Modern AC IOLs have a good track record. However,

in this setting, I would avoid their use because of the previ-

ous trauma.

The PMMA Sundmacher IOL has peripheral blackened

PMMA to cover the sector iridectomy. It is sutured to the

sclera. The problem with this option is that implantationrequires a 10.0 mm incision.

A standard scleral-sutured IOL such as the CZ series

(Alcon) could also be used. This also requires a slightly

large incision and would not deal with the iris defect.

It appears from Figure 1 that the remaining iris struc-

ture is normal; therefore, an iris-sutured IOL is a good op-

tion. The advantage is the ability to keep the incision small.

The IOL is folded in a mustache fashion so the haptics canbe placed below the iris while the optic remains in the

anterior chamber. The IOL is fixated by placing 10-0 Pro-

lene sutures peripherally. I would use triamcinolone aceto-

nide (Kenalog) to stain the anterior vitreous for removal

and then consider iris repair.

Alan Crandall, MD

Salt Lake City, Utah, USA

- This patient requires fixation of an IOL in the absence of

capsule support with a large superior sector iridectomy

spanning more than 2 clock hours with significant loss of

iris tissue. My general preference in these types of cases isto perform pupil reconstruction using multiple iris sutures

and then proceed to iris suture fixation of a foldable acrylic

PC IOL. However, in this case, the iris is likely insufficient

to completely perform this procedure.

Other options include scleral fixation of a PC IOL,

scleral fixation of an aniridia-type PC IOL, or an AC IOL.

In consideration of desired small-incision surgery,

minimizing the risk for vitreous prolapse or need for vitrec-tomy, and desire for satisfactory cosmetic and functional

iris/pupil anatomy, I would perform partial pupil recon-

struction and use an Artisan aphakia iris-claw IOL (Ophtec

BV). This iris-fixated IOL is 8.5 mm � 5.4 mm, permitting

insertion through a sub-6.0 mm clear corneal incision

(Figure 3). Despite the lack of complete closure of the

iris defect, the remaining iris is supportive enough of this

IOL. This would likely be safer than attempting to suturea PC IOL to the posterior iris. Unlike with an AC IOL,

sizing is not an issue with the iris-claw IOL.

Although insufficient iris is likely present for complete

closure of the sector iridectomy, a pupil can be constructed

with iris sutures to create a central aperture. The paracen-

tral iris can be brought together to close, creating a pupil.

The remainder of the superior iris defect can be partially

CONSULTATION SECTION

- This is truly an unfortunate situation. The first step is to

inquire about the patient’s degree of disability with aphakic

spectacles because he will be monocular. Thus, polycar-

bonate protective lenses would be advisable regardless of

optical needs. Based on the intraoperative view, that optionwas unsatisfactory and the patient elected to have second-

ary IOL placement.

As far as IOL selection, an AC IOL in the presence of

3 clock hours of missing iris is not likely to be stable long

term and may be undesirable in such a young patient, par-

ticularly one with a history of blunt injury and the com-

mensurately increased risk for future glaucoma.

A vitrectomy with a sutured PC IOL would be an ac-ceptable option for the correction of aphakia. The tech-

nique of suture fixation could be to the iris or the sclera.

Iris fixation, however, would be challenging, even if one

were able to successfully close or partially close the iris

defect, because centration of the IOL could be difficult to

achieve given such an altered iris anatomy. I would prefer

to suture a PMMA PC IOL with a 4-point fixation approach.

In a young patient such as this with a hopefully longhorizon, I would select Gore-Tex suture (off label). Al-

though new polyester suture may be of value, I do not yet

have clinical experience with it. I typically use ab externo

or ab interno suture passage, tying the suture externally.

Then, before cutting the needles off, I pass each free end

through partial-thickness sclera for 1.5 to 2.0 mm. The

knot can be crushed flat with a needle holder so that it

J CATARACT REFRACT SURG1600

lies flush with the ocular surface. The tension is snugged

on the free ends, and they are then cut flush to the episclera

as they exit the scleral passageway, effectively burying the

tags. Using limited or no cautery on the scleral surface

may reduce the risk for subsequent erosion over the suture.

Conjunctiva and Tenon’s closure should be performed(with surgeon’s suture of choice) to ensure the knot does

not become exposed with conjunctival flap retraction.

The superior iris should be addressed to reduce edge

glare from the IOL margin. In many instances, the iris

may be adequately stretched to close the defect enough to

cover the IOL optic margin using the Siepser sliding knot

suture or Ahmed intraocular tying technique.

Alternatively, a single-piece iris prosthetic device (notapproved by the U.S. Food and Drug Administration)

with an incorporated optic would address both problems

with a single approach, although it would require a much

larger incision (9.0 mm for Ophtec BV 311 device or 10.0

mm for the Morcher GmbH 67 series devices). Similar su-

ture techniques would be required for the combined pros-

thesis as described above for a standard PC IOL.

Michael Snyder, MD

Cincinnati, Ohio, USA

- VOL 32, OCTOBER 2006