Scleral fixation of brown diaphragm intraocular lens in cases of posttraumatic aniridia with aphakia

Ronel Soibam; Pritam Bawankar; Harsha Bhattacharjee; Krati Gupta

doi:10.4103/jcor.jcor_21_18

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Year : 2019 | Volume : 7 | Issue : 2 | Page : 76-78

Scleral fixation of brown diaphragm intraocular lens in cases of posttraumatic aniridia with aphakia

Ronel Soibam¹, Pritam Bawankar¹, Harsha Bhattacharjee², Krati Gupta²
¹ Department of Vitreo-Retina Surgery, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
² Department of Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India

Date of Submission	08-Feb-2018
Date of Acceptance	19-Feb-2019
Date of Web Publication	21-Aug-2019

Correspondence Address:
Pritam Bawankar
Department of Vitreo-Retina Surgery, Sri Sankaradeva Nethralaya, Beltola, Guwahati - 781 028, Assam
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcor.jcor_21_18

Abstract

Traumatic aniridia is a devastating complication of penetrating ocular injuries. Aniridia associated with aphakia can be treated with standard intraocular lens (IOL) implantation with or without scleral fixation; however, the problem of photophobia and glare remains still a concern. Although postoperative inflammation and secondary glaucoma are the main concerns, the scleral fixation of brown diaphragm IOL seems to be a good option for the management of traumatic aniridia and aphakia. Herein, we evaluated the clinical outcomes of three patients with posttraumatic aniridia who were treated with pars plana vitrectomy and scleral fixation of a brown-colored diaphragm IOL.

Keywords: Aphakia, colored diaphragm intraocular lens, pars plana vitrectomy, traumatic aniridia

How to cite this article:
Soibam R, Bawankar P, Bhattacharjee H, Gupta K. Scleral fixation of brown diaphragm intraocular lens in cases of posttraumatic aniridia with aphakia. J Clin Ophthalmol Res 2019;7:76-8

How to cite this URL:
Soibam R, Bawankar P, Bhattacharjee H, Gupta K. Scleral fixation of brown diaphragm intraocular lens in cases of posttraumatic aniridia with aphakia. J Clin Ophthalmol Res [serial online] 2019 [cited 2023 Mar 24];7:76-8. Available from: https://www.jcor.in/text.asp?2019/7/2/76/264890

Blunt or penetrating ocular trauma leads to devastating anterior segment complications such as corneal perforation, traumatic lenticular cataract, subluxation or dislocation of the lens, traumatic mydriasis, or sometimes, partial or complete 360° aniridia.^[1]

The iris tissue acts like a diaphragm of a camera and controls the spherical and chromatic aberration from the lens.^[2] Thus, its absence would lead to a significant amount of glare, photophobia, and photopic retinal damage and would hamper the quality of vision.^[2] Furthermore, an eye without the iris is cosmetically unappealing. Multiple treatment options available for patients with traumatic aniridia include colored contact lens, iridoplasty, corneal tattooing, foldable artificial iris, and eyelid surgery.^[3] Scleral fixation of intraocular lens (IOL) with colored diaphragm is a very good treatment option for these patients helping the surgeon to deal with aniridia and aphakia in a single procedure.

In this case series, we evaluated the clinical outcomes of three patients with posttraumatic aniridia who were treated with pars plana vitrectomy (PPV) and scleral fixation of a colored diaphragm IOL.

Case Report

We have described three eyes of three patients who reported to the emergency outpatient department of our institution from August 2010 to February 2016. All the patients underwent primary repair of the open wound following ocular trauma, elsewhere. The information regarding age, sex, laterality, mode of injury, and ocular damage due to trauma were noted [Table 1]. Pre- and postoperative best-corrected visual acuity (BCVA), pre- and postoperative intraocular pressure (IOP), postoperative long-term complications, and its management of patients who underwent implantation of brown diaphragm IOL were also recorded [Table 2].

Table 1: Demographics, mode of injury, ocular damage and management of 3 patients

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Table 2: Preoperative and postoperative patients' data

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All the patients with traumatic mydriasis, insufficient capsular support for IOL implantation, and normal IOP (<21 mmHg) underwent PPV and scleral fixation of a colored diaphragm IOL. All the three patients were followed up for a period of 4–9 months post first presentation. Once the eye was quiet, scleral-fixated IOL (SFIOL) using 311 aniridia lens II was planned. Preoperative assessment included BCVA examination using Snellen's chart, slit-lamp examination, ocular tension measurement using Goldmann applanation tonometer, gonioscopy, fundus examination by indirect ophthalmoscopy using +20 diopter (D), and biometry.

The surgery was performed under local anesthesia by giving peribulbar block. Conjunctival peritomy was done at 3 o'clock and 9 o'clock positions. The Tenon's fascia was dissected, and the sclera was exposed. Hemostasis was achieved using bipolar cautery. PPV was performed in all three cases using 23-gauge trocars placed as anteriorly as possible using 4-mm infusion cannulae. Triangular scleral flaps were created at 3 o'clock and 9 o'clock positions. In all the three patients, brown diaphragm IOL made up of polymethylmethacrylate with an overall diameter of 13.75 mm was used. Both ends of the C-shaped haptics had an eyelet for the passage of the suture. The 9-mm diameter optic part of the IOL had a 4-mm clear zone which served as an artificial pupillary aperture. A 10-0 prolene suture with the help of a double-arm straight needle was passed into the anterior chamber (AC) under the 9 o'clock scleral flap and it was pulled out below the 3 o'clock flap using a 26-gauge needle for guiding the suture. The AC was entered using a 2.2-mm keratome which was expanded by 5.5-mm expander. The IOL was introduced into the AC. The prolene suture was cut from the center, and each end was secured into the eyelet of the haptics and fastened. The loose ends were made taut by pulling the sutures at 3 o'clock and 9 o'clock ends. After the IOL was successfully placed in the ciliary sulcus, minimal dialing was done to secure its position. The scleral flaps were closed with 10-0 monofilament nylon. Furthermore, the superior incision was closed with 10-0 nylon. Injection vancomycin was instilled in the AC. Injection dexamethasone was given subconjunctivally. The eye was patched. Postoperatively, the patient was started on topical antibiotic and steroid.

All the patients reported a significant decrease in the visual glare and photophobia postoperatively. SFIOL was well centered in all the three cases [Figure 1]a and [Figure 1]b.

Figure 1: Clinical photographs of case 1. (a) Primary repair of the open wound following ocular trauma, complete iris loss, and aphakia is observed. The patient complained of debilitating glare and photophobia. (b) Appearance at the last follow-up visit. The patient's best-corrected visual acuity was 20/40, and glare and photophobia were absent

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Discussion

Traumatic aniridia and cataract are commonly seen in penetrating ocular injuries. The use of a standard IOL implantation with or without scleral fixation in a case of aniridia associated with aphakia improves the vision; however, the problem of photophobia and glare remains an issue.^[4] Sundmacher et al.^[5] in 1991 developed the black diaphragm IOL as the treatment option to deal with the problems of aphakia and aniridia. The use of this special type of lens helps in relieving photophobia and glare and in addition improves vision by correcting the refractive error and reducing glare.^[5]

In this case series, we report the use of the brown color diaphragm IOL to manage patients who had penetrating ocular injuries resulting in aphakia and traumatic aniridia. All of the patients had significantly better BCVA and experienced improvement of the photophobia and glare postoperatively.

All the patients had moderate-to-severe anterior segment reaction in the immediate postoperative period which was resolved within 2 weeks with topical steroids. The coexisting ocular trauma, relatively large sclera-corneal incision to implant the IOL, prolonged time of surgery, and the excessive manipulations may have contributed to this intraocular inflammation. Sundmacher et al.^[5] in their published case series reported persistent intraocular inflammation in all eight eyes that underwent implantation of a black diaphragm IOL. Postoperative inflammation was more obvious in traumatic cases as they reported. Another commonly reported complication of color diaphragm IOL implantation is secondary glaucoma. Preexisting trauma, direct compression of the trabecular meshwork by the haptics, or aqueous outflow obstruction by large colored diaphragm IOL may cause raised IOP.^[6],[7] Reinhard et al.^[6] reported postoperative secondary glaucoma in 4/19 eyes of traumatic aniridia. In another study, the authors reported persistently raised IOP in 2/7 eyes, which was controlled with topical treatment or surgery.^[8] In our case study, refractory glaucoma in case 3 was treated with Ahmed glaucoma valve surgery.

In conclusion, the scleral fixation of brown diaphragm IOL seems to be a good option for the management of traumatic aniridia and aphakia. Although secondary glaucoma and reduced visibility of peripheral fundus are still a concern, our experience with the colored diaphragm lens has been rewarding in terms of visual and esthetic rehabilitation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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