Large Amplitude Iris Fluttering Detected by Consecutive Anterior Segment Optical Coherence Tomography Images in Eyes with Intrascleral Fixation of an Intraocular Lens

Evaluation of Dynamic Intraocular Lens Movement Using Anterior Segment Optical Coherence Tomography Movie Analysis

PURPOSE

To introduce a method to quantitatively assess dynamic intraocular lens (IOL) positioning using anterior segment optical coherence tomography (AS-OCT).

METHODS

This retrospective observational study analyzed 13 eyes with in-the-bag IOL fixation between May and December 2023 at the Ophthalmology Department of The Jikei University School of Medicine Hospital in Tokyo. Using ASOCT imaging during horizontal eye movements, dynamic IOL and iris movement angles were quantitatively assessed, compared with conventional static IOL tilt and decentration, and their interrelations were examined.

RESULTS

Static measurements revealed an average IOL tilt of 4.1 ± 1.3 degrees (range: 1.9 to 5.9 degrees) and decentration of 0.17 ± 0.10 mm (range: 0.02 to 0.38 mm). Dynamic analysis showed IOL movement angles of 2.6 ± 2.1 degrees (range: 0.3 to 7.3 degrees) and iris movement angles of 4.1 ± 3.4 degrees (range: 0.3 to 10.3 degrees). No correlation was found between the dynamic IOL movement angle and static IOL tilt and decentration, with some cases showing discrepancies (Spearman's rank correlation, P > .05). However, a strong positive correlation was observed between the dynamic IOL and iris movement angles (Spearman's rank correlation, R = 0.83, P < .05).

CONCLUSIONS

Although the static IOL tilt and decentration were within normal ranges, significant oscillations in IOL positioning were detected, highlighting the importance of dynamic assessment for evaluating IOL stability during daily activities. This study underscores the potential value of dynamic evaluation of IOL position in routine clinical practice. [J Refract Surg. 2025;41(5):e444-e450.].

Reverse Pupillary Block after Implantation of a Sutureless Scleral Fixation Carlevale Intraocular Lens

PURPOSE

To describe the incidence, complications and management of reverse pupillary block (RPB) after implantation of Carlevale intraocular lens (IOL).

DESIGN

Multicenter, retrospective, cross-sectional study.

PARTICIPANTS

Of a sample of 128 patients that had undergone Carlevale IOL implantation, 19 patients were found to present RPB.

METHODS

Nineteen patients with RPB after Carlevale IOL implantation were evaluated and treated with laser peripheral iridotomy (LPI).

MAIN OUTCOME MEASURES

Demographic data (age and gender), data on preexisting medication, axial length (Zeiss IOLMaster 500 and Zeiss IOLMaster 700), presence of pseudoexfoliation material, presence of RPB (anterior segment swept-source SS-OCT Anterion, Heidelberg Engineering), presence of macular edema (Irvine Gass syndrome, OCT Spectralis, Heidelberg Engineering), anterior chamber depth (ACD) before and after LPI, best-corrected visual acuity (BCVA) before and after LPI, and intraocular pressure (IOP) before and after LPI were analyzed.

RESULTS

An incidence of RPB of 14.8% was found. The prevalence of pseudoexfoliation syndrome was 21.1%, and 42.1% of patients presented an axial length >24.00 mm. Mean pre-LPI ACD was 4.78 ± 0.465 mm and post-LPI ACD was 4.23 ± 0.404 mm, a statistically significant increase of 0.54 mm (P < 0.001; 95% confidence interval, 0.26-0.83) of ACD was observed. There were no differences between pre- and post-LPI BCVA. Pre-LPI IOP was 17.10 (range, 12-34) mmHg and post-LPI IOP was 14.47 (range, 10-21) mmHg, (P = 0.391). Cystic macular edema (Irvine Gass) was identified in 4 of 19 patients, reporting an incidence of 21.1% in RPB cases.

CONCLUSIONS

Reverse pupillary block is a relatively common complication after Carlevale lens implantation, which may be associated with an increase of macular edema incidence but does not clearly correlate an increase of IOP. Our hypothesis is that indentation of the sclera induces a posterior rotation of the peripheral iris, causing RPB. Our results encourage looking over the Carlevale IOL implantation technique to consider a routinely intraoperative surgical peripheral iridotomy to avoid RPB and its further complications.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Secondary Intrascleral Intraocular Lens Fixation With Lens Capsule Preservation for Aphakic Eyes in Patients With Pseudoexfoliation Syndrome: A Case Series

We describe three cases of pseudoexfoliation syndrome (PEX) in which good outcomes were achieved after secondary intrascleral intraocular lens (IOL) fixation with capsule preservation for aphakic eyes. Three Japanese patients with PEX underwent phacoemulsification and aspiration (PEA) owing to challenges in IOL intracapsular fixation caused by zonular weakness. Case 1 involved an 83-year-old man with PEX. Six weeks post-PEA, 30-gauge needles were inserted to exit between the capsule and the iris. The IOL was fixed intrasclerally using the double-needle technique. Case 2 involved a 90-year-old man with PEX. The same abovementioned double-needle intrascleral IOL fixation procedure was performed eight weeks post-PEA. Intraoperative vitreous prolapse into the anterior chamber was observed, and anterior vitrectomy was performed. Case 3 involved an 80-year-old man with PEX. Seven weeks post-PEA, the patient underwent the same double-needle intrascleral IOL fixation procedure. Good IOL fixation was achieved in all patients without postoperative iris capture. No serious complications, including retinal detachment and vitreous hemorrhage, were observed. Preserving the capsule during secondary IOL scleral fixation for aphakic eyes can effectively reduce intraoperative vitreous prolapse, minimize surgical invasiveness, suppress iris flutter, and prevent capture of the pupillary IOL, making it a meaningful and acceptable approach, although the long-term risks, such as potential lens capsule drop, should be studied further.

Evaluations of bridging sutures in preventing iris capture in eyes with intrascleral fixation of implanted intraocular lens

PURPOSE

The study aims to determine the effectiveness of bridging sutures in preventing iris capture and a subsequent reverse pupillary block after an intrascleral fixation of an implanted intraocular lens (IOL).

METHODS

We studied 6 eyes that had an iris capture with reverse pupillary block due to a dislocated IOL after an intrascleral fixation. After the dislocated IOL was repositioned, 10-0 polypropylene sutures were inserted 1.5 mm posterior to the limbus and directed to run between the iris and the IOL. The sutures were placed orthogonal to the haptics of the IOL. Anterior segment optical coherence tomography (AS-OCT) was used in 4 eyes to evaluate the degree of iridodonesis before and after the bridging sutures. The heights of the temporal and nasal sectors of the middle iris from the iris plane (the line between anterior chamber angles) were compared for each 0.2-s AS-OCT image taken immediately after the eye moved from a lateral to a primary position.

RESULTS

None of the eyes had a recurrence of the iris capture after the bridging sutures. The refractive error, anterior chamber depth, and vision were not significantly altered after the bridging sutures were placed. The AS-OCT images showed that the height of the nasal iris was decreased more at 0 s postoperatively blocking the excessive downward movement of the nasal iris but not the iridodonesis.

CONCLUSION

Bridging sutures were effective in preventing iris capture and subsequent reverse pupillary block after an intrascleral fixation of an IOL.