatively; improved significantly (p<0.05) compared to the preoperative all IOLs could be easily repositioned by re-enclavation of CDVA (mean 1.8±0.73) 1 day before surgery (Fig. ). Fifteen the loosened haptic. Cystoid macular edema (CME) occured eyes (65.2 %) even gained more than 2 lines after surgery.
in one eye (4.3 %) 8 weeks after primary surgery. CME was Only three eyes (13.1 %) achieved a final visual acuity equal detected clinically by funduscopy and verified by spectral to that measured pre-operatively. No loss in visual acuity was domain optical coherence tomography (SD-OCT). CME recorded despite 13 patients suffering from glaucoma preop- was successfully treated with systemic carbonic anhydrase eratively. The mean postoperative IOP 16.3 mmHg±4.0 did inhibitors (acetazolamide) and topical non-steroidal anti- not significantly (p>0.05) change compared to the preopera- inflammatory eye drops (ketorolac). All grafts remained tive IOP 15.6 mmHg±5.1 in all patients. In addition, the mean clear without any sign of graft rejection.
postoperative IOP (16.0 mmHg±3.9) of 13 patients sufferingfrom glaucoma preoperatively did not change significantly (p>0.05) change compared to the preoperative IOP (16.8 mmHg ±5.8). No worsening of glaucoma was observed and theamount of antiglaucomatous eye drops taken did not signifi- Pseudophakic bullous keratopathy (PBK) secondary to an cantly change (preoperative: mean 2.0±1.01 drugs, postoper- anterior chamber lens (ACIOL) is still an indication for full- ative: mean 1.96±0.98 drugs). The mean endothelial cell thickness penetrating keratoplasty (PKP) in the case of a dense densitiy (ECD) at last follow-up (mean 18 months) was corneal scar, and represents a surgical challenge involving a 1319±211 cells/mm2 (Fig. The mean preoperative ECD triple procedure: PKP, IOL explantation, and secondary IOL was 2325±240 cells/mm2.
implantation. At present, DSAEK and DMEK are the Fig. 1 CDVA (correcteddistance visual acuity) inlogMAR, * p<0.05(pre- to postoperative)

Graefes Arch Clin Exp Ophthalmol Fig. 2 ECD (endothelial celldensity, cells/mm2), * p<0.05(pre- to postoperative) procedure of choice to manage endothelial diseases such as longer surgical time, IOL decentration, hypotony, possible Fuchs endothelial dystrophy, PBK, and endothelial graft fail- intraoperative bleeding and damage to the ciliary body, ure. The advantages of DSAEK/DMEK over PKP include vitreous incarceration, and up to 20 % of IOL dislocation lack of induced astigmatism, increased wound stability, and faster visual recovery []. However, in the presence of a The first study of anterior fixation of an iris-claw IOL in dense corneal scar, PKP is the only surgical option because aphakia in combination with penetrating keratoplasty was pub- the visual axis clarity is inadequate for DSAEK/DMEK.
lished by Rijneveld et al. in 1994 with 19 eyes []. Visual The most appropriate method of secondary intraocular acuity improved in 83 % of their patients. Complications such lens implantation (or exchange) at the time of penetrating as pigment dispersion, glaucoma, peripheral synechiae, and keratoplasty (PKP) in the absence of capsular support is not lens decentration were rare. Although the difference between known. The safety and long-term efficacy of a transsclerally anterior and posterior fixation was not statistically significant, sutured PCIOL are less than satisfactory []. The trans- the authors prefered the anterior fixation technique.
sclerally sutured IOL is associated with a steep learning Mohr et al. published the first study on retropupillary iris- curve, and requires special steps that an anterior segment claw IOL fixation in 48 aphakic patients [No major surgeon may not use routinely. In a previous study ], complications were observed and the new retropupillary ultrasound biomicroscopy showed that transscleral suturing technique was shown to be superior (simplicity, reliability, of an IOL was associated with problems relating to accurate and best anatomical results) to other techniques.
suturing at the ciliary sulcus. In addition, there are issues Kanellopoulos studied Artisan® anterior iris-fixated IOL with IOL iris contact, pigment dispersion, high aqueous implantation associated with PKP for managing aphakic flare, cystoid macular edema, difficult suture technique, keratopathy in 11 patients ]. Kanellopulos and in 2006Dighiero et al. stated that the retropupillar fixation techniquewould better preserve the anatomy of the anterior segment.
Table 1 Complications This would explain the lower complication rate of endothe- lial cell loss and lower incidence of macular edema [ Gicquel et al. analyzed anterior (13 eyes) or posterior (14 Pupil ovalization eyes) iris fixation of Artisan®/Verisyse™ for the treatment of pseudophakic bullous keratopathy (PBK) using ultra- sound biomicroscopy []. Anterior IOL fixation led to more Graefes Arch Clin Exp Ophthalmol major complications including iridal synechias, endotheli- to normalize over time. Pupil ovalization can occur if the um–IOL contact, higher endothelial cell loss, and iridocor- fixation of the haptics is performed asymmetrically or to neal angle closure.
tight. This is not a common complication, although it has Another new surgical technique for managing bullous already been reported after iris-claw IOL implantation [ keratopathy secondary to anterior chamber intraocular lens ], and is an acceptable complication considering the se- (ACIOL) comprises femtosecond laser-assisted penetrating verity of the initial disease []. Three eyes (13.0 %) keratoplasty and ACIOL exchange with fibrin glue-assisted showed a postoperative partial dislocation of one haptic of sutureless posterior chamber intraocular lens (PCIOL) im- the Artisan PCIOL due to loosening of the enclavation in plantation ("glued IOL") ]. However this technique has mean 2 weeks (range 1–2 weeks) after surgery. This rare only been published in a small case series of three patients.
complication had been reported [Haptic repositioning is To our knowledge this is the largest case series of easily achieved through small incisions using local anesthe- Artisan®/Verisyse™ retropupillar iris-fixated IOL combined sia. Posterior fixation has the advantage over anterior fixa- with PKP. In our study we found a significant improvement tion, because if one haptic becomes disenclavated (bilateral (p<0.05) of the postoperative corrected distance visual acu- disenclavation has not been reported yet), no contact with ity (CDVA) in logMAR (mean 1.0±0.46) of all eyes com- the endothelium is possible. Cystoid macular edema occured pared to the preoperative CDVA (mean 1.8±0.73). Visual in one eye (4.3 %) 8 weeks after primary surgery. This rate acuity improved in 86.9 %, which is similar to previous is lower than the 14 % and 10 % rates reported in the largest studies , Even 65.2 % gained more than 2 lines after series on ACIOLs ] and scleral-fixated PCIOLs surgery. Only 13.1 % eyes achieved a final visual acuity implanted during PKP.
equal to that measured pre-operatively. No loss in visual In our study, all grafts remained clear, without any sign of acuity was recorded despite though 13 patients suffering endothelial decompensation or graft rejection. All compli- from glaucoma preoperatively. But the rather low postoper- cations associated with the retropupillary fixation technique ative visual acuity in general could be explained by optic seem acceptable considering the severity of the initial dis- nerve atrophy. The mean postoperative IOP (16.0 mmHg± ease. However, limitations of our retrospective, non- 3.9) of 13 patients suffering from glaucoma preoperatively comparitive cohort study are the rather short follow-up.
did not change significantly (p>0.05) change compared to Moreover, determination of small differences in visual out- the preoperative IOP (16.8 mmHg±5.8). No worsening of come or complication rates when compared to other existing glaucoma was observed.
techniques will require a large prospective randomized clin- The Artisan® Aphakia iris-claw IOL has a substantially ical trial. Although there is still no consensus on the best different lens design than previous generations of iris- IOL to implant in the absence of capsule support, we believe fixated IOLs, which also were associated with complica- retropupillar iris-claw IOL implantation is an effective, well- tions [The Artisan lenses are anchored to the midper- evaluated and interesting option during PKP.
iphery of the iris. They have a vaulted design. This providesoptimal clearance between iris and IOL. Except at the fixa- Anna-Karina B. Maier: Financial support pro- tion points under the iris, they are slightly raised below the vided by the "Friedrich C. Luft" Clinical Scientist Pilot Program iris plane, which prevents them from interfering with the funded by Volkswagen Foundation and Charité Foundation.
normal physiologic features of the iris We did not expectto see secondary pupillary blocked glaucoma. Therefore, we Conflict of interest None to declare.
did not have a preference for peripheral iridectomy.
The mean endothelial cell density at last follow-up (mean 18 months) was 1,319±211 cells/mm2. This is comparable to previous studies with lower patient numbers using poste-rior Artisan® Aphakia iris-claw IOL combined with PKP.
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