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Reenclavation of a partially disenclavated retropupillary iris-clipped intraocular lens in a child with Marfan Syndrome

Alvina Pauline Santiago, MD
Alvina Pauline Santiago, MD

Reenclavation of a partially disenclavated retropupillary iris-clipped intraocular lens in a child with Marfan Syndrome. 際際滷 deck was the basis of an e-poster presented at the 6th Asean Ophthalmology Congress in conjunction with the Philippine Academy of Ophthalmology Annual Convention held at the SMX Convention Center, Pasay City, MetroManila, Philippines October 2023.

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September 30, 2023 Reenclavation of a partially dis-enclavated retropupillary iris-clipped intraocular lens in a child with Marfan Syndrome Alvina Pauline Dy Santiago, MD https://actamedicaphilippina.upm.edu.ph/index.ph p/acta/article/view/6184/4414
INTRODUCTION Surgical management of lens with inadequate capsular support Lens extraction (LE), contact lenses LE with Capsular tension ring and IOL LE with Anterior chamber IOL LE with Sulcus fixated IOL LE with Scleral-fixated IOL LE with Iris-clipped IOL LE with retropupillary iris-clipped IOL (1,2) 1. Mohr A, Hengerer F, Eckardt C. Retropupillare Fixation der Irisklauenlinse bei Aphakie. Einjahresergebnisse einer neuen Implantationstechnik [Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation techniques]. Ophthalmologe. 2002 Jul;99(7):580-3. doi: 10.1007/s00347-001-0563-z. 2. Mohr A. Retropupillary fixation of artisan aphakia [Internet]. October 10, 2013. [cited 2013 Oct]. Available from: https://www. youtube.com/watch?v=cI9AwYE6uUc https://actamedicaphilippina.upm.edu.ph/index.ph p/acta/article/view/6184/4414
INTRODUCTION Long term follow-up of Retropupillary 鍖xation of iris-clipped IOL for children with inadequate support Follow-up at least 5 years Improved vision with 20/100 to 20/20 Focal iris atrophy No loss of enclavation Santiago APD, Cari単o NS. Long Term Follow-up of Retropupillary Fixation of Iris-clipped Intraocular Lens for Children with Inadequate Capsular Support. Acta Med Philipp [Internet]. 2023Feb.27 [cited 2023Sep.28];57(2). Available from: https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/6184
s/p lensectomy, core vitrectomy, retropupillary iris clipped IOL Doing well for 5 years, best VA 20/30 either eye. About a month from publication, left eye was hit by a water bottle causing immediate blurring of vision, that improved in the prone position.
3 days after trauma to left eye Dry Refraction +7.50 sphere Vision with +7.50 Finger counting, improved to 20/150 only Slit lamp examination Enclavated haptic at 9 oclock visible, no enclavation at 3 oclock Fundus No retinal detachment, no wrinkling of retina This is a slide structure based on a Clinical Case presentation You can delete this slide when youre done editing the presentation
IOL peeking, hanging from nasal enclavation
Trochar Insertion
IOL supported with spatula as haptic anteriorized on top of iris
IOL reenclavation
IOL temporal reenclavation completed
Day 1 Reenclavation Ocular Hypotony Sutured Sclerostomy Postoperative Course Day 1 Hypotony Repair
6 months post-op VISUAL ACUITY OD -2.00 -0.50 x 90 20/25 OS -2.50 -1.00 x 90 20/20 PUPILS Ovoid
DISCUSSION Prior Total Vitrectomy for signi鍖cant lens subluxation worked in our favor Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology. Ophthalmology. 2020 Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID: 32507620. Indication for total vitrectomy: Significant lens subluxation of 75% Simplified reenclavation, using fluid to float IOL No vitrectomy required Prevented traction and retinal detachment
DISCUSSION Traumatic Disenclavation on Posterior Iris-claw IOL Tilted Haptics Decentered and twisted fixation Haptics did not provide adequate closure Brockmann T, Gonnermann J, Brockmann C, Torun N, Joussen AM, Bertelmann E. Morphologic alterations on posterior iris-claw intraocular lenses after traumatic disenclavation. Br J Ophthalmol. 2014 Sep;98(9):1303-7. doi: 10.1136/bjophthalmol-2014-305364. Epub 2014 Jul 1. PMID: 24985724. Spontaneous Disenclavation on Posterior Iris-claw IOL Symmetric haptics Centered iris claws Adequate closure still provided LUCK of PATIENT: Despite traumatic disenclavation, haptics remained symmetric, with centered iris-claws and adequate closure.
DISCUSSION Prevent Ocular Hypotony Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology. Ophthalmology. 2020 Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID: 32507620. Turaga K, Senthil S, Jalali S. Recurrent spontaneous scleral rupture in Marfan's syndrome. BMJ Case Rep. 2016 May 19;2016:bcr2016214764. doi: 10.1136/bcr-2016-214764. PMID: 27199441; PMCID: PMC4885340. Suture sclerostomy site Sclera in Marfan syndrome have defective collagen tissue and maybe a little bit more leaky than normal Recurrent spontaneous scleral rupture in Marfan Syndrome reported (Turaga et al 2016) Histopath disorganized collagen and focal hyalinization
DISCUSSION Prevent traumatic injury to eye Eyeglasses or protective goggles Avoid contact sports and rough play Protect the eyes and face Retropupillary Iris-claw IOL Remains relatively safe Requires more vigilance in protecting the eye from trauma Vitrectomy to prevent traction retinal detachment recommended
REFERENCES 1. Mohr A, Hengerer F, Eckardt C. Retropupillare Fixation der Irisklauenlinse bei Aphakie. Einjahresergebnisse einer neuen Implantationstechnik [Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation techniques]. Ophthalmologe. 2002 Jul;99(7):580-3. doi: 10.1007/s00347-001-0563-z. 2. Mohr A. Retropupillary fixation of artisan aphakia [Internet]. October 10, 2013. [cited 2013 Oct]. Available from:https://www.youtube.com/watch?v=cI9AwYE6uUc 3. Santiago APD, Cari単o NS. Long Term Follow-up of Retropupillary Fixation of Iris-clipped Intraocular Lens for Children with Inadequate Capsular Support. Acta Med Philipp [Internet]. 2023Feb.27 [cited 2023Sep.28];57(2). Available from: https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/6184 4. Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology. Ophthalmology. 2020 Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID: 32507620 5. Turaga K, Senthil S, Jalali S. Recurrent spontaneous scleral rupture in Marfan's syndrome. BMJ Case Rep. 2016 May 19;2016:bcr2016214764. doi: 10.1136/bcr-2016-214764. PMID: 27199441; PMCID: PMC4885340. 6. Brockmann T, Gonnermann J, Brockmann C, Torun N, Joussen AM, Bertelmann E. Morphologic alterations on posterior iris-claw intraocular lenses after traumatic disenclavation. Br J Ophthalmol. 2014 Sep;98(9):1303-7. doi: 10.1136/bjophthalmol-2014-305364. Epub 2014 Jul 1. PMID: 24985724.
CREDITS: This presentation template was created by 際際滷sgo, including icons by Flaticon, infographics & images by Freepik THANKS Do you have any questions? youremail@freepik.com +91 620 421 838 yourwebsite.com Please keep this slide for attribution CLINICAL CASE 2023

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Reenclavation of a partially disenclavated retropupillary iris-clipped intraocular lens in a child with Marfan Syndrome

  • 1. September 30, 2023 Reenclavation of a partially dis-enclavated retropupillary iris-clipped intraocular lens in a child with Marfan Syndrome Alvina Pauline Dy Santiago, MD https://actamedicaphilippina.upm.edu.ph/index.ph p/acta/article/view/6184/4414
  • 2. INTRODUCTION Surgical management of lens with inadequate capsular support Lens extraction (LE), contact lenses LE with Capsular tension ring and IOL LE with Anterior chamber IOL LE with Sulcus fixated IOL LE with Scleral-fixated IOL LE with Iris-clipped IOL LE with retropupillary iris-clipped IOL (1,2) 1. Mohr A, Hengerer F, Eckardt C. Retropupillare Fixation der Irisklauenlinse bei Aphakie. Einjahresergebnisse einer neuen Implantationstechnik [Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation techniques]. Ophthalmologe. 2002 Jul;99(7):580-3. doi: 10.1007/s00347-001-0563-z. 2. Mohr A. Retropupillary fixation of artisan aphakia [Internet]. October 10, 2013. [cited 2013 Oct]. Available from: https://www. youtube.com/watch?v=cI9AwYE6uUc https://actamedicaphilippina.upm.edu.ph/index.ph p/acta/article/view/6184/4414
  • 3. INTRODUCTION Long term follow-up of Retropupillary 鍖xation of iris-clipped IOL for children with inadequate support Follow-up at least 5 years Improved vision with 20/100 to 20/20 Focal iris atrophy No loss of enclavation Santiago APD, Cari単o NS. Long Term Follow-up of Retropupillary Fixation of Iris-clipped Intraocular Lens for Children with Inadequate Capsular Support. Acta Med Philipp [Internet]. 2023Feb.27 [cited 2023Sep.28];57(2). Available from: https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/6184
  • 4. s/p lensectomy, core vitrectomy, retropupillary iris clipped IOL Doing well for 5 years, best VA 20/30 either eye. About a month from publication, left eye was hit by a water bottle causing immediate blurring of vision, that improved in the prone position.
  • 5. 3 days after trauma to left eye Dry Refraction +7.50 sphere Vision with +7.50 Finger counting, improved to 20/150 only Slit lamp examination Enclavated haptic at 9 oclock visible, no enclavation at 3 oclock Fundus No retinal detachment, no wrinkling of retina This is a slide structure based on a Clinical Case presentation You can delete this slide when youre done editing the presentation
  • 6. IOL peeking, hanging from nasal enclavation
  • 8. IOL supported with spatula as haptic anteriorized on top of iris
  • 11. Day 1 Reenclavation Ocular Hypotony Sutured Sclerostomy Postoperative Course Day 1 Hypotony Repair
  • 12. 6 months post-op VISUAL ACUITY OD -2.00 -0.50 x 90 20/25 OS -2.50 -1.00 x 90 20/20 PUPILS Ovoid
  • 13. DISCUSSION Prior Total Vitrectomy for signi鍖cant lens subluxation worked in our favor Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology. Ophthalmology. 2020 Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID: 32507620. Indication for total vitrectomy: Significant lens subluxation of 75% Simplified reenclavation, using fluid to float IOL No vitrectomy required Prevented traction and retinal detachment
  • 14. DISCUSSION Traumatic Disenclavation on Posterior Iris-claw IOL Tilted Haptics Decentered and twisted fixation Haptics did not provide adequate closure Brockmann T, Gonnermann J, Brockmann C, Torun N, Joussen AM, Bertelmann E. Morphologic alterations on posterior iris-claw intraocular lenses after traumatic disenclavation. Br J Ophthalmol. 2014 Sep;98(9):1303-7. doi: 10.1136/bjophthalmol-2014-305364. Epub 2014 Jul 1. PMID: 24985724. Spontaneous Disenclavation on Posterior Iris-claw IOL Symmetric haptics Centered iris claws Adequate closure still provided LUCK of PATIENT: Despite traumatic disenclavation, haptics remained symmetric, with centered iris-claws and adequate closure.
  • 15. DISCUSSION Prevent Ocular Hypotony Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology. Ophthalmology. 2020 Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID: 32507620. Turaga K, Senthil S, Jalali S. Recurrent spontaneous scleral rupture in Marfan's syndrome. BMJ Case Rep. 2016 May 19;2016:bcr2016214764. doi: 10.1136/bcr-2016-214764. PMID: 27199441; PMCID: PMC4885340. Suture sclerostomy site Sclera in Marfan syndrome have defective collagen tissue and maybe a little bit more leaky than normal Recurrent spontaneous scleral rupture in Marfan Syndrome reported (Turaga et al 2016) Histopath disorganized collagen and focal hyalinization
  • 16. DISCUSSION Prevent traumatic injury to eye Eyeglasses or protective goggles Avoid contact sports and rough play Protect the eyes and face Retropupillary Iris-claw IOL Remains relatively safe Requires more vigilance in protecting the eye from trauma Vitrectomy to prevent traction retinal detachment recommended
  • 17. REFERENCES 1. Mohr A, Hengerer F, Eckardt C. Retropupillare Fixation der Irisklauenlinse bei Aphakie. Einjahresergebnisse einer neuen Implantationstechnik [Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation techniques]. Ophthalmologe. 2002 Jul;99(7):580-3. doi: 10.1007/s00347-001-0563-z. 2. Mohr A. Retropupillary fixation of artisan aphakia [Internet]. October 10, 2013. [cited 2013 Oct]. Available from:https://www.youtube.com/watch?v=cI9AwYE6uUc 3. Santiago APD, Cari単o NS. Long Term Follow-up of Retropupillary Fixation of Iris-clipped Intraocular Lens for Children with Inadequate Capsular Support. Acta Med Philipp [Internet]. 2023Feb.27 [cited 2023Sep.28];57(2). Available from: https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/6184 4. Shen JF, Deng S, Hammersmith KM, Kuo AN, Li JY, Weikert MP, Shtein RM. Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology. Ophthalmology. 2020 Sep;127(9):1234-1258. doi: 10.1016/j.ophtha.2020.03.005. Epub 2020 Jun 5. PMID: 32507620 5. Turaga K, Senthil S, Jalali S. Recurrent spontaneous scleral rupture in Marfan's syndrome. BMJ Case Rep. 2016 May 19;2016:bcr2016214764. doi: 10.1136/bcr-2016-214764. PMID: 27199441; PMCID: PMC4885340. 6. Brockmann T, Gonnermann J, Brockmann C, Torun N, Joussen AM, Bertelmann E. Morphologic alterations on posterior iris-claw intraocular lenses after traumatic disenclavation. Br J Ophthalmol. 2014 Sep;98(9):1303-7. doi: 10.1136/bjophthalmol-2014-305364. Epub 2014 Jul 1. PMID: 24985724.
  • 18. CREDITS: This presentation template was created by 際際滷sgo, including icons by Flaticon, infographics & images by Freepik THANKS Do you have any questions? youremail@freepik.com +91 620 421 838 yourwebsite.com Please keep this slide for attribution CLINICAL CASE 2023