Special no-suture IOL sits tight in eyes with weakened zonular fibres

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Oct 14, 2013 (3 years and 9 months ago)

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Pieter Rieck
Stefanie Petrou Binder MD
in Heidelberg
THE Binderflex IOL offers a fixed solution
for eyes with weakened zonular fibres,
providing a new option in a time of
increasing cases of pseudoexfoliation
syndrome,according to a report at the
DGII (Deutschsprachige Gesellschaft für
Intraokular Linsen Implantation und
refractive Chirurgie) earlier this year.
“Although this very specific lens is not
indicated often,the current increase in eyes
with pseudoexfoliation syndrome resulting
from perfectly successful
phacoemulsification surgery with IOL
implantation may call for the Binderflex lens
to be implanted more frequently and has
sparked an interest among ophthalmic
surgeons,” said Peter Rieck MD,PhD at the
Department of Ophthalmology,Charité
University School of Medicine,Berlin,
Germany.
In a retrospective study,Dr Rieck
analysed the last 50 cases of subluxated and
luxated IOLs in his clinic.He calculated an
average of 7.5 years for a lens to subluxate
or luxate completely.The subluxations and
luxations occurred independently of the
shape of the lens and,interestingly,capsular
tension rings gave no guarantee against
subluxation,he noted.
Dr Rieck has removed subluxated lenses
and implanted the Binderflex IOL in 22 eyes
thus far,with a follow-up ranging from six
months to 2.5 years.All cases are stable
with perfectly centred IOLs,he noted.
Dr Rieck had very few complications
after these surgeries.A slight early,
reversible hyperaemia of the iris vessels
around the haptic-end anchor disappeared
within several weeks.Later-onset,slightly
enlarged iridotomies that began three to six
months postoperatively also occurred.The
side effects by no means affected the
stability of the lens,he said.
He said that surgeons generally opt to
avoid implantation of IOLs in the anterior
chamber,and therefore choose posterior
chamber lenses.Posterior chamber lenses
are either iris fixated,with low
complications but high IOL mobility due to
the loose iris diaphragm,or sulcus
supported,which work well but need scleral
suture fixation.He noted that tilting,
decentration,suture erosion,choroid
haemorrhages,macular oedema,and
endophthalmitis were all associated with
sutured sulcus-fixated lenses,to varying
degrees.
Iris-fixated posterior chamber lenses can
be implanted in two ways:either using
sutures for a standard acrylic IOL or by the
inverse implantation of an iris-claw lens,the
aphakic Verisyse,AMO.
Dr Rieck believes that the Binderflex IOL
(IOLution) offers a viable alternative,as a
suture-free,sulcus-fixated posterior
chamber lens.
The key to the stability of this lens is its
special design,he noted.The acrylic
Binderflex lens has a 6.0mm lens diameter
and a 15.0mm overall diameter.The haptics
have three main functional areas:the long C-
haptics,which lodge in the sulcus;the neck
of the anchors,which extend through
iridotomies;and the head of the anchors,
which lie on the surface of the iris.
The very long C-haptics with end anchors
secure the lens in the ciliary sulcus and
buttoned onto the iris.This prevents the
sinking of the lens in the vitreous,as is now
more commonly encountered with
subluxated lenses in eyes with
pseudoexfoliation syndrome,Dr Rieck
observed.
The haptics are angulated at 12 from the
plane of the lens,and the haptic-end anchors
are angulated at 45 from the plane of the
lens.
Implantation of the Binderflex lens
involved placing two paracenteses at about 3
and 9 o’clock,a little wider as is done in
phaco surgery.Dr Rieck then made a scleral
tunnel for IOL explantation.A clear corneal
incision is made in cases without extractions,
he noted.
He performed an anterior vitrectomy and
injected viscoelastic at 3 and 9 o’clock.He
then made two iridotomies in dry modus
with the vitrectomy machine,using the
smallest diameter.
The Binderflex is pre-folded in a cartridge,
which allows the surgeon to easily take it
with his forceps,with the lens already in
position.
Dr Rieck inserted the lens through the
tunnel or clear corneal incision,watching
that the anchor of the leading haptic does
not get caught.Once inside,he allowed the
first anchor to hang onto the inner
circumference of the iris,and letting go with
the forceps,allowed the lens to unfold within
the eye.
He then hung the second haptic onto the
iris,and began to rotate the lens towards 3
and 9 o’clock.Once positioned,Dr Rieck
used a haptic forceps that he put through
the scleral/clear corneal tunnel or
paracenteses to grasp and position the
haptic-ends (anchors) through the
iridotomies.
Dr Rieck observed that this step was
pivotal to a successful operation,and
affords a certain learning curve for the
right-handed surgeon since one of the
haptics has to be inserted with the left
hand.
He said that the properly positioned end-
anchors were visible on the iris surface,
signifying the end of surgery.The centred
lens was also easy to see with the help of
the retinal reflex behind the dilated pupil,
he said.
The Binderflex has the advantage of
offering stability in every special dimension
with negligible side effects.One
disadvantage,though,is the learning curve,
Dr Rieck maintained.
“This lens can be used in cases of
trauma,primary lens luxation,IC
extraction,and posterior chamber lens
luxation and subluxation,in which the
structures that offer IOL support are
damaged or lacking.We are seeing this last
case scenario more and more often these
days,” he noted.
peter.rieck@charite.de
After both anchors are securely placed in the iridotomies, the optic of the IOL is always exactly
centered and stabilised in every spatial axis
Courtesy of Peter Rieck MD, PhD
The iris anchors are inserted through the iridotomies from behind the iris
using a Simcoe- or Guerain-type forceps
Special no-suture IOL sits tight in eyes
with weakened zonular fibres
Cataract
14
Implantation of the IOL through a sclerocorneal tunnel. While pushing the IOL forwards, the leading
haptic is implanted under the pupil towards an imaginary capsular bag – until the anchor is
temporarily hooked onto the pupil (arrow). If this is achieved, the IOL is unfolded behind the iris plane
like a standard foldable IOL
The implanted IOL is rotated with an alternative use of an anchor- and a Y-hook for pulling and pushing
both anchors clock-wise – until they reach a position at 3 and 9 o´clock, neighboring the iridotomies