By Ana Hidalgo-Simon, MD, Ph.D.

BRUSSELS - Implantation of the iris-claw IOL (Artisan™) in combination with penetrating keratoplasty (PK) is a simple and effective approach to the management of patients with aphakic bullous keratopathy, according to John Kanellopoulos, MD, Associate Clinical Professor of Ophthalmology, Manhattan Eye, Ear and Throat Hospital, New York City.

In addition to its simplicity and efficacy, the combined procedure may have the added advantage of improving aqueous outflow in patients who may have pre-existing glaucoma or in whom the disease may later develop, he told the ESCRS Congress in Brussels.

Noting that he has now used the combined procedure in 11 patients with good visual outcome, Dr. Kanellopoulos said that although it appears that the incidence of aphakic bullous keratoplasty is declining, it still affects a significant number of patients both in Europe and the USA.

Older Procedures Have Shortcomings
"Up until now, the main options for treating these patients include leaving the eye aphakic, and implantation of an angle-supported anterior chamber IOL-with the consequent risk of angle closure and close contact with the corneal epithelium. Sommering ring fixation is another elegant technique, but you need a definite supporting ring and also lengthier and more challenging intraoperative manipulations to be able to fixate the IOL very accurately because in the long term, dislocation of the lens may occur.

"Although trans-scleral implantation of a posterior chamber IOL can offer definitive management of the patient's aphakia, my own experience with this approach shows that it is not the easiest technique to perform, and the IOLs are not always well- centered. To these problems we have to add the long period of inflammation after surgery and the relatively frequent patient complaints of chronic pain. Consequently we decided to investigate the alternative approach of combining penetrating keratoplasty with the implantation of an iris-fixated IOL, in this case, the Artisan, " he explained.

The combined procedure begins with trephination of the host cornea, followed by vitrectomy and if necessary synechiolysis and iridoplasty. The next step involves enclavation of the iris claw IOL-with an optic diametre of 6 mm, total length of 8.5 mm. It attaches in the mid-periphery of the iris, an area which is not prone to move around much. This precludes iris inflammation and atrophy. We have had excellent long-term results using the same lens as a phakic intraocular lens implant in high myopes and hyperopes. The donor button is then sutured in place, he pointed out, adding:

"In our study, 14 eyes of 11 patients with aphakic bullous keratopathy underwent the combined procedure and were followed for from 6 to 24 months (mean 14 months). Post-operatively, we found that mean visual acuity improved from 20/400 to 20/50, with a spherical refractive error of -2.65 dioptres. Mean intraocular pressure was 17.5 mm Hg, an important result to consider, since these patients have a tendency to develop glaucoma following other procedures.

"We also found that the patient's tonography improved by 35%. This would be mainly the result of a careful vitrectomy and angle synechiolysis. Aphakia is very commonly associated with secondary glaucoma. In addition, all grafts were clear; no significant IOL decentrations were observed and there were no complications. Consequently, I believe that this combination of PK and an iris-fixated IOL is an effective and simple technique, and offers a very good alternative for the management of aphakic bullous keratopathy."

Dr. Kanellopoulos has no proprietary interest in any of the materials mentioned.

For more information on the technique, please visit the website: www.brilliantvision.com