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Iris fixation of unstable anterior chamber

intraocular lenses
Julio Narvaez, MD, Enoch Nam, MD

Cataract surgeons are sometimes challenged with a patient who has an unstable anterior chamber
intraocular lens (AC IOL). Over time, an unstable AC IOL can lead to significant complications. This
problem is most often addressed with an IOL exchange using an appropriately sized AC IOL or a
posterior chamber IOL with iris or scleral fixation. We present a technique of 2-point iris fixation of
unstable AC IOLs as a simpler and less traumatic alternative.
Financial Disclosure: Neither author has a financial or proprietary interest in any material or
method mentioned.
J Cataract Refract Surg 2016; 42:961964 Q 2016 ASCRS and ESCRS
Online Video

Complications associated with anterior chamber intra- with a proper-sized AC IOL or a PC IOL fixated to the
ocular lenses (AC IOLs) have significantly decreased iris or sclera to prevent further complications. Explant-
since the advent of flexible open-loop AC IOLs.1 In ing these rigid AC IOLs requires large incisions, and
the past, the flawed design of the closed-loop AC these exchange procedures carry the risks for surgically
IOL led to a high incidence of corneal decompensation, induced astigmatism, suprachoroidal hemorrhage,
chronic intraocular inflammation, cystoid macular retinal detachment, and endophthalmitis.6
edema (CME), and glaucoma.2 The modern open- We report a simpler 2-point fixation technique of iris
loop AC IOLs are designed to have minimal vault fixation of the unstable AC IOL using a modified
and some haptic flexibility, thus minimizing damage Siepser knot as described by Osher et al.7 This is a valu-
to the corneal endothelium and angle structures. As able option to both patient and surgeon to resolve the
a result, numerous studies35 are finding open-loop clinical problem while avoiding the risks of more com-
AC IOLs to be a safe and comparable alternative to plex and traumatic surgeries.
sutured posterior chamber IOLs (PC IOLs).
Despite advances in AC IOL design, improper sizing
of the IOL can lead to the same complications of closed-
loop IOLs. In general, these patients have IOL exchange After a local block is placed, the eye is prepared and
draped in the usual sterile fashion for ophthalmic sur-
gery. A paracentesis is placed superiorly, inferonasally,
Submitted: February 15, 2016. and inferotemporally. An intraocular miotic is used to
Final revision submitted: June 7, 2016. constrict the iris, and the anterior segment is filled
Accepted: June 7, 2016. with an ophthalmic viscosurgical device (OVD). The
unstable AC IOL is then rotated to a horizontal posi-
From the Department of Ophthalmology (Narvaez, Nam), Loma Lin-
tion, if the iris anatomy will allow, to evenly distribute
da University, Loma Linda, and the Delta Eye Medical Group
the weight of the AC IOL on the iris. A 10-0 polypro-
(Narvaez), Stockton, California, USA.
pylene suture on a long needle is entered through the
Presented in part as videos at the XXX Congress of the European superior paracentesis to perforate the iris anteriorly
Society of Cataract and Refractive Surgery, Milan, Italy, September with the needle directed around the nasal optichaptic
2012, and at the ASCRS Symposium on Cataract, IOL and Refrac- junction. Subsequently, the iris is perforated again pos-
tive Surgery, Chicago, Illinois, USA, April 2012. teriorly before exiting out to the limbus inferonasally. A
Corresponding author: Julio Narvaez, MD, 1617 Saint Marks spatula is used to support the iris while the needle is
Plaza, Suite D, Stockton, California 95207, USA. E-mail: passed to facilitate penetration. A modified locking
narvaezjd@gmail.com. Siepser knot is used to secure the haptic to the iris.

Q 2016 ASCRS and ESCRS http://dx.doi.org/10.1016/j.jcrs.2016.06.023 961

Published by Elsevier Inc. 0886-3350

Figure 1. Iris-fixation of an unstable flexible open-loop AC IOL. Figure 2. Iris-fixation of an unstable flexible open-loop AC IOL.

The sutures are cut using intraocular scissors. The tem- and cause endothelial damage, iritis, peripheral ante-
poral optichaptic junction is sutured in the same rior synechiae, and glaucoma.9
manner with the exception of using the inferotemporal The surgical management of an unstable AC IOL
paracentesis sites. The anterior chamber OVD is finally typically involves exchange of the IOL. Recently, iris
thoroughly irrigated out of the anterior chamber with a fixation of unstable AC IOLs has been published.8
balanced salt solution (Figures 1 and 2). This method offers a less traumatic solution than an
IOL exchange using a 4-point fixation technique of
RESULTS the AC IOL haptics to the iris. In 2009, one of the au-
thors (J.N.) independently conceptualized and imple-
We have used this technique in 2 eyes of 2 patients, suc-
mented a technique of AC IOL iris fixation that only
cessfully resolving AC IOL rotation and pseudophaco-
requires a 2-point fixation, securing the mobile IOL
donesis. We encountered no complications during
by suturing the AC IOL at the optichaptic junctions.
follow-up, as has been the case with a previous larger
This technique is more efficient than 4-point fixation
series of AC IOLs fixated to the iris.8 Video 1 (available
by reducing in half the number of intraocular knots
at http://jcrsjournal.org) shows the surgical technique.
required for fixation. Although we have no experience
with 4-point fixation, our technique also appears
DISCUSSION simpler to perform because first the suture is passed
The modern flexible open-loop AC IOL and advances more centrally in the cornea, where the anterior cham-
in surgical technique have reduced the incidence of ber is deeper and there is more room to maneuver. Sec-
complications requiring IOL repositioning, exchange, ond, the orientation during the needle pass (Figure 3,
or removal.9 A comprehensive review of the literature broken vertical line) around the optichaptic junction
by Wagoner et al.3 showed that open-loop AC IOLs appears to be more ergonomic because it allows the
are not susceptible to the high rates of corneal endothe- needle as it enters and exits the iris more space than
lial decompensation, secondary glaucoma, and CME would be the case in 4-point fixation, where the exiting
associated with the older generation of closed-loop needle must make a sharp upward turn to be able to
AC IOLs. In addition, they found insufficient evidence clear the peripheral haptic in an area with diminished
of the superiority of 1 IOL type or fixation site when anterior chamber depth (Figure 3, broken horizontal
comparing open-loop AC IOLs with scleral or iris- line).
sutured PC IOLs for the correction of aphakia in eyes Most IOL suture fixation techniques use 1 suture per
without adequate capsule support. haptic. When properly performed, these 2-point fixa-
The advantages of AC IOLs are that implantation is tion techniques have shown long-term effectiveness.
less complex than scleral-wall fixation. The disadvan- We have observed no tilting or pseudophacodonesis
tages are that they are not recommended if the corneal in our patients who have had 2-point fixation and
endothelium or angle structures are compromised. In anticipate this stability to continue.
addition, inaccurate sizing of the AC IOL can lead to After the suturing procedure, the anteriorly vaulted
complications. An oversized AC IOL can cause exces- AC IOL is pulled back toward the iris and each of the 2
sive pressure on the iris root and angle recess, leading haptics end up pressing evenly against the anterior
to pupil ovalization, iris atrophy, hemorrhage, and surface of the iris, effectively distributing pressure at
iritis.9 An undersized AC IOL might become mobile the entire area of irishaptic touch. This prevents



haptic to iris fixation. Condon et al.15 suggest that the

Siepser knot allows the suture ends to be pulled in oppo-
site directions, which allows more precise knot
tensioning and locking. In their study of 46 eyes with
iris fixation of the PC IOL using the Siepser knot, there
were no cases of haptic slippage. The modification of
the Siepser knot by Osher et al.7 results in a true locking
knot and might promote more secure long-term fixation.
In conclusion, 2-point iris fixation of the unstable
open-loop AC IOL using the modified Siepser knot ap-
pears to be an effective, simpler, and less traumatic
alternative to IOL exchange or 4-point iris fixation.


 Patients with unstable AC IOLs can be treated with IOL ex-
change or 4-point iris fixation.

Figure 3. Diagram of suture passes with 2-point (left vertical hatched WHAT THIS PAPER ADDS
line) and 4-point fixation (right horizontal hatched line).  Two-point iris fixation is a simpler and less traumatic
treatment option in patients with unstable AC IOLs.
tilting, rotation, and pseudophacodonesis. Moreover,
because the AC IOL in this situation is smaller than
usual, fixation to the iris effectively suspends the IOL
away from angle structures, further protecting the
endothelium and delicate angle structures.
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