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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 141-154

Study of visual outcome and complications of iris-claw intraocular lens implantation to correct aphakia


Department of Ophthalmology, Jawaharlal Nehru Medical College, Wardha, Sawangi(M), Maharashtra, India

Date of Submission04-Jan-2019
Date of Decision30-Jun-2019
Date of Acceptance30-Jul-2019
Date of Web Publication2-May-2020

Correspondence Address:
Dr. Vishal Kalode
Department of Ophthalmology, Jawaharlal Nehru Medical College, Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_3_19

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  Abstract 


Aim: To study the visual outcome and complications of irisclaw intraocular lens implantation to correct aphakia. Objectives: To study the visual outcome in patients with irisclaw lens implantation. To document the various complications associated with irisclaw lens implantation. To evaluate the safety of irisclaw lens implantation. Materials and Methods: Patient's eyes with no capsular support that had iris claw intraocular lens to correct aphakia between 2016 to 2018. Results: The study comprises of 50 eyes of 50 patients who underwent iris claw intraocular lens implantation to correct aphakia with no posterior capsular support. In our study population, the maximum number (70%) of patients had the preoperative BCVA of logMAR 0.18, ranging 0.18–0.78, with a mean of 0.28 ± 0.18, At 6month postoperative followup, of the total patients, 4% had the BCVA of log MAR 0.78, 2% had the BCVA of logMAR 0.6, maximum 88% had the BCVA of logMAR 0.18, and 6% had the BCVA of logMAR 0.3. In the early postoperative complications, 22% of patients had raised IOP, which was controlled on a shortterm antiglaucoma drug (timolol e/d bd); 12% of patients had pupil distortion; and 12% had corneal edema, which subsides on subsequent followup. 6% of patients had anterior chamber reaction and hyphema. Conclusion: Irisclaw lens implantation gives the good visual outcome in the patients of cataract with inadequate capsular support. The anatomical position of IOL is well maintained by the technique. Minor complications were treatable with no visionthreatening complication. Few patients had the late postoperative complication, which needs to be minimized. The technique is easy to master, generally safe, and effective on shortterm followup.

Keywords: Aphakia, iris claw intraocular lens, visual outcome and complications


How to cite this article:
Kalode V, Daigavane S. Study of visual outcome and complications of iris-claw intraocular lens implantation to correct aphakia. J Datta Meghe Inst Med Sci Univ 2019;14:141-54

How to cite this URL:
Kalode V, Daigavane S. Study of visual outcome and complications of iris-claw intraocular lens implantation to correct aphakia. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Sep 19];14:141-54. Available from: http://www.journaldmims.com/text.asp?2019/14/3/141/283585




  Introduction Top


Surgery for cataract has undergone drastic refinements over the last century. Pioneers in various fields continue to introduce and propagate newer techniques of cataract surgery and intraocular lens implantation.

Small-incision cataract extraction or phacoemulsification with a primary insertion of posterior chamber intraocular lens (PCIOL) implantation is at present the procedure of choice for managing cataract in the adult patient, even in complicated cases such as traumatic cataract and subluxated cataract with insufficient capsular and zonular support, as well as in cases with accidental posterior capsular rupture during cataract surgery.[1]

However, some surgeons prefer secondary intraocular lens (IOL) implantation in such complicated cases. There are several ways to proceed with intraocular implantation. They include:

  1. Anterior chamber intraocular lens (ACIOL) implantation
  2. Iris-claw intraocular lens implantation
  3. Scleralfixated intraocular lens implantation.[2]


No consensus currently exists on the optimal method for intraocular implantation in cases without capsular support.

ACIOL is associated with undersized IOL and corneal endothelial cell damage due to IOL rotation, resulting in corneal decompensation.

In oversized ACIOL, the patient develops iris ischemia, iritis, secondary glaucoma, and hyphema.

In the last decades, iris-claw IOL is common in use. Iris-claw IOL implantation has been used more commonly over the last decade, originally designed for fixation on the anterior surface of the iris; a few cases showed advantages of fixating the iris-claw lens, by maintaining the anterior chamber depth and reducing the corneal endothelial cell loss. Rigid polymethylmethacrylate is used for making iris-claw lens. It is implanted through 5.4 mm of corneal or scleral incision.[3]

Iris-claw foldable lens allows a smaller corneal incision approximately 2.8 mm that would reduce postoperative astigmatism.

In this research work, we tried to study the indication, safety, efficacy, postoperative visual outcome, and complication rate in cases where iris-claw lens implantation was done.

Aim and objectives

Aim

To study the visual outcome and complications of iris-claw intraocular lens implantation to correct aphakia.

Objectives

  1. To study the visual outcome in patients with iris-claw lens implantation
  2. To document the various complications associated with iris-claw lens implantation
  3. To evaluate the safety of iris-claw lens implantation.



  Materials and Methods Top


  • Study site: Tertiary care center
  • Design: Hospital-based prospective interventional clinical study
  • Sample size: 50 eyes of 50 patients
  • Study period: 24 months
  • Case record form: Attached with this protocol
  • Ethical committee approval: September 2016.


Inclusion criteria

  • Age group of 40–80 years of both sexes
  • Monocular or binocular surgical aphakia with no capsular support due to posterior capsular rupture in an extracapsular cataract extraction surgery, where PCIOL implantation could not be possible.


Exclusion criteria

  • Patients having no Perception of light (PL) and defective projection of rays (PR) in traumatic cataract
  • Significant iris pathology
  • Glaucoma
  • Chronic or recurrent uveitis/iritis
  • Severe diabetic eye disease
  • Rubeosis iridis
  • Traumatic cataract with angle recession
  • Traumatic cataract with retained intraocular foreign body
  • Corneal pathology: Corneal scarring, irregularities, or opacities
  • Age group of <20 years.


All patients were investigated thoroughly, and proper consent was taken.

Ethical considerations

The study was approved by the institutional ethics committee of the university and was carried out in accordance with the Declaration of Helsinki [Annexure I]. All the patients enrolled in the study were briefed about the nature of the study and necessity of examination. Informed consent was obtained in the local language. It was ensured that the consent was (a) given voluntarily, (b) was fully informed, and (c) was obtained from persons who were competent to do so.

Study design

This was a hospital-based, prospective, interventional, clinical study done in a tertiary center setup. We studied the secondary iris-claw IOL implantation in 50 patients who fulfilled the above-mentioned criteria over a period of 2 years. All patients were thoroughly investigated and underwent secondary iris-claw lens implantation. Postoperatively, best-corrected visual acuity (BCVA), intraocular pressure (IOP), keratometry, and complication encountered were noted at a regular follow-up of 1 week, 1 month, 3 months, and 6 months.

Fifty eyes of 50 patients fulfilled the above-mentioned criteria.

Preoperative visual acuity and BCVA in logMAR, IOP by applanation tonometer, slit-lamp examination, gonioscopy, and B-scan were recorded.

Postoperative BCVA, IOP, and keratometry at 1 week, 1 month, 3 months, and 6 months were recorded. Postoperative complication was also recorded, if any.

Analysis of result and conclusion.

Implication

At the end of this study, we would be able to assess the anatomical, visual outcome, and complication encountered with secondary implantation of iris-claw lens.

Preoperative assessment

History

Detailed ocular and medical history was taken. Special emphasis was given to the history of diminution of vision (gradual or sudden), trauma to the eye, and the trauma occurred. Patients were asked about any other ocular complaints to rule out other ocular pathology and previous ocular surgery.

Trauma to the eye, diabetes mellitus, hypertension, and any other medical or surgical history in the past were noted. Hence, the patients with other causes of poor vision could be excluded from the study.

Study design

Fifty consecutive patients who underwent extracapsular cataract extraction with posterior capsular rent resulting in surgical aphakia.

Preoperative uncorrected visual acuity (UCVA), BCVA in logMAR, IOP, slit-lamp examination, gonioscopy, and B scan.

Operated by same surgeon.

Anterior vitrectomy when indicated and iris-claw lens implantation was done.

Recording of postoperative BCVA, IOP, and keratometry at 1 week, 4 week, 3 month, and 6 month. Postoperative complication noted.

Analysis of result and conclusion.

Ocular examination

  1. Visual acuity: Uncorrected, with the pinhole as well as BCVA was recorded preoperatively in each patient in logMAR
  2. Anterior segment examination: Detailed anterior segment examination was done including slit-lamp biomicroscopy and assessment of grades of vitreous herniation into the anterior chamber. Slit-lamp examination with previous surgical peripheral iridectomy and pupil was done
  3. Distant direct ophthalmoscopy and detailed dilated fundus evaluation were done using +90 D lens or indirect ophthalmoscopy
  4. B-scan ultrasonography was done when media opacities precluded adequate visualization of the fundus
  5. IOP was taken with Goldmann's applanation tonometer
  6. Syringing of both eyes to rule out any focus of infection of the sac
  7. Keratometry and A-scan were done. IOL power was calculated using SRK II formula.


P = A − 2.5 L − 0.9 K.

Where P: power of IOL in Diopter, A: constant, L: axial length of the eyeball in millimeter, and K: average corneal curvature.

After the examination, the following investigations were done in all the patients preoperatively:

  1. Conjunctival swab for culture and sensitivity
  2. Electrocardiography
  3. Blood sugar random and if necessary fasting and postprandial
  4. Chest X-ray if advised by the physician
  5. The operative fitness of each patient was obtained from the physician.


Consent

Informed consent was taken from the patients after explaining the need for surgery and also visual prognosis [Annexure II].

Preoperative preparation: Every patient who was included in the study was admitted 1 day before operation.

  • Xylocaine sensitivity test was done
  • Preoperative antibiotic eyedrop was instilled 6 hourly.


Instrument and material required during surgery are as follows:

  • Wire speculum
  • Round-bodied needle with thread to take superior rectus stay suture
  • Conjunctival forceps
  • Section enlarging scissors
  • Bard-Parker handle
  • #15 blade
  • Lance tip blade
  • Crescent blade
  • 2.8-mm keratome blade
  • 5.5-mm keratome blade
  • Iris-claw lens holding forceps
  • Injection pilocarpine
  • Enclavation rod
  • Vannas scissors
  • Iris repositor
  • Syringe with fine cannula
  • Bipolar wet cautery
  • 10-0 nylon suture
  • Automated vitrectomy probe
  • 26 G needle
  • Mcpherson forceps
  • Injection dexamethasone and gentamicin for subconjunctival injection
  • 0.05 mL intracameral injection of moxifloxacin.


Surgical procedure

Anesthesia

Topical surface anesthesia was given with 4% lignocaine. Then, peribulbar block was given using 2% lignocaine + adrenaline + hyaluronidase injection(3ml) and injection 0.5% bupivacaine (2 ml).

All surgeries were performed by a single surgeon using the same surgical technique.

Surgical technique

Superotemporal scleral incision

  1. Surgeon was required to sit laterally toward the patient's shoulder and perform surgery
  2. For the right eye, incision was need to be placed at 10–12 o'clock and for the left eye at 12–2 o'clock position
  3. Superior rectus suture was fixed for superotemporal incision
  4. Fornixbased conjunctival flap was prepared to expose the limbus
  5. Hemostasis was achieved using a wet-field bipolar cautery
  6. Paracentesis was created at 5 o'clock and 10 o'clock position using a 15° lance tip knife
  7. Partial-thickness groove was made through about two-thirds depth of anterior limbal area from 12 o'clock to 3 o'clock (150°) with the help of a razor (#11 surgical blade) knife
  8. A self-sealing sclerocorneal tunnel incision was made
  9. Anterior vitrectomy was performed with the help of an automated vitrectomy probe if there is a vitreous loss (vitrectomy probe setting: vacuum 150 mmHg, aspiration flow rate of 22 ml/min, and power of 420 Hz)
  10. Injection pilocarpine 0.5% was injected through the side port
  11. Viscoelastic material was introduced in the anterior chamber to help protect the cornea and facilitate the positioning of the iris-claw IOL implantation
  12. The iris-claw lens was inserted posterior to the iris (lens has 5 mm optic and a total diameter of 8.5 mm) in the anterior chamber with the help of a iris-claw lens holding forceps
  13. The IOL was rotated and centered over the pupil
  14. The IOL was enclavated into the iris using enclavation rod
  15. Thereafter, a peripheral iridectomy was performed at 12 o'clock position using the scissors to avoid a pupillary block
  16. Viscoelastic material was removed through irrigation and aspiration cannula
  17. The anterior chamber was formed with normal saline and air
  18. 10.0 nylon-interrupted suturing was done
  19. The conjunctival flap was cauterized
  20. Subconjunctival injection of gentamicin and dexamethasone was given (0.5 ml)
  21. Dexamethasone (Ocupol) ointment was applied in the eye
  22. Pad and Bandage were given.


Postoperative treatment

  • Tablet ofloxacin 200 mg twice a day for 3 days
  • Tablet pantoprazole 40 mg once a day for 3 days
  • Tablet aceclofenac 100 mg twice a day for 3 days
  • Tablet acetazolamide as and when required.


Local treatment

Steroid eyedrop (dexamethasone 0.1%) was given 6 times/day for 6 weeks in tapering dose and antibiotic eyedrop (moxifloxacin eyedrop 0.5 mg %) 6 times/day for 6 weeks in tapering dose.

Antiglaucoma drug was given if required.

Postoperatively, visual acuity, IOP, slit-lamp finding, and complication, if any, were noted on the 1st postoperative day. Patients were then discharged on the 3rd postoperative day and were called for follow-up weekly for 4 weeks and then at 3rd and 6th months postoperatively. On every follow-up visit, the eye was examined on the slit lamp, and BCVA, IOP, and keratometry reading were recorded. The patients pro forma was duly filled and records were kept.

The statistical analysis of the main outcome variables was done by the application of appropriate statistical methods.

Statistical analysis

All data were analyzed with the assistance of biostatistician, Department of Community Medicine, Jawaharlal Nehru Medical College, Sawangi, Wardha.

Using descriptive and inferential statistics by Chi-square test, Student's paired t-test, and one-way ANOVA, statistical analysis was done. SPSS 22.0 version (Chicago, Illinois, USA) and GraphPad Prism 6.0 version software were used.

P < 0.05 was considered the level of significance.

All numerical patient data were entered into a Microsoft Excel spreadsheet.

η =16 σ22.

Where Δ represents expected mean and σ standard deviation (SD) of variable based on paired sample.

The minimum sample size was 44 and hence we choose 50 eyes of 50 patients.


  Observations and Results Top


The study was done at the department of ophthalmology in a tertiary care center from October 01, 2016, to September 30, 2018. The study included 50 eyes of 50 patients which required iris-claw lens implantation. Preoperative and postoperative visual acuity, IOP, astigmatism, and postoperative complications were recorded. All patients were followed up at a regular interval of 1 week, 4 weeks, 3 months, and 6 months. None of the patients was lost to follow-up.

The maximum number (62%) of patients were in the age group of 61–70 years, whereas the least were in 41–50 years of age group, with a mean of 65.14 ± 5.62 years [Table 1].
Table 1: Distribution of patients according to age

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Of 50 cases, 54% were female and 46% were male and male: female ratio was 1:1.17, which shows female dominance [Table 2].
Table 2: Gender-wise distribution of patients

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Of 50 cases, 52% were of the right eye and 48% were of the left eye [Table 3].
Table 3: According to laterality distribution of patients

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In our study population, the maximum number (58%) of patients had the UCVA of logMAR 1.48 [Table 4].
Table 4: Distribution of patients according to preoperative uncorrected visual acuity

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In our study population, the maximum number (70%) of patients had the preoperative BCVA of logMAR 0.18, with a mean of 0.28 ± 0.18 [Table 5].
Table 5: Distribution of patients according to preoperative best-corrected visual acuity

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In our study, the maximum number (34%) of patients had the preoperative IOP of 18 mmHg, ranging 14–24 mmHg, with a mean of 18.24 ± 2.00 [Table 6].
Table 6: Distribution of patients according to preoperative Intraocular pressure

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In our study population, the preoperative astigmatism ranged from 0.75 to 1.75 with a mean of 1.30 ± 0.22. The maximum number of patients had the astigmatism of 1.25–1.5 D [Table 7].
Table 7: Distribution of patients according to preoperative astigmatism

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At day 1 postoperative followup, of the total patients, 10% had the BCVA of logMAR 1, 34% had the BCVA of logMAR 0.78, maximum 38% had the BCVA of logMAR 0.60, 12% had the BCVA of logMAR 0.48, and 6% had the BCVA of logMAR 0.18 which had the mean of 0.68 ± 0.16 with a mean reduction of 0.40 ± 0.25 from baseline, had the P = 0.0001 which was significant [Table 8].
Table 8: Distribution of patients according to postoperative best-corrected visual acuity on day 1 follow-up

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At 1-week postoperative follow-up, of the total patients, 6% had the BCVA of logMAR 1, 14% had the BCVA of logMAR 0.78, 26% had the BCVA of logMAR 0.60, maximum 30% had the BCVA of logMAR 0.48, 20% had the BCVA of logMAR 0.18, and 4% had the BCVA of logMAR 0.3. Fifty patients had the mean of 0.51 ± 0.22 with a mean reduction of 0.23 ± 0.28 from baseline, and had the P = 0.0001 which was significant [Table 9].
Table 9: Distribution of patients according to postoperative on 1-week follow-up

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At 1-month postoperative follow-up, of the total patients, 4% had the BCVA of logMAR 0.78, 2% had the BCVA of logMAR 0.60, 2% had the BCVA of logMAR 0.48, maximum 88% had the BCVA of logMAR 0.18, and 4% had the BCVA of logMAR 0.13. Fifty patients had the mean of 0.22 ± 0.13 with a mean reduction of 0.05 ± 0.16 from baseline, and had the P = 0.016 which was significant [Table 10].
Table 10: Distribution of patients according to postoperative best-corrected visual acuity on 1-month follow-up

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At 3 month postoperative follow up, of the total patients, 2% had the BCVA of logMAR 0.78, 0.6, and 0.48; maximum 88% had the BCVA of logMAR 0.18; and 6% had the BCVA of logMAR 0.3 which had the mean of 0.21 ± 0.11 with a mean reduction of 0.06 ± 0.16 from baseline, and had the P = 0.007 which was significant [Table 11].
Table 11: Distribution of patients according to postoperative on 3-month follow-up

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At 6 month postoperative follow up, of the total patients, 4% had the BCVA of logMAR 0.78, 2% had the BCVA of logMAR 0.6, maximum 88% had the BCVA of logMAR 0.18, and 6% had the BCVA of logMAR 0.3 which had the mean of 0.21 ± 0.13 with a mean reduction of 0.06 ± 0.16 from baseline, and had the P = 0.010 which was significant [Table 12].
Table 12: Distribution of patients according to postoperative on 6-month follow-up

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In our study, the mean preoperative BCVA was 0.28 ± 0.18 after the irisclaw lens implantation, the BCVA improved at 1st day postoperative with a mean of 0.68 ± 0.16, had the mean reduction of 0.40 ± 0.25 from baseline, at end of 1week followup the mean BCVA 0.51 ± 0.22 with a mean reduction 0.23 ± 0.28 from baseline. At end of 1month follow-up the mean BCVA 0.22 ± 0.13 with a mean reduction of 0.05 ± 0.16, at 3 months follow-up the mean BCVA was 0.21 ± 0.11 with a mean reduction of 0.06 ± 0.16 from the baseline. At 6-month follow-up, the mean BCVA was 0.21 ± 0.13 with a mean reduction of 0.06 ± 0.16 from baseline. The P value at each follow-up was 0.0001, which was statistically significant. By applying one-way repeated measures ANOVA test, the mean value of BCVA was significantly increased at different follow-up periods from baseline (F = 70) [Table 13].
Table 13: Pre- and postoperative best-corrected visual acuity in different follow-up periods

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In our study population, the maximum number (48%) of patients had the postoperative 1-week IOP of 18, ranging 16–20, with a mean of 17.32 ± 1.43 [Table 14].
Table 14: Distribution of patients according to postoperative 1-week intraocular pressure

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In our study population, the maximum number (54%) of patients had the postoperative 1-month IOP of 16, ranging 16–20, with a mean of 17.16 ± 1.40 [Table 15].
Table 15: Distribution of patients according to postoperative 1-month intraocular pressure

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In our study population, the maximum number (48%) of patients had the postoperative 1-month IOP of 16, ranging 16–20, with a mean of 17.52 ± 1.37 [Table 16].
Table 16: Distribution of patients according to postoperative 3-month intraocular pressure

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In our study population, the maximum number (70%) of patients had the postoperative 6-month IOP of 16, ranging 16–20, with a mean of 16.52 ± 0.97 [Table 17].
Table 17: Distribution of patients according to postoperative 6-month intraocular pressure

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In our study, the mean baseline preoperative IOP was 18.24 ± 2.00 and at 1week followup it was 17.32 ± 1.43 with a mean increase of 0.92 ± 1.86 from baseline had P = 0.001S, at 1month follow-up the mean IOP was 17.16 ± 1.40 had the mean increase of 1.08 ± 1.98 from baseline had P = 0.0001S, at 3month followup the mean IOP was 17.52 ± 1.37 and mean increase of 0.72 ± 2.31 had the P = 0.032S, at 6month follow-up the mean IOP was 16.52 ± 0.97 had the mean reduction of 1.72 ± 2.21 from baseline having P = 0.0001S. There was no significant change in IOP at different follow-up periods from baseline (F = 8.87) with mean P = 0.0001S [Table 18].
Table 18: Pre- and post-operative intraocular pressure at different follow-up periods

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In our study, the maximum number (46%) of patients had the postoperative astigmatism of 1.25, with a mean of 1.48 ± 0.30 [Table 19].
Table 19: Distribution of patients according to postoperative astigmatism

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In our study, the preoperative astigmatism was 1.30 ± 0.22 and postoperative astigmatism was 1.48 ± 0.30, which was statistically significant (t = 5.14, P = 0.0001) [Table 20].
Table 20: Pre and postoperative astigmatism

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In the early postoperative complications, 22% of patients had raised IOP, which was controlled on the short-term antiglaucoma drug (timolol e/d bd); 12% of patients had pupil distortion; and 12% of patients had corneal edema, which subsides on subsequent follow-up. 6% of patients had anterior chamber reaction and hyphema [Table 22].
Table 22: Distribution of patients according to early postoperative complications

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In the late postoperative complications, 8% of patients had cystoid macular edema (CME), which had responsible for low vision in that patients, which was managed with topical treatment following sub-Tenon's triamcinolone; 12% of patients had pupil distortion; 4% of patients had IOL tilt; 2% of patients had IOL decentralization [Table 23].
Table 23: Distribution of patients according to late postoperative complications

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  Discussion Top


In the present prospective clinical study, we studied visual outcome with associated complication in iris-claw lens implantation. The study was done for the period of 24 months from October 01, 2016, to September 30, 2018. We studied the result of iris-claw lens implantation in 50 cases.

In our study, we correct aphakia using iris-claw IOL. It is a single-piece polymethylmethacrylate IOL with 5.5 mm optic and 8.5 mm overall length, with two holes with a diameter of 1.25 mm each with 0° claw cut.

All patients were operated by the same surgeon and they were followed up for 6 months and the results were noted.

During this study period of 2 years, we came across 57 patients with an indication for iris-claw lens implantation. However, on detailed examination and investigation, it was seen that some of these patients were not suitable for this technique due to other causes of poor vision. Hence, we performed iris claw in 50 cases and included all of these in our study.

We discussed the age- and gender-wise distribution of study patients, the indication for iris-claw IOL implantation, preoperative and postoperative visual outcome, and associated complications both early and late.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81]

Age- and gender-wise distribution patients with iris-claw lens implantation

[Table 1] shows that the maximum number (62%) of patients were in the age group of 61–70 years, whereas the least cases found in 41–50 years of age group, with a mean of 65.14 ± 5.62 years.

[Table 2] shows that of 50 cases, 27 (54%) were female and 23 (46%) were female and male: female ratio was 1:1.17, which shows female dominance.

[Table 3] shows that of 50 cases, 26 (52%) were of the right eye and 24 (48%) were of the left eye. Six months of follow-up was done.

In a study by Mohamed,[82] the mean age for surgery was 58.7 years (range, 46–74 years); 66% were male and 34% were female. The cause of aphakia was following a complicated phacoemulsification (13 eyes) and a complicated extracapsular cataract extraction (11 eyes). The mean follow-up was 7.1 ± 1.1 months (range, 6–9 months).

In a study by Raghavendra Rao and Ajita Sasidharan,[83] the mean age for surgery was 57 ± 10 years (range, 30–75 years); 50% were male and 50% were female. Following complications such as Posterior capsular rupture, large zonular dialysis (>180°), and patients of intracapsular cataract extraction (ICCE) in the subluxated cataractous lens (>180°) where a PCIOL could not be placed and eye remains aphakic. The mean followup period was 6 months.

In a study by Rashad et al.,[84] the mean age for surgery was 54.64 years; 35% were male and 65% were female. The cause of aphakia was inadequate capsular support after complicated phacoemulsification or Extra capsular cataract extraction surgery (14%).

Five eyes were aphakic after ICCE, and two eyes were aphakic after traumatic cataract with posterior capsule rupture. The mean follow-up was 3 months.

In a study by Sri Ganesh, Sheetal Brar, and Kirti Relekar,[85] the mean age was 51.1 years, having 59 cases. The causes of aphakia were surgical aphakia due to cataract surgery (58%), subluxated lens (24%), traumatic cataract (5%), and subluxated IOL (13%). The mean follows-up was 13.09 months.

In a study by Maurice Schallenberg et al.,[86] the mean age was 72.66 years (range, 45–86 years). Of 31 patients selected for the study, 20 were male and 11 were female. The causes of aphakia included IOL luxation (52%), ocular trauma (6%), aphakia after congenital cataract (3%), complicated cataract surgery (36%), and secondary glaucoma after anterior chamber lens (3%). The mean follow-up was 25.2 months (range, 4–48 months).

Our study result is comparable with the studies by Mohamed, Raghavendra Rao, Ajita Sasidharan, and Rashad et al.

Astigmatism

In our study, [Table 17] shows that the preoperative astigmatism was 1.31 with SD 0.23 and postoperative astigmatism was 1.49 with SD 0.31, which was statistically significant.

In a study conducted by Matteo Forlini et al.,[87] the postoperative residual spherical equivalent error was −1.5 ± 1.15 (D), which was statistically significant.

In a study by Mohamed,[82] the mean postoperative spherical equivalent was 1.00 ± 0.67 D, whereas it was 9.50 ± 1.7 D preoperatively.

In a study conducted by Sri Ganesh et al.,[85] the postoperative astigmatism was found to be ±2.25 D.

Our study result is comparable with the study by Ahmed H and Mohamed et al. and Matteo Forlini et al.

Preoperative visual acuity BCVA [All values are taken in logMAR scale].

Preoperatively, the visual acuity was measured to compare the postoperative BCVA after iris-claw lens implantation. As shown in [Table 5], the preoperative mean BCVA was logMAR 0.28 ± 0.18 (range, logMAR 0.18–0.78).

Raghavendra Rao and Ajita Sasidharan[83] in their study noticed preoperative BCVA of logMAR 1.0 with +10 Diopters on Snellen chart.

In a study by Rashad et al.,[84] the preoperative BCVA was found to be logMAR 0.36 ± 0.21.

In a study by Mohamed,[82] the preoperative BCVA was logMAR 0.55 ± 0.19.

In a study by Sri Ganesh, Sheetal Brar, and Kirti Releka,[85] the preoperative BCVA was 0.86 ± 0.81.

In a study by Maurice Schallenberg et al.,[86] the preoperative BCVA was found to be 0.85 ± 0.42.

Our study is comparable with the study by Sri Ganesh, Sheetal Brar, Kirti Releka, and Maurice Schallenberg et al.

Postoperative visual acuity

BCVA was measured on the 1st postoperative day by Snellen chart. Similarly, on follow-up visits at 1 week, 1 month, 3 months, and 6 months, visual acuity was noted.

In this study, as shown in [Table 14], the BCVA on day 1 was logMAR 0.68 ± 0.16 with an average increase of 0.40 with baseline, having P = 0.0.0001, which was highly significant. Four of our patients developed CME in late postoperative period responsible for low vision in that patients.

At a follow-up period of 6 months, the BCVA was logMAR 0.21 ± 0.13 postoperatively as compared to preoperative, having P = 0.010, which was statistically significant.

In a study by Mohamed,[82] the postoperative BCVA logMAR paired sample test for preoperative BCVA and postoperative BCVA having a P value < 0.001.

In a study by Raghavendra Rao and Ajita Sasidhara,[83] the postoperative BCVA was logMAR 0.2 or more in 80% of cases. 20% of cases had logMAR <0.2. The P value was found to be statistically significant.

In a study by Rashad et al.,[84] at the end of 3 months, the BCVA was logMAR 0.22 ± 0.11, which was statistically significant.

In a study by Sri Ganesh, Sheetal Brar, and Kirti Relekaat,[85] at the end of follow-up period, the BCVA was logMAR 0.38 ± 0.51, having P < 0.001.

In a study by Maurice Schallenberg et al.,[86] the BCVA was logMAR 0.64 ± 0.62, which was statistically significant.

Our study result is comparable with the study by Raghavendra Rao, Ajita Sasidhara, and Dina Mohammad Rashad et al.

Intraocular pressure

The preoperative IOP was measured with Goldmann's applanation tonometer, which was found to be 18.24 ± 2.00 mmHg with the range of 14–24 mmHg. The IOP was measured on the postoperative 1 week, 1 month, 3 months, and 6 months.

On the 1st postoperative week, the mean IOP was 17.32 ± 1.43 mmHg, which was slightly raised from the preoperative baseline value. This rise in IOP was attributed to postoperative iridocyclitis and residual viscoelastic substance. These cases received topical steroid and topical antiglaucoma medications. This rise was statistically significant, having P = 0.001.

After the 1st postoperative month, the IOP was 17.16 ± 1.40 mmHg, which was found to be near the baseline. At the end of postoperative 6 months, the IOP was 16.52 ± 0.97 mmHg, which was statistically significant.

In a study conducted by Rashad et al.,[84] on the 1st postoperative day, the IOP ranged from 12 to 21 mmHg, with a mean of 15.62 ± 2.59 mmHg, which was statistically significant. This rise in IOP was attributed to postoperative iridocyclitis. After the 1st postoperative week, the IOP ranged from 12 to 18 mmHg, with a mean of 15.28 ± 2 mmHg, which was statistically insignificant. After the 1st postoperative month, the IOP ranged from 12 to 19 mmHg, with a mean of 15.1 ± 1.87 mmHg, and after the first 3 months postoperatively, the IOP ranged from 13 to 20 mmHg, with a mean of 15.52 ± 2 mmHg.

In a study conducted by Mohamed,[82] in two cases, the IOP was higher than 21 mmHg in the early postoperative period that was controlled with topical antiglaucoma drugs. The postoperative rise of IOP may be attributed to incomplete removal of the viscoelastic substance.

In a study conducted by Matteo Forlini et al.,[87] the mean postoperative IOP was 16.4 ± 3.4 mmHg. Two cases presented with postoperatively increased IOP, which was managed medically with topical antiglaucoma drugs.

Our study result is comparable with the study by Dina Mohammad Rashad et al. and Matteo Forlini.

In a study conducted by Sezer Helvacı,[88] they have increased IOP which were statistically significant for each group at 1st week (P < 0.05). All patients’ increased IOP values were controlled adequately with a fixed-dose combination of hypotensive drop (timolol 2 times/day). When the treatment stopped just a few weeks later, there was no permanent increase of IOP.

Complication

Intraoperative complication

In our study, one of our patients had vitreous prolapse, whereas the another one had iridodialysis [Table 21].
Table 21: Distribution of patients according to intraoperative complications

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In a study conducted by Rashadet al.,[84] 2% of patients had intraoperative hyphema, according to their result hemorrhage due to peripheral iridectomy and had no other complication.

Postoperative complication

As shown in [Table 22] and [Table 23], the postoperative complications observed were divided into two groups. Early postoperative complications included those observed within the 1st postoperative month and late complications included those which were seen after 1 month up to 6 months postoperatively. The preoperative and postoperative intraocular parameters are also discussed here.

Early postoperative complication

In our study, as shown in [Table 22], the raised IOP was observed in 22% of patients in early postoperative days. All these patients were started on antiglaucoma medication and their IOP was controlled. None of our patients had persistent raised IOP.

Transient corneal edema was found in 12% of patients, which was cleared in all patients by 2–3 weeks. Four of them required topical 6% sodium chloride eye ointment.

Corneal edema is most often caused by the combination of mechanical trauma, prolonged surgery time, inflammation, and raised IOP. The edema from surgical trauma generally resolved completely within 4–6 weeks of surgery.

One (2%) patient had the shallow anterior chamber and 3 (6%) patients had hyphema, which was reduced in subsequent follow-up period.

Postoperative anterior chamber reaction was seen in 6% of patients.

We also got two cases of IOL tilt, which was managed on follow-up period.

Late postoperative complication

We found 4 (8%) patients with CME, which was responsible for low vision in that patients.

One (2%) patient was IOL decentration, which was not visually significant.

In our case study, 6 (12%) patients were found to have pupil distortion.

Two (4%) patients had IOL tilt, which was managed on follow-up.

In a study conducted by Raghavendra Rao and Ajita Sasidharan,[83] they noticed no significant complications, such as increased IOP, CME, AC reaction, or IOL tilt.

In a study conducted by Sezer Helvaci,[88] there was no any patient of hypotony, uveitis, CME, IOL dislocation, hyphema, and vitreous hemorrhage at long-term follow-up (1st week to 6th month). All the IOLs were well centered. Pupillary distortion was seen in one patient. They had found one case of retinal detachment. Elevated IOP was noted in four patients postoperatively. All patients’ increased IOP values were controlled adequately with a fixed-dose combination of hypotensive drop (timolol 2 times/day). When the treatment stopped just a few weeks later, there was no permanent increase of IOP. There was no statistically significance when complications range compared between the two groups (P = 0.067).

In a study conducted by Matteo Forlini et al.,[87] they found subluxation of IOL in three cases because of slippage of one of the iris-claw haptics after a mean follow-up of 12 months (range, 10–14 months). One case presented with complete spontaneous dislocation of the iris claw in the vitreous cavity. One case developed retinal detachment after Retro pupillary iris claw intraocular lens (RPICIOL) implantation for posttraumatic aphakia, and there was no cases of uveitis after RPICIOL implantation. Eight cases complained of chronic dull eye pain following RPICIOL implantation, which decreased with time; five cases showed severe iridodonesis; and three cases had CME, which developed 2 months after RPICIOL implantation. Oval pupil was seen in 5% (16 eyes) of the patients.

In a study conducted by Mohamed,[82] they found 1 (4%) patient had CME, 2 (8%) patients had pigment dispersion on the surface of IOL, and 2 (8%) patients had developed transient IOP rise; no eye showed IOL displacement or dislocation; and no other severe adverse events such as postoperative retinal detachment or endophthalmitis were noted.

The result of our study group is comparable with the study by Sezer Helvaci, Selahaddin Demirduzen, Huseyin oksuz, Ahmed H. Mohamed, and Matteo Forlini.[89]


  Summary Top


A study of visual and anatomical outcome in cases of iris-claw lens implantation was undertaken at the department of ophthalmology in a tertiary care center. The study was performed on 50 eyes of 50 patients having complicated extracapsular cataract extraction with posterior capsular rupture during cataract extraction in which primary PCIOL implantation was not possible.

  • The maximum number (62%) of patients were in the age group of 61–70 years, whereas the least cases were found in 41–50 years of age group. The mean age of patients in our study was 65.14 ± 5.62 years
  • Of 50 cases, 54% were male and 46% were female and male: Female ratio was 1:1.17, which shows female dominance.
  • Of 50 cases, 52% were of the right eye and 48% were of the left eye
  • Iris-claw lens implantation was done in aphakia due to posterior capsular rupture due to complicated small-incision cataract surgery, in which primary PCIOL implantation was not done
  • In our study population, the maximum number (58%) of patients had the UCVA of logMAR 1.48
  • In our study population, the maximum number (70%) of patients had the preoperative BCVA of logMAR 0.18, ranging 0.18–0.78, with a mean of 0.28 ± 0.18
  • In our study, the maximum number (34%) of patients had the preoperative IOP of 18 mmHg, ranging 14–24 mmHg, with a mean of 18.24 ± 2.00
  • In our study population, the preoperative astigmatism ranged from 0.75 to 1.75 with a mean of 1.30 ± 0.22. The maximum number of patients had the astigmatism of 1.25–1.5 D
  • At day 1 postoperative follow-up, of the total patients, 10% had the BCVA of logMAR 1, 34% had the BCVA of logMAR 0.78, maximum 38% had the BCVA of logMAR 0.60, 12% had the BCVA of logMAR 0.48, and 6% had the BCVA of logMAR 0.18 which had the mean of 0.68 ± 0.16 with a mean reduction of 0.40 ± 0.25 from baseline, had the P value of 0.0.0001.
  • At day 7 postoperative follow-up, of the total patients, 6% had the BCVA of logMAR 1, 14% had the BCVA of logMAR 0.78, 26% had the BCVA of logMAR 0.60, maximum 30% had the BCVA of logMAR 0.48, 20% had the BCVA of logMAR 0.18, and 4% had the BCVA of logMAR 0.3 which had the mean of 0.51 ± 0.22 with a mean reduction of 0.23 ± 0.28 from baseline, and had the P = 0.0001
  • At 1month postoperative follow-up, of the total patients, 4% had the BCVA of logMAR 0.78, 2% had the BCVA of logMAR 0.60, 2% had the BCVA of logMAR 0.48, maximum 88% had the BCVA of logMAR 0.18, and 4% had the BCVA of logMAR 0.13 which had the mean of 0.22 ± 0.13 with a mean reduction of 0.05 ± 0.16 from baseline, and had the P = 0.016
  • At 3-month postoperative follow-up, of the total patients, 2% had the BCVA of logMAR 0.78, 0.6, and 0.48; maximum 88% of patients had the BCVA of logMAR 0.18; and 6% of patients had the BCVA of logMAR 0.3. Fifty patients had the mean of 0.21 ± 0.11 with a mean reduction of 0.06 ± 0.16 from baseline, and had the P value of 0.007
  • At 6 months postoperative follow-up, of the total patients, 4% had the BCVA of logMAR 0.78, 2% had the BCVA of logMAR 0.6, maximum 88% had the BCVA of logMAR 0.18, and 6% had the BCVA of logMAR 0.3. Fifty patients had the mean of 0.21 ± 0.13 with a mean reduction of 0.06 ± 0.16 from baseline, and had the P = 0.010
  • In our study population, the maximum number (48%) of patients had the postoperative 1-week IOP of 18, ranging 16–20, with a mean of 17.32 ± 1.43
  • In our study population, the maximum number (54%) of patients had the postoperative 1-month IOP of 16, ranging 16–20, with a mean of 17.16 ± 1.40
  • In our study population, the maximum number (48%) of patients had the postoperative 1-month IOP of 16, ranging 16–20, with a mean of 17.52 ± 1.37
  • In our study population, the maximum number (70) of patients had postoperative 6-month IOP of 16, ranging 16–20, with a mean of 16.52 ± 0.97
  • In our study, the maximum number (46%) of patients had the postoperative astigmatism of 1.25, with a mean of 1.48 ± 0.30
  • In our study, the preoperative astigmatism was 1.30 ± 0.22 and postoperative astigmatism was 1.48 ± 0.30. This was insignificant (t = 5.14, P = 0.0001)
  • In the early postoperative complications, 22% of patients had raised IOP, which was controlled on a short-term antiglaucoma drug (timolol e/d bd); 12% of patients had pupil distortion; and 12% had corneal edema, which subsides on subsequent follow-up. 6% of patients had anterior chamber reaction and hyphema


  • In the early postoperative complications, 20% of patients had raised IOP, which was controlled on a short-term antiglaucoma drug (timolol e/d bd); 13.3% of patients had pupil distortion; and 11.1% had corneal edema, which subsides on subsequent follow-up. 4.4% of patients had anterior chamber reaction and one patient had IOL decentralization and shallow AC, which was managed on follow-up.


To summarize, in short, the visual outcome was satisfactory in iris-claw lens implantation with 88% of patients having postoperative BCVA of logMAR 0.18. Few cases developed pupil distortion (12%), CME (8%), and IOL decentralization (2%). Early postoperative complications were mostly minor and controlled with few days of medication. Most IOL maintained the optical position well. None of the vision-threatening complications were noted.


  Conclusion Top


  1. Iris-claw lens implantation gives the good visual outcome in the patients of cataract with inadequate capsular support
  2. The anatomical position of IOL is well maintained by the technique
  3. Minor complications were treatable with no vision-threatening complication
  4. Few patients had the late postoperative complication, which needs to be minimized
  5. The technique is easy to master, generally safe, and effective on short-term follow-up.


Recommendations

  1. In our experience, insertion of posterior iris-fixated IOL is well within the skillsets and maneuvers familiar to a cataract surgeon and provides a very easy, simple, and affordable option with no serious adverse effect during the follow-up period
  2. This type of implantation should be considered, especially in all aphakic patients with contraindications for anterior chamber implant because of glaucoma or endothelial abnormality
  3. The retropupillary iris-claw IOL provided good visual outcomes with a favorable complication rate and can be used for a wide range of indications in eyes without adequate capsule support.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexure I and II Top


Use of “Should“ And “Must“ in the 2000 and 2008 Versions of the World Medical Association's Declaration of Helsinki



Note: Only the respective sentences and the immediate context have been reproduced, and only those provisions where changes have been made. Occurrences of “should“ and “must“ have been highlighted in italics. Changes and new additions in the 2008 penultimate draft, and 2008 final version vis a vis the 2000 version have been highlighted in bold. Paragraph numbers are given in (). Since there have been changes in the number of paragraphs, text in the same row refers to the same provision, even though the paragraph numbering may differ.

2000 version May 2008 penultimate draft version

October 2008 final version

[new addition in 2008 version]

[new addition in 2008 version]

The Declaration is intended to be read as a whole and each of its constituent paragraphs should not be applied without consideration of all other relevant paragraphs. Medical progress is based on research which ultimately must rest in part on experimentation involving human subjects.

Medical progress is based on research that ultimately must include studies involving humans. Populations that are underrepresented in medical research should be provided appropriate access to participation in research. Medical progress is based on research that ultimately must include studies involving human subjects. Populations that are underrepresented in medical research should be provided appropriate access to participation in research.

In medical research on human subjects, considerations related to the well-being of the human subject should take precedence over the interests of science and society. In medical research involving humans, the wellbeing of the individual research subject should take precedence over all other interests.

In medical research involving human subjects, the well-being of the individual research subject must take precedence over all other interests. Even the best proven prophylactic, diagnostic, and therapeutic methods must continuously be challenged through research for their effectiveness, efficiency, accessibility and quality. Even the best current methods should continually be evaluated through research for their safety, effectiveness, efficiency, accessibility and quality.

Even the best current interventions must be evaluated continually through research for their safety, effectiveness, efficiency, accessibility and quality Some research populations are vulnerable and need special protection. The particular needs of the economically and medically disadvantaged must be recognized [sentence including “must“ omitted] [sentence including “must“ omitted]

Medical research involving human subjects must conform to generally accepted scientific principles, be based on a thorough knowledge of the scientific literature, other relevant sources of information, and on adequate laboratory and, where appropriate, animal experimentation. Medical research involving humans should conform to generally accepted scientific principles, be based on a thorough knowledge of the scientific literature, other relevant sources of information, and adequate laboratory and, as appropriate, animal experimentation. The welfare of animals used for research should be respected. [last sentence found in paragraph 12 of 2000 version, see row below] (12) Medical research involving human subjects must conform to generally accepted scientific principles, be based on a thorough knowledge of the scientific literature, other relevant sources of information, and adequate laboratory and, as appropriate, animal experimentation. The welfare of animals used for research must be respected. Appropriate caution must be exercised in the conduct of research which may affect the environment, and the welfare of animals used for research must be respected. Appropriate caution should be exercised in the conduct of research that may affect the environment. Appropriate caution must be exercised in the conduct of medical research that may harm the environment. The design and performance of each experimental procedure involving human subjects should be clearly formulated in an experimental protocol. This protocol should be submitted for consideration, comment, guidance, and where appropriate, approval to a specially appointed ethical review committee, which must be independent of the investigator, the sponsor or any other kind of undue influence. This independent committee should be in conformity with the laws and regulations of the country in which the research experiment is performed. The committee has the right to monitor ongoing trials. The researcher has the obligation to provide monitoring information to the committee, especially any serious adverse events. The researcher should also submit to the committee, for review, information regarding funding, sponsors, institutional affiliations, other potential conflicts of interest and incentives for subjects. The design and performance of each research study involving humans should be clearly described in a research protocol. The protocol should contain a statement of the ethical considerations involved and should indicate how the principles in this Declaration have been addressed. The protocol should include information regarding funding, sponsors, institutional affiliations, other potential conflicts of interest, incentives for subjects and provisions for treating and/or compensating subjects who are harmed as a consequence of participation in the research study. The protocol should describe arrangements for access by study subjects to methods identified as beneficial in the study or access to other appropriate care or benefits. [Note: vis a vis the 2000 version, paragraphs 13 and 14 have been reorganized so that the protocol is dealt with in 13 and the research ethics . The design and performance of each research study involving human subjects must be clearly described in a research protocol. The protocol should contain a statement of the ethical considerations involved and should indicate how the principles in this Declaration have been addressed. The protocol should include information regarding funding, sponsors, institutional affiliations, other potential conflicts of interest, incentives for subjects and provisions for treating and/or compensating subjects who are harmed as a consequence of participation in the research study. The protocol should describe arrangements for post-study access by study subjects to interventions identified as beneficial in the study or access to other appropriate care or benefits. The research protocol should always contain a statement of the ethical considerations involved and should indicate that there is compliance with the principles enunciated in this Declaration.

The research protocol should be submitted for consideration, comment, guidance and approval to a research ethics committee, which should be independent of the researcher, the sponsor and any kind of undue influence. This committee should be in conformity with the laws and regulations of the country or countries in which the research is to be performed. The committee should have the right to monitor ongoing studies. The researcher should provide monitoring information to the committee, especially information about any serious adverse events. No change in the protocol should be made without consideration and approval by the committee. The research protocol must be submitted for consideration, comment, guidance and approval to a research ethics committee before the study begins. This committee must be independent of the researcher, the sponsor and any other undue influence. It must take into consideration the laws and regulations of the country or countries in which the research is to be performed as well as applicable international norms and standards but these must not be allowed to reduce or eliminate any of the protections for research subjects set forth in this Declaration. The committee must have the right to monitor ongoing studies. The researcher must provide monitoring information to the committee, especially information about any serious adverse events. No change to the protocol may be made without consideration and approval by the committee. Medical research involving human subjects should be conducted only by scientifically qualified persons and under the supervision of a clinically competent medical person. The responsibility for the human subject must always rest with a medically qualified person and never rest on the subject of the research, even though the Medical research involving humans should be conducted only by scientifically qualified persons under the supervision of a competent and appropriately qualified physician. The responsibility for the protection of research subjects should always rest 16. Medical research involving human subjects must be conducted only by individuals with the appropriate scientific training and qualifications. Research on patients or healthy volunteers requires the supervision of a competent and appropriately qualified physician or other health care professional. Every medical research project involving human subjects should be preceded by careful assessment of predictable risks and burdens in comparison with foreseeable benefits to the subject or to others. This does not preclude the participation of healthy volunteers in medical research. The design of all studies should be publicly available.

Every medical research study involving humans should be preceded by careful assessment of predictable risks and burdens to the individuals and communities involved in the research in comparison with foreseeable benefits to them and to other individuals or communities affected by the condition under investigation. [Note: vis a vis the 2000 version, paragraphs 16 and 17 have been reorganized so that publication of data is addressed in a separate paragraph] 18. Every medical research study involving human subjects must be preceded by careful assessment of predictable risks and burdens to the individuals and communities involved in the research in comparison with foreseeable benefits to them and to other individuals or communities affected by the condition under investigation. Every clinical trial should be registered in a publicly accessible database before recruitment of the first subject. Every clinical trial must be registered in a publicly accessible database before recruitment of the first subject. Physicians should abstain from engaging in research projects involving human subjects unless they are confident that the risks involved have been adequately assessed and can be satisfactorily managed. Physicians should cease any investigation if the risks are found to outweigh the potential benefits or if there is conclusive proof of positive and beneficial results. Physicians should not participate in a research study involving humans unless they are confident that the risks involved have been adequately assessed and can be satisfactorily managed. Physicians should cease any investigation as soon as the risks are found to outweigh the potential benefits or as soon as there is 20. Physicians may not participate in a research study involving human subjects unless they are confident that the risks involved have been adequately assessed and can be satisfactorily managed. Physicians must immediately stop a study when the risks are found to outweigh the potential benefits or when there is conclusive proof of positive and beneficial results.

The subjects must be volunteers and informed participants in the research project. Participation by legally competent individuals in medical research involving humans must be voluntary. Although it may be appropriate to consult family members or community leaders, no competent individual should be enrolled in a research study unless he or she freely agrees. Participation by competent individuals as subjects in medical research must be voluntary. Although it may be appropriate to consult family members or community leaders, no competent individual may be enrolled in a research study unless he or she freely agrees. 21. The right of research subjects to safeguard their integrity must always be respected. Every precaution should be taken to respect the privacy of the subject, the confidentiality of the patient's information and to minimize the impact of the study on the subject's physical and mental integrity and on the personality of the subject. The dignity and integrity of human subjects in medical research must always be respected. Every precaution should be taken to protect their privacy and the confidentiality of their personal health information and to minimize the impact of the study on their physical, mental and social integrity and their personality. Medical research involving human subjects may only be conducted if the importance of the objective outweighs the inherent risks and burdens to the research subjects. [note: section on dignity and privacy has been moved to paragraph 11] In any research on human beings, each potential subject must be adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, institutional affiliations of the researcher, the anticipated benefits and potential risks of the study and the discomfort it may entail. The subject should be informed of the right to abstain from participation in the study or to withdraw consent to participate at any time without reprisal. After ensuring that the subject has understood the information, 22. In medical research involving legally competent human subjects, each potential subject should be adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, institutional affiliations of the researcher, the anticipated benefits and potential risks of the study and the discomfort it may entail, and any other relevant aspects of 24. In medical research involving competent human subjects, each potential subject must be adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, institutional affiliations of the researcher, the anticipated benefits and potential risks of the study and the discomfort it may entail, and any other relevant aspects of the study. The potential subject must be informed of the right to refuse to participate in the study or to withdraw consent to participate at any time

For medical research using human tissues or data, physicians should seek consent for the collection, investigation, storage and reuse of samples. There may be situations where consent would be impossible or impractical to obtain for such research or would pose a threat to the validity of the research. In such situations the research should be done only after consideration and approval of a research ethics committee. For medical research using identifiable human material or data, physicians must normally seek consent for the collection, analysis, storage and/or reuse. There may be situations where consent would be impossible or impractical to obtain for such research or would pose a threat to the validity of the research. In such situations the research may be done only after consideration and approval of a research ethics committee. For a research subject who is legally incompetent, physically or mentally incapable of giving consent or is a legally incompetent minor, the investigator must obtain informed consent from the legally authorized representative in accordance with applicable law. These groups should not be included in research unless the research is necessary to promote the health of the population represented and this research cannot instead be performed on legally competent persons. For a potential research subject who is legally incompetent, the physician should seek informed consent from the legally authorized representative in accordance with applicable law. These individuals should not be included in a research study unless it is intended to promote the health of the population represented by the potential subject, the research cannot instead be performed with legally competent persons, and the research entails only minimal risk and minimal. For a potential research subject who is incompetent, the physician must seek informed consent from the legally authorized representative. These individuals must not be included in a research study that has no likelihood of benefit for them unless it is intended to promote the health of the population represented by the potential subject, the research cannot instead be performed with competent persons, and the research entails only minimal risk and minimal burden.

The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods.

The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best proven current method, except in the following circumstances 32. The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best current proven intervention, except in the following circumstances:

At the conclusion of the study, every patient entered into the study should be assured of access to the best proven prophylactic, diagnostic and therapeutic methods identified by the study.

At the conclusion of the study, patients entered into the study are entitled to be informed about the outcome of the study and to share benefits that may result from it, for example, access to methods identified by the study. 33. At the conclusion of the study, patients entered into the study are entitled to be informed about the outcome of the study and to share any benefits that result from it, for example, access to interventions identified as beneficial in the study or to other appropriate care or benefits. 31. The physician should fully inform the patient which aspects of the care are related to the research. The refusal of a patient to participate in a study must never interfere with the patient-physician relationship.



 
  References Top

1.
Das P, Ram J, Brar GS, Dogra MR. Results of intraocular lens implantation with capsular tension ring in subluxated crystalline or cataractous lenses in children. Indian J Ophthalmol 2009;57:431-6.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Sarioglu FA, Tasci YY, Kurtul BE, Boluk SO. Implantation of a double iris-claw intraocular lens in an aphakic nanophthalmic eye. Indian J Ophthalmol 2017;65:490-2.  Back to cited text no. 2
    
3.
Coli AF, Price FW Jr, Whitson WE. Intraocular lens exchange for anterior chamber intraocular lens-induced corneal endothelial damage: Pubmed 1993;100;384-93.  Back to cited text no. 3
    
4.
Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012;96:614-8.  Back to cited text no. 4
    
5.
The world health report, 1998: Life in the 21st century: A vision for all. Geneva: World Health Organization; 1998.   Back to cited text no. 5
    
6.
Vajpayee R, Joshi S, Saxena R, Gupta SK. Epidemiology of cataract in India: Combating plans and strategies. Ophthalmic Res 1999;31:86-92.   Back to cited text no. 6
    
7.
Williamson S, Seewoodhary R. Cataract blindness in older people and sight restoration: A reflection. Int J Ophthalmic Pract 2013;4:212-8.  Back to cited text no. 7
    
8.
Foster A. Vision 2020: The cataract challenge. Community Eye Health 2000;13:17-9.   Back to cited text no. 8
    
9.
Bali SJ, Hodge C, Lawless M, Roberts TV, Sutton G. Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012; 119:891-9.  Back to cited text no. 9
    
10.
Zhao J, Ellwein LB, Cui H, Ge J, Guan H, Lv J, et al. Prevalence and outcomes of cataract surgery in rural China: The china nine-province survey. Ophthalmology 2010;117:2120-8   Back to cited text no. 10
    
11.
Van Minnen K, Spilsbury K, Ng J, Morlet N, Xia J, Semmens J changing patterns of access to cataract surgery: A population study spanning 22 years. Health Place 2009;15:394-8.   Back to cited text no. 11
    
12.
Khanna R, Pujari S, Sangwan V. Cataract surgery in developing countries. Curr Opin Ophthalmol 2011;22:10-4.   Back to cited text no. 12
    
13.
Shah SP, Gilbert CE, Razavi H, Turner EL, Lindfield RJ. International eye research network. Preoperative visual acuity among cataract surgery patients and countries’ state of development: A global study. Bull World Health Organ 2011;89:749-56.   Back to cited text no. 13
    
14.
Rao GN, Khanna R, Payal A. The global burden of cataract. Curr Opin Ophthalmol 2011;22:4-9.   Back to cited text no. 14
    
15.
Batlle JF, Lansingh VC, Silva JC, Eckert KA, Resnikoff S. The cataract situation in latin america: Barriers to cataract surgery. Am J Ophthalmol 2014;158:242-50.e1.   Back to cited text no. 15
    
16.
Visser N, Nuijts RM, de Vries NE, Bauer NJ. Visual outcomes and patient satisfaction after cataract surgery with toric multifocal intraocular lens implantation. J Cataract Refract Surg 2011;37:2034-42.   Back to cited text no. 16
    
17.
Naidu G, Correia M, Nirmalan P, Verma N, Thomas R. Functional and visual acuity outcomes of cataract surgery in timor-leste (East Timor). Ophthalmic Epidemiol 2014;21:397-405.  Back to cited text no. 17
    
18.
Friling E, Lundström M, Stenevi U, Montan P. Six-year incidence of endophthalmitis after cataract surgery: Swedish national study. J Cataract Refract Surg 2013;39:15-21.   Back to cited text no. 18
    
19.
Lundström M, Barry P, Henry Y, Rosen P, Stenevi U. Evidence-based guidelines for cataract surgery: guidelines based on data in the european registry of quality outcomes for cataract and refractive surgery database. J Cataract Refract Surg 2012;38:1086-93.   Back to cited text no. 19
    
20.
Duker, Myron Yanoff, Jay S. Ophthalmology. 3rd ed Edinburgh: Mosby. 2008. p. 382.   Back to cited text no. 20
    
21.
Forrester J, Dick A, McMenamin P, Lee W. The eye: Basic sciences in practice. London: W.B. Saunders Company Ltd; 1996. p. 28.  Back to cited text no. 21
    
22.
Candia. Electrolyte and fluid transport across corneal, conjunctival and lens epithelia. Experimental Eye Research 2004;78:527-35.   Back to cited text no. 22
    
23.
Whikehart, David R. Biochemistry of the eye, 2nd ed Philadelphia: Butterworth Heinemann; 2003. p. 107-8.   Back to cited text no. 23
    
24.
Allen D, Vasavada A. Cataract and surgery for cataract BMJ 2006;333:128-32.  Back to cited text no. 24
    
25.
Prevention of Blindness and Visual Impairment. World Health Organization. Archived from the original on 2015.   Back to cited text no. 25
    
26.
Ruit S, Tabin G, Chang D, Bajracharya L, Kline DC, Richheimer W, et al. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol 2007;143:32-8.   Back to cited text no. 26
    
27.
Intraoperative Complications of Cataract Surgery in Tehran. Optometry and Vision Science 2016;93:266-71.  Back to cited text no. 27
    
28.
Dabezies OH Jr. Defects of vision through aphakic spectacle lenses. Ophthalmology. 1979;86:352-79.   Back to cited text no. 28
    
29.
Hickson-Curran S, Spyridon M, Hunt C, Young G. The use of daily disposable lenses in problematic reusable contact lens wearers. Cont Lens Anterior Eye 2014;37:285-91.   Back to cited text no. 29
    
30.
Apple DJ, Sims J. Harold ridley and the invention of the intraocular lens. Surv Ophthalmol1996;40:279-92.   Back to cited text no. 30
    
31.
Evereklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparision of secondary implantation of flexible open-loop anterior chamber and scleral fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2003;29:301-8.   Back to cited text no. 31
    
32.
Cook CD, Evans JR, Johnson GJ. Is anterior lens implantation after intracapsular cataract extraction safe in rural black patients in africa? A pilot study in KwaZulu-Natal, South Africa. Eye 1998;12:821-5.   Back to cited text no. 32
    
33.
Weirong C, Yizhi L, Ningli W, Yan G, Mingguang H. E Comparison of the effect of two type of intraocular lens. Chinese Medical Journal 2001; 114:1286-9.   Back to cited text no. 33
    
34.
Donaldson KE, Gorscak JJ, Budenz DL, Feuer WJ, Benz MS, Forster RK. Anterior chamber and sutured posterior chamber intraocular lenses in eyes with poor capsular support. J Cataract Refract Surg 2005;31:903-9.   Back to cited text no. 34
    
35.
Muslubas IB, Kandemir B, Aydin AY, Kugu S, Dastan M. Long-term vision-threatening complications of phakic intraocular lens implantation for high myopia. Int J Ophthalmol 2014;7:376-80.   Back to cited text no. 35
    
36.
Taskapilli M, Gulkilik G, Engin G. Trans scleral fixation of single piece hydrophilic foldable acrylic iol. Can J Ophthalmology 2007;42:256-61.   Back to cited text no. 36
    
37.
Gabric N, Henc-petrinoric L. Complication following two method of pciol suturing. Documenta Ophthalmologica 1996;92:107-16.   Back to cited text no. 37
    
38.
Chakrobarti A, Gandhi RK, Chakrabarti M. Ab-externo 4-point scleral fixation of posterior chamber intraocular lenses. J Cataract Refract Surgery 1999;25:420-6.   Back to cited text no. 38
    
39.
Narain S, Guta S, Ahuja A. A newer surgical technique for single and 2-point scleral fixation of posterior chamber iolaioc. Ophthalmology Abstract 2003;35:245.  Back to cited text no. 39
    
40.
Agrawal A, Kumar DA, Jacob S, Baid C, Shrinivasan. Sfibrin glue -assisted sutureless posterior chamber iol implantation eyes with deficient posterior capsule. J Cataract Refract Surg 2008:34;1433-38.   Back to cited text no. 40
    
41.
Berler DK, Friedberg M. Ascleral fixation of posterior chamber intraocular lens implant combined with vitrectomytr. Am Ophthal. Society 1991;89:215-34.  Back to cited text no. 41
    
42.
Sharpe MR, Biglan AW, Gerontis C. Cscleral fixation of pciol in children. Ophthalmology surg and lasers 1996;27:37-41.   Back to cited text no. 42
    
43.
Maggi R, Maggi C. Sutureless scleral fixation of intraocular lenses.J Cataract Refract Surg 1997;23:1289-94.   Back to cited text no. 43
    
44.
Lanzetta P, Bandello FM, Virgilli GIS. Scleral fixation a safe procedure for lens implantation. Documenta Opjthalmologica 1999;97:317-24.   Back to cited text no. 44
    
45.
Romaniuk W, Fronczek M, Wylegala E, Nita E, Muskalski K. Transsclerally fixated pciol: 6 year of investigationk. Lin Oczna 1999;101:267-70.   Back to cited text no. 45
    
46.
Assia EI, Nemet A, Sachs D. Bilateral spontaneous subluxation of scleral-fixated intraocular lenses. J Cataract Refract Surg 2002;28:2214-6.   Back to cited text no. 46
    
47.
Mimura T, Amano S, Sujiura T, Funatsu H, Yamagami S. Ten year follow up study of secondary transcleral ciliary sulcus fixated posterior chamber intraocular lens. Am J ophthalmology 2003;136:931-3.   Back to cited text no. 47
    
48.
Balta F. Nsurgical technique for repositioning subluxated previously scleral fixated intraocular lenses. Am J Ophthalmol 2004;138:676-7.   Back to cited text no. 48
    
49.
Srinivasan R, Subashini H. Comparison of scleral fixation of iol with aciol aioc. Abstract 2005;261:1192-8.  Back to cited text no. 49
    
50.
Nirupama R, Chandrakanta KS. Tresa prospective study of 25 eyes which underwent scleral fixation iol (1 year study). AIOC Proceeding 2006;112:68-74.   Back to cited text no. 50
    
51.
Kjeka O, Bohnstedt J, Meberg K, Seland JH. Implantation of scleral fixated posterior chamber iol in adult. Acta Ophthalmol 2008;86;537-42.   Back to cited text no. 51
    
52.
Shroff AP, Kumar K. Long term evaluation of 4 point scleral fixation iols in marfan sundromeaioc. Abstract 2009;274:148-52.   Back to cited text no. 52
    
53.
Banaee T, Sagheb S. Scleral fixation of intraocular lens in eyes with history of open globe injury. J Pediatr Ophthalmol Strabismus 2011;48:292-7.   Back to cited text no. 53
    
54.
Benayoun Y, Petitpas S, Turki K, Adenis JP, Robert PY. Sutureless scleral intraocular lens fixation: report of nine cases. J Fr Ophtalmol 2013;36:658-68.   Back to cited text no. 54
    
55.
Cho YW, Chung IY, Yoo JM, Kim SJ. Sutureless intrascleral pocket technique of transscleral fixation of intraocular lens in previous vitrectomized eyes. Korean J Ophthalmol 2014;28:181-5.   Back to cited text no. 55
    
56.
Agrawal S, Singh V, Gupta SK, Misra N, Srivastava RM. Transscleral fixation of closed loop haptic acrylic posterior chamber intraocular lens in aphakic nonvitrectomized eyes. Indian J Ophthalmol 2015;63:649-53.   Back to cited text no. 56
[PUBMED]  [Full text]  
57.
Eum SJ, Kim MJ, Kim HK. A comparison of clinical outcomes of dislocated intraocular lens fixation between in situ refixation and conventional exchange technique combined with vitrectomy. J Ophthalmol 2016;2016:5942687.   Back to cited text no. 57
    
58.
Kumar S, Singh S, Singh G, Rajwade NS, Bhalerao SA, Singh V. Visual outcome and complications of various techniques of secondary intraocular lens. Oman J Ophthalmol 2017;10:198-204.   Back to cited text no. 58
[PUBMED]  [Full text]  
59.
Amar L. Posterior chember iris claw lens. Am Intra Ocular Implant Soc1980;6:27.   Back to cited text no. 59
    
60.
Rijneveld WJ, Beekhuis WH, Hassman EF, Dellaert MM, Geerards AJ. Iris claw lens : anterior and posterior iris surface fixation in the abscence of capsular support during penetration keratoplasty. J Refract Corneal Surg 1994;10:14-9.   Back to cited text no. 60
    
61.
Mohr A, Hengerer F, Eckardt C. Retropupillary iris claw lens in aphakia, 1 year outcome of a new implantation techniquesophthalmologe 2002;99:580-3.   Back to cited text no. 61
    
62.
Menezo JL, Martinez MC, Cisneros AL. Iris-fixated worst claw versus sulcus-fixated posterior chamber lenses in the absence of capsular support..J Cataract Refract Surg 1996;22:1476-84.   Back to cited text no. 62
    
63.
Menezo JL, Cisneros AL, Rodriguez-Salvador V. Endothelial study of iris-claw phakic lens: four year follow-up. J Cataract Refract Surg 1998;24:1039-49.   Back to cited text no. 63
    
64.
Mohr A, Hengerer F, Eckardt C. Retropupillary fixation of the iris claw lens in aphakia. 1 Year outcome of a new implantation techniques. Ophthal. 2002;99:580-3.   Back to cited text no. 64
    
65.
Dadeya S, Kamlesh, Kumari Sodhi P. Secondary intraocular lens (iol) implantation: Anterior chamber versus scleral fixation long-term comparative evaluation. Eur J Ophthalmol 2003;13:627-33.   Back to cited text no. 65
    
66.
De Silva SR, Arun K, Anandan M, Glover N, Patel CK, Rosen P. Iris-claw intraocular lenses to correct aphakia in the absence of capsule support. J Cataract Refract Surg 2011;37:1667-72.   Back to cited text no. 66
    
67.
Lett KS, Chaudhuri PR. Visual outcomes following artisan aphakia iris claw lens implantation. Eye (Lond). 2011;25:73-6.   Back to cited text no. 67
    
68.
Gonnermann J, Klamann MK, Maier AK, Rjasanow J, Joussen AM, Bertelmann E, et al. Visual outcome and complications after posterior iris-claw aphakic intraocular lens implantation. J Cataract Refract Surg 2012;38:2139-43.   Back to cited text no. 68
    
69.
Zheng D, Wan P, Liang J, Song T, Liu Y. Comparison of clinical outcomes between iris-fixated anterior chamber intraocular lenses and scleral-fixated posterior chamber intraocular lenses in marfan syndrome with lens subluxation. Clin Exp Ophthalmol 2012;40:268-74.   Back to cited text no. 69
    
70.
Hsing YE, Lee GA. Retropupillary iris claw intraocular lens for aphakia. Clin Exp Ophthalmol 2012;40:849-54.   Back to cited text no. 70
    
71.
Gonnermann J, Torun N, Klamann MK, Maier AK, Sonnleithner CV, Joussen AM, et al. Visual outcomes and complications following posterior iris-claw aphakic intraocular lens implantation combined with penetrating keratoplasty. Graefes Arch Clin Exp Ophthalmol 2013;251:1151-6.   Back to cited text no. 71
    
72.
Schallenberg M, Dekowski D, Hahn A, Laube T, Steuhl KP, Meller D. Aphakia correction with retropupillary fixated iris-claw lens (artisan) - long-term results. Clin Ophthalmol 2014;8:137-41.   Back to cited text no. 72
    
73.
Brandner M, Thaler-Saliba S, Plainer S, Vidic B, El-Shabrawi Y, Ardjomand N. Retropupillary fixation of iris-claw intraocular lens for aphakic eyes in children.=Plos one. 2015;10:e0126614.   Back to cited text no. 73
    
74.
Forlini M, Soliman W, Bratu A, Rossini P, Cavallini GM, Forlini C. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: A retrospective analysis. BMC Ophthalmol 2015;15:143.  Back to cited text no. 74
    
75.
Kavitha V, Balasubramanian P, Heralgi MM. Iris-claw versus posterior chamber fixation intraocular lens implantation in pediatric traumatic cataract. Taiwan J Ophthalmol 2016;6:69-74.   Back to cited text no. 75
[PUBMED]  [Full text]  
76.
Fouda SM, Al Aswad MA, Ibrahim BM, Bori A, Mattout HK. Retropupillary iris-claw intraocular lens for the surgical correction of aphakia in cases with microspherophakia. Indian J Ophthalmol 2016;64:884-7.   Back to cited text no. 76
[PUBMED]  [Full text]  
77.
Jayamadhury G, Potti S, Kumar KV, Kumar RM, Divyansh Mishra KC, Nambula SR. Retropupillary fixation of iris-claw lens in visual rehabilitation of aphakic eyes. Indian J Ophthalmol 2016;64:743-6.   Back to cited text no. 77
[PUBMED]  [Full text]  
78.
Choragiewicz T, Rejdak R, Grzybowski A, Nowomiejska K, Moneta-Wielgoś J, Ozimek M, et al. Outcomes of sutureless iris-claw lens implantation. J Ophthalmol 2016;2016:701370-9.   Back to cited text no. 78
    
79.
Faria MY, Ferreira NP, Pinto JM, Sousa DC, Leal I, Neto E, et al. Retropupillary iris claw intraocular lens implantation in aphakia for dislocated intraocular lens. Int Med Case Rep J 2016;9:261-5.   Back to cited text no. 79
    
80.
Helvaci S, Demirduzen S, Oksuz H. Iris-claw intraocular lens implantation: Anterior chamber versus retropupillary implantation. Indian J Ophthalmol. 2016;64:45-9.   Back to cited text no. 80
    
81.
Rastogi A, Goray A, Thacker P, Babita K. Assessment of the safety and efficacy of primary retropupillary fixation of iris-claw intraocular lenses in children with large lens subluxations. Int Ophthalmol 2017;???:???.   Back to cited text no. 81
    
82.
Mohamed AH. Secondary artisan iris-fixated intraocular lens implantation for correction of aphakia. Delta J Ophthalmol 2016;17:9-13.   Back to cited text no. 82
  [Full text]  
83.
Rao R, Sasidharan. Airis claw intraocular lens: a viable option in monocular surgical aphakia. Indian J ophthalmol 2013;61:74-5.   Back to cited text no. 83
[PUBMED]  [Full text]  
84.
Rashad DM, Afifi OM, Elmotie GA, Khattab HA. Retropupillary fixation of iris-claw intraocular lens versus trans-scleral suturing fixation for aphakic eyes without capsular support. J Egypt Ophthalmol Soc 2015;108:157-66.   Back to cited text no. 84
  [Full text]  
85.
Ganesh S, Brar S, Relekar K. Long Term Clinical and Visual Outcomes of Retrofixated Iris Claw Lenses Implantation in Complicated Cases. Open Ophthalmol J 2016;10:111-8.   Back to cited text no. 85
    
86.
Schallenberg M, Dekowski D, Hahn A, Laube T, Steuhl KP, Meller D. Aphakia correction with retropupillary fixated iris-claw lens (artisan) – long-term results. Clin Ophthalmol 2014;8:137-41.   Back to cited text no. 86
    
87.
Forlini M, Soliman W, Bratu A, Rossini P, Cavallini GM, Forlini C. Long-term follow-up of retropupillary iris-claw intraocular lens implantation: a retrospective analysis. BMC Ophthalmology 2015;15:143.   Back to cited text no. 87
    
88.
Helvaci S, Demirduzen S, Oksuz H. Iris-claw intraocular lens implantation: anterior chamber versus retropupillary implantation. Indian J Ophthalmol 2016;64:45-9.   Back to cited text no. 88
[PUBMED]  [Full text]  
89.
Jare NM, Kesari AG, Gadkari SS, Deshpande MD. The posterior iris claw lens outcome study: 6 month follow up. Indian J Ophthalmol. 2016:64:878-83.  Back to cited text no. 89
    



 
 
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