By Lisa B. Arbisser, MD
The vexing problem of visual rehabilitation in the pediatric aphakic eye without capsule support is great reason for using techniques that spare the two-chambered eye in the first place.
This retrospective, observational case study reports the results of 12 consecutive pediatric patients (17 eyes) implanted with foldable iris-sutured posterior chamber IOLs. Five of the eyes had Marfan-associated ectopia lentis, six had non-Marfan-associated ectopia lentis, four were aphakic after lens aspiration and anterior vitrectomy for traumatic cataracts and two were aphakic after pars plana vitrectomy-lensectomy in infancy, one because of a retinopathy of prematurity-related retinal detachment and the other from a neonatal vitreous hemorrhage. All of the eyes lacked capsular support, zonular support or both for a sulcus-fixated IOL and had demonstrated binocular vision-threatening noncompliance with standard treatments, such as contact lenses or aphakic spectacles, or were deemed poor candidates for them.
IOL dislocation occurred in 29 percent of the eyes after a mean follow-up of six months. However, 45 percent of the eyes with ectopia lentis experienced a dislocated IOL compared with none of the eyes without ectopia lentis.
Unfortunately, there is no discussion in either this article or the related editorial published in the same journal issue of the use of Cionni modified capsular tension rings (CTRs) to allow bag lens fixation in ectopia lentis cases, although this would be appropriate. There is likewise no mention of the alternative of off-label use of 8-0 GORE-TEX Suture, which is my suture of choice in these cases of bag stabilization with sulcus-sutured CTRs. I also failed to understand why planned lensectomy-vitrectomy did not leave the children's eyes with adequate anterior capsular support to permit unsutured sulcus fixation.
Given the fact that the study's authors were faced with a pediatric aphakic population with no capsule support, they reviewed the logic and technique for iris fixation nicely in their article. However, the fact that they experienced such a high rate of early IOL subluxation and dislocation bodes very poorly for the use of this technique in this population. Of greater interest is the little-discussed fact that these IOLs subluxated despite well-placed and undisturbed sutures, and the etiology of the haptic escaping its tether is unknown. Although it is interesting that the authors saw this mainly in their ectopia lentis population rather than in post-surgical or traumatic aphakic eyes, this is even seen in the adult population and deserves more discussion and recognition.
It is time that the FDA and industry allow us access to other options available outside the United States for these unfortunate patients and that iris-claw or other phakic-style anterior chamber lenses become available in aphakic powers.
Financial Disclosures
Dr. Arbisser has received honoraria and research grants from Alcon Laboratories, Inc., and Advanced Medical Optics, Inc.