Late Iris Cerclage Suture Cheese-Wiring.

PURPOSE: Mydriatic pupil repair by cerclage has been thought to be a permanent fix for glare, visual function and cosmesis. Iris repair can develop late cheese-wiring of cerclage sutures with resultant loss of benefits. We describe a case series of cerclage failures due to cheese-wiring. SETTING: Cincinnati Eye Institute, Cincinnati, Ohio. DESIGN: Retrospective single-surgeon case series. METHODS: A retrospective chart review sought patients that underwent iris cerclage at the Cincinnati Eye Institute who later developed suture cheese-wiring. The patient symptoms, demographics, cerclage size, suture type, knot type, iris status, and suture status at final follow up were ascertained. RESULTS: Six cases of cerclage suture cheese-wiring with loss of the original surgical benefit were identified. 10-0 polypropylene suture and a 3-1-1 knot were utilized in each case. The suture remained intact with an intact knot and suture loop in all cases. CONCLUSION: Cheese-wiring with return of mydriasis is a potential long-term outcome of iris cerclage suture placement, with return of pre-operative symptoms. Awareness of this potential eventuality provides physicians and patients a broader perspective when selecting between cerclage suture, iris prosthesis placement or other surgical and non-surgical options.

Microscopic analysis of preinsertion cutting modalities on custom, flexible iris prostheses.

PURPOSE: To determine the induced edge effects of different clinically used device postmanufacture modification styles and modalities on custom iris implants. SETTINGS: An academically affiliated multispecialty private practice group and an academic medical center. DESIGN: Laboratory study. METHODS: Sample custom iris prostheses were cut using patterns, blades, and surgical instruments described in the literature. The cut edges were evaluated with slitlamp microscopy, light microscopy, and scanning electron microscopy. RESULTS: Disposable blades yielded smoother cuts than scissors. Trephine blade brand significantly affected the cut surface smoothness of the silicone matrix. Meshwork-embedded prostheses had some irregular sharp edges where the mesh fibers were cut with all modalities, although these were worse with scissors and one tested trephine brand compared with the other. Pseudoiridectomies and scissor cuts created sharp points and corners in the device periphery. CONCLUSIONS: Postmanufacture modifications of iris implants should be minimized. The cut margins of the fiber-free implants have fewer sharp edges and may be preferable for sulcus placement. In-the-bag device placement may mitigate clinical impact of sharp edges and corners. These practices may help to minimize inflammatory sequelae postimplantation.

Structural effects on custom, flexible iris prostheses passing through injector systems.

PURPOSE: To determine the suitability of various commercially available intraocular lens injection systems for the implantation of custom, flexible artificial irides of various sizes, both with and without fiber meshwork. SETTING: Cincinnati Eye Institute, Blue Ash, Ohio. DESIGN: Laboratory study. METHODS: Custom, flexible iris prostheses, both with and without fiber meshwork, were either maintained at a 12.8 mm diameter or trephinated to a 10 mm diameter and subsequently inserted through 7 different intraocular lens injector systems. The ease of load, difficulty of injection, control of injection, and level of prosthetic distortion, if any, were observed and recorded. RESULTS: The fiber-free devices universally passed through the injectors unaffected. Each of the iris prostheses with embedded fiber meshwork appeared grossly distorted after injection. The injection systems had differing amounts of effort to load the device into the cartridge, to advance the prosthetic through the system, and varying levels of control when the prosthetic was released, although all the systems delivered the device effectively. CONCLUSIONS: Any of the 7 injection systems tested in this study can be used effectively for fiber-free artificial irides. Caution should be taken to ensure that control of insertion is maintained throughout the injection process. Screw-type injectors required less effort and yielded more control than plunger-type injector. Fiber meshwork-containing artificial irides should not be inserted through an injector.

A peculiar case of aqueous misdirection from a pseudophakic secluded pupil in a patient with chronic angle closure glaucoma.

Purpose: To explore the course of a pseudophakic and pseudoiridic 61-year-old man with a history of open angle glaucoma in his right eye who developed a sub-totally secluded pupil then later presented with angle closure, a significant pressure spike, and a marked myopic refractive shift, consistent with aqueous misdirection. Observations: Goniosynechialysis, surgical removal of much of the native peripheral iris, and zonulohyaloidectomy led to a return to his prior refraction and improve intraocular pressure (IOP) control. Conclusions and Importance: This case demonstrates that a diagnosis of aqueous misdirection should not be disregarded in the presence of a prior vitrectomy and that aqueous misdirection should be strongly considered in cases of elevated IOP with a patent peripheral iridotomy, myopic shift and angle narrowing.

Scleral suture fixation of a custom, flexible iris prosthesis.

INTRODUCTION: Iris prostheses are an integral tool for the management of symptoms in the setting of damaged, insufficient, or absent irides. Fixation of a custom iris prosthesis in the absence of capsular support raises similar challenges to the fixation of an intraocular lens (IOLs) without capsular support. Centration and planar orientation of these larger iris devices are perhaps even more important than with IOLs. METHODS: We describe two variations of a reliably reproducible suture fixation technique for securing these special devices using a modification of the tiltless, centration-adjustable suture technique for sclerally-fixated posterior chamber IOLs. RESULTS: We described a few techniques that are safe and reproductible. That have been used in more than 300 cases in our co-hort with success and follow-ups of over 10 year. CONCLUSION: We go over the technique step-by-step, highlighting the critical steps and pitfalls to avoid complications and achieve satisfactory results and aiming to get more surgeons to use these techniques and help facilitate the steep learning curve some of the steps might have.

Intraocular methotrexate for epithelial downgrowth: long-term outcomes in a multicentre case series.

BACKGROUND/AIMS: Sheet-like type of epithelial downgrowth (EDG) is not easily amenable to surgical excision. We describe long-term outcomes in patients with EDG treated with intraocular methotrexate (MTX). METHODS: This is a retrospective, multicentric case series including 10 eyes (nine patients) treated with intraocular MTX for sheet-like EDG. Relevant ocular history, previous EDG treatments, MTX injection regimen, long-term outcomes and complications are reported. RESULTS: All cases were associated with intraocular surgery. Most patients were treated with 400 µm/0.1 mL MTX injections with a starting frequency of two times per week or weekly injections. Mean and SD number of injections per eye was 16±13 injections and duration of follow-up was 54±36 months (range: 7-120 months). Eradication of EDG was achieved in seven eyes of which one required a second MTX treatment course to achieve eradication, while clinical resolution with recurrence was observed in two. One treatment failure occurred despite eight weekly injections which slowed but did not halt EDG progression; the patient later requested that treatments be stopped given difficulty to come to follow-ups. Surface epitheliopathy developed in eight patients and was used to titrate MTX treatment. Six patients also developed endothelial failure. CONCLUSION: We report the largest case series of diffuse, sheet-like EDG treated with intraocular MTX with follow-ups up to 10 years. Intraocular MTX may be used effectively to achieve eradication of EDG in cases where surgery is not amenable. However, further recommendations to guide treatment remain warranted.

In-the-bag injection and overfold technique for custom flexible prosthetic iris prostheses.

In-the-bag placement is the ideal location for an anterior segment implant, including the custom flexible artificial iris prosthesis (CUSTOMFLEX ARTIFICIALIRIS). Yet, an injection of a bag-filling iris device through a reasonably sized capsulorhexis creates a geometric challenge. First, the device must be placed into an injection cartridge. Folding into a conoid, trifold orientation improves the facility with which the device is loaded into the injector barrel. To facilitate placement into the capsular bag, the device that is approximately 10+ mm is injected into the nasal bag, and the temporal portion is overfolded on itself to reduce its outer diameter.

Results of the United States Food and Drug Administration Clinical Trial of the CustomFlex Artificial Iris.

PURPOSE: To evaluate safety and efficacy of a custom-manufactured artificial iris device (CustomFlex Artificial Iris; HumanOptics AG) for the treatment of congenital and acquired iris defects. DESIGN: Multicenter, prospective, unmasked, nonrandomized, interventional clinical trial. PARTICIPANTS: Patients with photophobia, sensitivity secondary to partial or complete congenital or acquired iris defects, or both. METHODS: Eyes were implanted from November 26, 2013, to December 1, 2017, with a custom, foldable artificial iris by 1 of 4 different surgical techniques. Patients were evaluated 1 day, 1 week, and 1, 3, 6, and 12 months after surgery. At each examination, slit-lamp findings, intraocular pressure, implant position, subjective visual symptoms, and complications were recorded. Corrected distance visual acuity (CDVA) and endothelial cell density (ECD) were measured at 3, 6, or 12 months as additional safety evaluations. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was used to assess health-related quality of life affected by vision. The Global Aesthetic Improvement Scale was used to assess cosmetic results. MAIN OUTCOME MEASURES: Photosensitivity, glare, visual symptoms, NEI VFQ-25 score, Global Aesthetic Improvement Scale rating, prosthesis-related adverse events, intraocular lens (IOL)-related adverse events, and surgery-related adverse events 12 months after surgery. RESULTS: At the 12-month postoperative examination, a 59.7% reduction in marked to severe daytime light sensitivity (P < 0.0001), a 41.5% reduction in marked to severe nighttime light sensitivity (P < 0.0001), a 53.1% reduction in marked to severe daytime glare (P < 0.0001), and a 48.5% reduction in severe nighttime glare (P < 0.0001) were found. A 15.4-point improvement (P < 0.0001) in the NEI VFQ-25 total score was found, and 93.8% of patients reported an improvement in cosmesis as measured by the Global Aesthetic Improvement Scale 12 months after surgery. No loss of CDVA of > 2 lines related to the device was found. Median ECD loss was 5.3% at 6 months after surgery and 7.2% at 12 months after surgery. CONCLUSIONS: The artificial iris surpassed all key safety end points for adverse events related to the device, IOL, or implant surgery and met all key efficacy end points, including decreased light and glare sensitivity, improved health-related quality of life, and satisfaction with cosmesis. The device is safe and effective for the treatment of symptoms and an unacceptable cosmetic appearance created by congenital or acquired iris defects.

COMBINED PHACOEMULSIFICATION SURGERY WITH MULTIFOCAL INTRAOCULAR LENS IMPLANTATION AND PARS PLANA VITRECTOMY FOR SYMPTOMATIC VITREOUS OPACITIES.

PURPOSE: To report surgical outcomes of combined vitrectomy for vitreous floaters and phacoemulsification surgery with multifocal intraocular lens implantation. METHODS: Retrospective, interventional, noncomparative case series of five eyes from five patients who underwent same-day combined phacoemulsification surgeries with apodized, diffractive multifocal intraocular lens implantation for cataract and pars plana vitrectomy for symptomatic vitreous opacities, that is, floaters. Primary outcomes were distance and near visual acuities, and resolution of symptoms. Secondary outcomes included intraocular pressure, refractive outcomes, and surgical complications. RESULTS: Mean logarithm of the minimum angle of resolution glare distance visual acuity improved from 0.36 (best-corrected Snellen 20/47) preoperatively to an uncorrected distance visual acuity of 0.05 (Snellen 20/23) at 6 months postoperatively (P = 0.042). All but one patient achieved multifocality with a near visual acuity of J2 or better. All patients noted subjective improvement in symptoms from floaters postoperatively. Mean intraocular pressure remained stable during follow-up. Two eyes ultimately required YAG capsulotomies for symptomatic posterior capsular opacification, one of which additionally received LASEK for refractive correction. CONCLUSION: Multifocality and improvement in symptoms from symptomatic vitreous opacities were observed in this pilot series of carefully selected patients who underwent combined phacovitrectomy with multifocal intraocular lens implantation. A high rate of retinal tears was found in these patients. Appropriate caution should be taken in preoperative assessment and patient selection for the combined procedure.

Management of common iatrogenic iris defects induced by cataract surgery.

The proximity of the iris to the instruments and currents of cataract surgery makes iatrogenic damage to the iris a common complication of cataract surgery. This article discusses techniques to prevent or minimize this damage. When damage does occur, the surgeon must decide if, when, and how to repair the damage. Principles governing these decisions and techniques for repair are discussed. Figures and videos, included as online Supplemental Data files, illustrate cases of iatrogenic damage and repair techniques.

Lamellar Dissection Technique for Traumatic Cataract With Corneal Incarceration.

PURPOSE: To describe a technique for traumatic cataract management for cases in which part of the anterior capsule has been incarcerated into a healed corneal laceration. METHODS: This is a single-center retrospective chart review of 3 patients with capsular/corneal incarceration after penetrating injury. Each patient underwent primary globe repair, followed by subsequent cataract surgery with intraocular lens (IOL) and iris prosthesis placement. The main outcome measure was corrected distance visual acuity. RESULTS: At a mean of 19-month postoperative follow-up (range 12-26 mo), corrected distance visual acuity ranged from 20/25 to 20/80 and all patients had improved vision compared with before cataract surgery. At the final follow-up, all IOLs and iris prostheses were in stable position and no eyes required corneal transplantation. CONCLUSIONS: Traumatic cataracts may be complicated by incarceration of the anterior capsule into the cornea. Incorporating the posterior aspect of the cornea into the anterior capsulotomy enables cataract removal and IOL placement in a stable capsular bag complex.

Long-term follow-up of a custom-made prosthetic iris device in patients with congenital aniridia.

PURPOSE: To investigate the effectiveness and safety of a custom-made iris prosthetic device used to reduce photic symptoms in patients with congenital aniridia. SETTING: Cincinnati Eye Institute, Cincinnati, Ohio, USA. DESIGN: Retrospective single-surgeon case series. METHODS: The charts of all eyes of patients diagnosed with congenital aniridia syndrome who underwent implantation of the custom-made iris prosthesis at the setting institution between 2008 and 2018 were reviewed. Eyes with more than 6 months of follow-up were included in evaluation. Charts were carefully reviewed for comorbid conditions, interventions, and outcomes. RESULTS: Ninety-six eyes of 50 patients were included in the study. Subjective reduction in photophobia and glare was reported in 95.7% and 95.2% of cases, respectively. The incidence of aniridia fibrosis syndrome (AFS) in this study (3.1%; 95% confidence interval, 0.6%-8.9%) was similar to previous studies in the literature. CONCLUSIONS: The custom-made iris prosthesis was an effective and safe option to reduce photic symptoms in patients with congenital aniridia. The custom, flexible iris implant does not appear to alter the risk for AFS. These highly complex eyes with significant comorbid pathologies demand an individualized approach and careful long-term follow-up.