Eyeworld

EW NEWS & OPINION 16 approached the case in the following way. (Perhaps some day I will do the same with a standard CTR and HumanOptics artificial iris in the bag or a section sewn into the sulcus.) The meridian of astigmatism is appropriately marked for a toric lens. I would place an iris hook (or my preferred Yamaguchi capsule ex- pander hook) on the iris edge in the meridian of the iridocyclectomy. If there is any doubt about vitreous around the zonules at the start of the case it should first be identified with triamcinolone acetonide and removed with bimanual vitrectomy through a pars plana incision with anterior irrigation or pushed back, if possible with OVD. Once the CCC is complete and the bag stabilized with the hook my routine vertical chop technique is unremarkable. The bag is then well expanded with cohesive OVD, the partial Morcher aniridia ring (96 F) in- serted. Next a one-piece hy- drophobic acrylic toric IOL is in- serted under the Morcher ring seg- ment. This patient should do very well." Dr. Snyder agreed that a toric IOL (or even a multifocal with the use of LRIs to control astigma- tism) should be considered and that a CTR "will be required." He further elaborated on the options for iris augmentation. "Iris aug- menting devices can be broken down into in-the- bag devices or rigid, sulcus-fix- ated iris prosthe- ses. I try to avoid the larger rigid de- vices in these vulnerable eyes, as the 9.5 mm incisions required preclude the control of the small incision, thereby increasing risks for vitreous prolapse, along with the other atten- dant challenges of large wounds. Three styles of in-the-bag devices exist. Morcher makes a series of black PMMA elements on a CTR backbone that can cover the aphakic and focally aniridic space. They can be placed through small incisions and have a long track history. While Ophtec (Groningen, the Netherlands) makes a multi-piece (Hermeking IPS) iris device, the col- ors are suboptimal for an iris of this coloration, and the devices and lock- ing element require extraordinary dexterity to place, challenging even the most experienced surgeon. HumanOptics/Dr. Schmit Intraocu- larlinsen makes the Customflex, a custom-made silicone device colored to match a photo of the residual iris. It can be injected into the capsular bag through a small incision. We have used each of these de- vices in iridocyclectomy patients (paper in submission for publica- tion) with highly satisfactory results. As none of the devices are currently FDA approved, each was used under FDA compassionate use exemption (CUDE). Recently, the FDA has indi- cated that it will not approve CUDE requests for the Morcher iris devices for the indefinite future. We will soon be launching a multicenter FDA IDE study for the HumanOptics device." Treatment This patient's surgery was performed 18 months ago, prior to my discus- sion with this expert panel. As was agreed by all, iris retractors were used to control the iris, a CTR was placed after phaco, and a toric IOL was used. The phacoemulsification went uneventfully and almost rou- tinely. Take-home points When planning the placement of the toric lens it became clear to me that the broad haptic would be in a position to block some stray light rays from entering a peripheral iris defect, so my surgical repair of the iris was planned to take advantage of this. The iris defect was repaired by suturing the iris to the scleral wall at an angle rather than directly. The tension on the mattress suture used to suture the iris to the sclera was adjusted to reduce deformation of the pupil (as Dr. Masket suggested doing). The remaining peripheral iris defect was almost completely blocked by the position of the broad haptic of the AcrySof Toric T5 IOL (Alcon), the highest power available at the time. The patient was 20/20-2 uncorrected immediately after sur- gery, and she has experienced no glare problems since. 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