EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW RESIDENTS 58 August 2014 even without obvious closure of the angle by the peripheral iris. I asked about his preferred surgical approach. "I find that tube shunt implantation is a viable option in these cases." Dr. Miller has extensive expe- rience with artificial iris implan- tation. He said, "An acceptable cosmetic and refractive result could be achieved with a colored contact lens." Unfortunately, this patient was unable to tolerate a rigid gas permeable lens secondary to his irregular corneal surface and recur- rent erosions. He was not a good candidate for a traditional secondary IOL because of the markedly dilated pupil. He was, however, an excellent candidate for an Ophtec 311, an iris reconstruction lens that combines an artificial iris and optic. It provides satisfactory cosmetic results and would address both the aniridia and the aphakia. 2 Dr. Deng commented from the cornea and anterior segment per- spective. She stated: "The patient is status post corneal transplantation, aniridic and aphakic. A standard IOL will not achieve the best outcome." Regarding the patient being hyper- opic and suffering from significant glare, "I agree with Dr. Miller. I would address the patient's symp- toms and proceed with iris recon- struction and lens implantation. Unfortunately, this procedure may cause further graft decompensation. The patient already had two failed grafts and suffered from an abnor- mal corneal surface due to limbal stem cell deficiency. If the current graft further decompensated, he would likely benefit most from a Boston type 1 keratoprosthesis (Massachusetts Eye and Ear Infirma- ry, Boston). The keratoprosthesis has an expanding role in visual rehabilitation." 3 All three attendings shared a common suggestion regarding pre- operative counseling. The possible limited outcomes and complications should be discussed in detail with the patient. Combining several prosthetic devices in the anterior chamber will have an unknown long-term outcome. They also stated that his pinhole vision of 20/50 was an excellent indicator that he had a good possibility of visual rehabilitation. Case outcome Dr. Miller decided to address the pa- tient's physical, optical and cosmetic discomfort with a combined proce- dure. The patient underwent repeat penetrating keratoplasty OS com- bined with anterior synechiolysis and implantation of a 15 D brown Ophtec 311 iris reconstruction lens that was suture-fixated to the sclera. The Ophtec 311 combines a colored artificial iris with a clear intraocular lens. The patient's postoperative course was complicated by persistent hyphema requiring an anterior chamber washout. He also devel- oped medically uncontrolled sec- ondary angle closure glaucoma for which he underwent Ahmed tube shunt (New World Medical, Rancho Cucamonga, Calif.) implantation OS. His UDVA remained 20/400 OS with a CDVA of 20/70 secondary to persistent corneal surface disease and irregularity. However, he re- ported a significant improvement in photophobia and glare sensitivity. As a result of the persistent cor- neal surface disease, a Boston type 1 keratoprosthesis was implanted OS. His immediate postoperative appear- ance is shown in photographs taken 1 month after surgery (Figure 2). At this point, his anterior segment was almost completely artificial. Four months after the keratoprosthesis surgery, the patient had a UDVA of 20/40 and a CDVA of 20/30. Elev- en months after surgery, he had a UCVA of 20/40. Intraocular pressure (IOP) was estimated to be 10 mmHg by digital palpation and measured to be 14 mmHg by pneumotonom- etry at the limbus on no IOP-low- ering agents. His optic nerve head revealed moderate glaucomatous cupping with mild pallor and a cup- to-disc ratio of approximately 0.55. Take-home points This patient presented with multi- ple ocular comorbidities and a long history of anterior segment degener- ation. The patient's visual rehabilita- tion required multiple surgeries and a unique combination of prosthetic devices. The case demonstrates the successful incorporation of multiple prosthetic elements to achieve an excellent visual outcome. EW References 1. Sugar A, Tanner JP, Dontchev M, Tennant B, Schultze RL, Dunn SP, Lindquist TD, Gal RL, Beck RW, Kollman C, Mannis MJ, Holland EJ. Recipient risk factors for graft failure in the cornea donor study; Cornea Donor Study Investigator Group. Ophthalmology 2009; 116:1023–8. 2. Pozdeyeva NA, Pashtayev NP, Lukin VP, Batkov YN. Artificial iris-lens diaphragm in reconstruc- tive surgery for aniridia and aphakia. J Cataract Refract Surg 2005; 31:1750–1759. 3. Aldave AJ, Kamal KM, Vo RC, Yu F. The Boston type I keratoprosthesis: improving outcomes and expanding indications. Ophthalmology 2009; 116: 640–651. Contact information Miller: kmiller@ucla.edu Roybal: christopher-roybal@uiowa.edu Artificial anterior segment continued from page 57