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Purpose To describe the indications, motivations, and outcomes of artificial iris exchange. Setting Stein Eye Institute. Design Consecutive case series. Methods Review of medical records of patients implanted with an artificial iris device who underwent a subsequent artificial iris exchange. Results Five patients were identified: 4 women and 1 man. Their ages ranged from 19 to 58 years at the time of the exchange. One patient had congenital aniridia; the other 4 had acquired iris defects. Three exchanges were simultaneous; 2 were consecutive. Corneal decompensation was the most common indication for the surgery precipitating the exchange. Explanted iris devices included models from Ophtec, Morcher, BrightOcular, and HumanOptics. Replacement models were from Morcher and HumanOptics. Three of the original irides were passively fixated in the capsular bag or ciliary sulcus. All of the replacement irides were suture-fixated to the sclera, either directly or secondarily by way of an intraocular lens. The motivation for the exchange was improved cosmesis in 4 patients and sustained cosmesis in 1 patient. Final visual acuities were 20/25 for 2 patients, 20/100 for 1 patient, and hand motion for 2 patients. Conclusions No 2 iris exchanges were similar. Clinical indications and outcomes varied considerably from patient to patient. A common thread was each patient's motivation to maintain or improve on the functional and cosmetic benefits of having been previously implanted with an artificial iris device. Final visual acuity results were often poor because of the effects of comorbidities, especially glaucoma and corneal decompensation.

Purpose To investigate the effectiveness and safety of a custom-made iris prosthetic device used to reduce photic symptoms in patients with congenital aniridia. Setting Cincinnati Eye Institute, Cincinnati, Ohio, USA. Design Retrospective single-surgeon case series. Methods The charts of all eyes of patients diagnosed with congenital aniridia syndrome who underwent implantation of the custom-made iris prosthesis at the setting institution between 2008 and 2018 were reviewed. Eyes with more than 6 months of follow-up were included in evaluation. Charts were carefully reviewed for comorbid conditions, interventions, and outcomes. Results Ninety-six eyes of 50 patients were included in the study. Subjective reduction in photophobia and glare was reported in 95.7% and 95.2% of cases, respectively. The incidence of aniridia fibrosis syndrome (AFS) in this study (3.1%; 95% confidence interval, 0.6%-8.9%) was similar to previous studies in the literature. Conclusions The custom-made iris prosthesis was an effective and safe option to reduce photic symptoms in patients with congenital aniridia. The custom, flexible iris implant does not appear to alter the risk for AFS. These highly complex eyes with significant comorbid pathologies demand an individualized approach and careful long-term follow-up.

A 24-year-old man was involved in a high-velocity motor vehicle accident with polytrauma 2 years after implantation of a copolymer phakic IOL (pIOL) (Visian ICL). After being released from the intensive care unit, he reported decreased vision, pain, glare, and photophobia and was treated for hyphema without globe rupture. He was found to be aniridic during anterior chamber washout of the hyphema. In the first reported case, to our knowledge, of aniridia after pIOL placement, blunt trauma likely caused expulsion of the iris through dehiscence of the previously placed wound for pIOL implantation.

Purpose To present results of cataract surgery combined with aniridia ring implantation in patients with oculocutaneous albinism (OCA) in terms of vision, refraction, eye movements, and subjective photophobia and glare. Setting Anterior segment services of Noor Eye Hospital, Tehran, Iran. Design Consecutive clinical case series study. Methods Enrolled patients underwent phacoemulsification and posterior chamber intraocular lens (PC IOL) implantation and had 2 Morcher aniridia rings (types 50 F or 50 E) inserted intracapsularly. Preoperative and postoperative examinations included tests for visual acuity, manifest refraction, measurement of ocular alignment, and electronystagmography. After surgery, patients also completed a questionnaire to subjectively assess glare reduction. Results Twelve eyes of 6 OCA patients were included. Minimum follow-up was 6 months. None of the patients had any intraoperative or postoperative complications. In addition to improved uncorrected and corrected distance visual acuity and significant reduction of refractive error, all patients had a marked reduction of glare and photophobia after surgery. Conclusion Iris ring implantation during cataract surgery was an effective procedure for increasing vision and reducing glare disability in patients with OCA. In light of the results and patients' expressed satisfaction, a study should be performed to assess the outcomes of refractive lens exchange along with implantation of a PC IOL and prosthetic iris device in OCA patients seeking refractive correction.

To evaluate the safety and efficacy of Morcher 96F iris diaphragm implantation to manage small defects of the human iris.Jules Stein Eye Institute, UCLA, Los Angeles, California, USA.Prospective nonrandomized interventional case series.Demographic, preoperative, and postoperative data of patients who had implantation of the modified capsular tension ring (CTR) and followed to 1 year were reviewed. Safety measures included loss of corrected distance visual acuity (CDVA), perioperative complications, adverse events, and secondary surgical interventions. Efficacy measures included CDVA with glare, daytime and nighttime glare symptom scores, and subjective cosmesis scores.Sixteen patients had CTR implantation. There was a statistically significant improvement in the median CDVA of 2.5 Snellen lines (P.01), with 4 patients having minor decreases in CDVA for reasons unrelated to the device. There were no intraoperative complications. Three adverse events were reported: 1 ocular hypertension, 1 postoperative retinal detachment, and 1 25-degree rotation of the CTR. There were 4 secondary surgical interventions. There was a statistically significant improvement in the median CDVA with glare of 8 Snellen lines (P.01), but 2 patients had a decrease in CDVA with glare for reasons unrelated to the device. There were statistically significant improvements in the median daytime and nighttime glare symptom scores of 5 points and 4 points, respectively (both P.01). There was no change in cosmesis for most patients.Iris diaphragm CTR implantation was relatively safe and effective at reducing light and glare sensitivity in eyes with small iris defects.No author has a financial or proprietary interest in any material or method mentioned.

We describe a technique for sutureless intrascleral fixation of a 3-piece intraocular lens (IOL) and custom silicone iris prosthesis complex to address the optical and functional issues of aphakia and aniridia, as well as to restore excellent cosmesis. The 3-piece IOL is anchored to the iris prosthesis using the belt-loop technique. We believe the intrascleral haptic fixation is overall a more robust fixation method in patients with aphakia and aniridia, who are often younger and require a long-lasting anterior segment reconstruction. Financial Disclosure Dr. Ahmed is a consultant to Alcon Laboratories, Inc., and Abbott Medical Optics, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Purpose To evaluate the complications and visual outcomes of glued intrascleral-fixated foldable intraocular lens (IOL) in eyes with deficient capsules. Setting Dr Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. Design Case series. Methods Data were evaluated from the records of patients with a primary glued foldable IOL for intraoperative capsular loss or subluxated lens or secondary glued foldable IOL for aphakia. Exclusion criteria included preoperative glaucoma, aniridia, macular scar, traumatic subluxation, combined surgeries, incomplete operative medical records, and postoperative follow-up less than 6 months. The intraoperative and postoperative complication rates, reoperation rate, and visual outcomes were analyzed. Results The study comprised 208 eyes (185 patients). The mean follow-up was 16.7 months ± 10.2 (SD). The intraoperative complications were hyphema (0.4%), haptic breakage (0.4%), and deformed haptics (0.9%). Early complications occurred in 29 eyes (13.9%) and included corneal edema (5.7%), epithelial defect (1.9%), and grade 2 anterior chamber reaction (2.4%). Late complications occurred in 39 eyes (18.7%) and included optic capture (4.3%), IOL decentration (3.3%), haptic extrusion (1.9%), subconjunctival haptic (1.4%), macular edema (1.9%), and pigment dispersion (1.9%). Reoperation was required in 16 eyes (7.7%). Haptic position was altered in eyes with IOL decentration. Corrected distance visual acuity (CDVA) improved or remained unchanged in 84.6% of eyes. The postoperative CDVA was 20/40 or better and 20/60 or better in 38.9% and 48.5% of eyes, respectively. Conclusions The foldable glued-IOL procedure showed satisfactory visual outcomes without serious complications. Intraocular lens decentration was due to haptic-related problems. Financial Disclosure Dr. Agarwal is a paid consultant to Staar Surgical Co. No author has a financial or proprietary interest in any material or method mentioned.

We present the case of a 36-year-old Hispanic man who presented with photophobia and hand motion acuity from a lacerated cornea. Primary repair had been performed 13 years earlier. In addition to a densely scarred cornea and a fibrotic, partially resorbed cataract, more than 300 degrees of iris loss was noted. The patient was treated with penetrating keratoplasty, cataract extraction, and implantation of a transsclerally fixated, small-diameter aniridic intraocular lens (IOL). Despite the significant iris loss, a small-diameter IOL was chosen over a standard larger aniridic IOL to allow safer, more controlled insertion through an 8.0 mm trephination. Following surgery, the visual acuity improved to 20/25 with no symptoms of glare or photophobia.

Purpose To determine the functional and cosmetic outcomes of combined iris reconstruction lens (Ophtec) implantation and penetrating keratoplasty (PK) in eyes with acquired partial or complete aniridia. Setting Jules Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Methods In a prospective nonrandomized single-center interventional case series, efficacy measures included improvement in cosmesis and reduction in glare, star bursts, and photophobia. Safety measures included changes in best corrected visual acuity (BCVA), reports of adverse events, and surgical complications. Results The 9 eyes in the study had a history of penetrating or blunt trauma and were aphakic or in need of cataract surgery. Corneal pathologies necessitating transplantation included scarring, decompensation, or failure of a previous graft. Postoperatively, all patients were pleased with the cosmetic improvement of the study eye and all reported a reduction in visual disturbances. By the final follow-up examination, the BCVA improved in 4 patients but worsened in 5. Three adverse events were reported. There were no intraoperative surgical complications. The most serious postoperative complications were a pressure spike leading to loss of light perception, corneal graft rejection, and graft failure. The most common postoperative problem was surgically induced irregular corneal astigmatism. Conclusions Ophtec iris reconstruction lens implantation and simultaneous PK reduced visual disturbances and improved the aesthetic appearance of the eyes. The long-term safety of the procedure, judged by BCVA and postoperative complications, was mixed, with both good and bad outcomes.

We describe special techniques to visualize the donor tissue in Descemet's stripping endothelial keratoplasty and to prevent the tissue or stripped recipient Descemet's membrane from dropping onto the retina. The techniques were used successfully to treat corneal decompensation in 3 consecutive cases with no iris or lens present. The results indicate that with careful planning and a good technique, aniridic aphakic patients can benefit from the rapid corneal rehabilitation provided by endothelial keratoplasty.

We present the case of a 16-year-old adolescent boy with congenital aniridia and pseudophakia who developed decompression retinopathy in a glaucomatous eye after Ahmed glaucoma valve implantation combined with anterior vitrectomy. On the first postoperative day, dot and blot-shaped hemorrhages scattered in the posterior pole were observed. The hemorrhages resolved over 6 months, and the visual acuity returned to the preoperative level. Severe deterioration of the visual field was not observed in the late postoperative period. Despite the sudden visual acuity decrease postoperatively, decompression retinopathy is a benign condition and resolution of hemorrhages without sequelae is the natural course.

Puncturing the anterior capsule in a patient with a very soft lens, an elastic capsule, and/or deficient zonular countertraction can be challenging even with a sharp needle or blade. The crossed-swords, capsule-pinch technique capitalizes on opposing forces from 2 needles directed toward each other with a “pinch” of the capsule between their tips. This affords a controlled and facile puncture of the capsule without creating stress on the zonules or anteroposterior displacement of the lens. Financial Disclosure Neither author has a financial or proprietary interest in any material or method mentioned.

Purpose To present long-term results of implantation of a black diaphragm aniridia intraocular lens (IOL) in eyes with congenital aniridia. Setting Eye Hospital, Heinrich-Heine-University, Dusseldorf, Germany. Methods Cataract surgery was performed in 19 eyes of 14 patients with congenital aniridia. The black diaphragm aniridia IOL was implanted in front of the capsular bag in the ciliary sulcus. Mean patient age was 30 years (range 10 to 59 years) and mean follow-up, 46 months (range 12 to 84 months). Before surgery, corneal epithelial disorders; corneal pannus; cataract; hypoplasia of the macula, optic nerve, or both; and nystagmus were present in all 19 eyes. Clinically detectable glaucoma was present in 5 eyes. Results Despite the presence of amblyopia and nystagmus, visual acuity improved in 14 of the 19 eyes. The main postoperative problems were glaucoma deterioration (4 of 19 eyes) or development (4 of 19 eyes), cystoid macular edema (2 of 11 eyes), chronic endothelial cell loss (3 of 11 eyes), and progression of corneal epithelial disorders (4 of 19 eyes). Glaucoma was controlled by medical or surgical therapy in all patients. Intraocular lens explantation was performed in 2 eyes with glaucoma. Conclusion Implantation of the black diaphragm aniridia IOL improved visual acuity in the majority of patients with a variety of endogenous problems in addition to aniridia.

We present the first reported use in the United States of a black iris-diaphragm intraocular lens (IOL) for the treatment of traumatic aniridia and aphakic bullous keratopathy. The patient presented to a university-based practice with contact-lens-intolerant aniridia and aphakia with painful bullous keratopathy from a failed corneal graft. He was treated with combined penetrating keratoplasty and transscleral fixation of an aniridia IOL. The patient's preoperative symptoms of debilitating glare and photophobia resolved substantially after surgery, despite mild postoperative inflammation that resolved. The symptoms associated with aniridia can be successfully treated with a black iris-diaphragm IOL; however, chronic low-grade inflammation has been reported with its use in some cases.

We describe 6 patients who presented with cataract or aphakia and absent or nonfunctional irides. The etiologies included congenital aniridia, traumatic iris loss, and chronic mydriasis secondary to recurrent herpetic uveitis. In 5 eyes, a prosthetic iris was successfully implanted in combination with small incision cataract surgery. In 2 eyes, a single-piece iris diaphragm and optical lens was implanted. Artificial irides offer a safe alternative for patients who previously had no viable options for iris reconstruction.

Purpose To evaluate the suitability and safety of a black diaphragm posterior chamber intraocular lens (IOL). Setting Department of Ophthalmology, Leeds General Infirmary, Leeds, United Kingdom. Methods Seven patients who had secondary implantation of a Morcher 67G black diaphragm posterior chamber IOL were identified. All patients were men with a mean age of 42 years who had previous ocular trauma resulting in extensive loss of iris tissue (traumatic aniridia). Simultaneous penetrating keratoplasty was performed in 4 cases. Minimum follow-up was 10 months (mean 19 months). Results Best corrected visual acuity improved in 5 cases and was unchanged in 1 case. The lens was well centered in 5 cases. Two cases developed secondary glaucoma, 1 requiring trabeculectomy. One case developed infective endophthalmitis but had a visual acuity of 6/18 at last follow-up, and 1 had a vitreous and anterior chamber hemorrhage, which resolved. Conclusions The black diaphragm posterior chamber IOL overcame aphakia in eyes with considerable loss of iris tissue and may mitigate the visually disabling effects of traumatic aniridia. Although this lens appears safe, caution should be used in its implantation until more patients with longer follow-up are studied.

Purpose To evaluate the outcomes of transscleral sutured posterior chamber intraocular lens (PC IOL) implantation. Setting Public university hospital, Auckland, New Zealand. Design Retrospective case series. Methods A modified no-touch transscleral sutured PC IOL implantation technique with a 1-piece monofocal IOL (Alcon CZ70BD) or an aniridia IOL (type 67G, Morcher) was assessed. Results Seventy-eight cases (80.8% men; 53.9% aphakic) were identified. The mean follow-up was 35.5 months and the mean age at surgery, 41 years ± 21 (SD). The preoperative corrected distance visual acuity (CDVA) was worse than 6/30 in 66.7%. Indications included ocular trauma (46.2%), nontraumatic crystalline lens subluxation (16.7%), post-complicated cataract surgery (10.3%), idiopathic IOL dislocation (10.3%), and congenital cataract/aphakia (10.3%). An aniridia IOL was required in 39.7% of eyes. There were no significant intraoperative complications in 74.4% of eyes. Postoperative complications included transient corneal edema (15.4%), wound leak requiring resuturing (7.7%), retinal detachment (7.7%), and cystoid macular edema (6.4%). One eye (1.3%) developed suture breakage–related late IOL dislocation. Overall, 91.3% of eyes had improved visual acuity or were within 1 line of the presenting CDVA. In eyes with a guarded prognosis, 34.8% achieved a CDVA of 6/12 or better and 43.5% a CDVA of 6/15 to 6/48. In the better prognosis group, 73.9% achieved a CDVA of better than 6/12 and all achieved better than 6/30. Conclusions Scleral-sutured IOLs achieved good visual outcomes in a public hospital setting. The rate of complications was moderate in this series with a high proportion of severe ocular trauma and a large percentage of aniridia IOLs. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

A 25-year-old man had a penetrating injury to the left eye. Ocular examination revealed a full-thickness corneal laceration, total aniridia, anterior capsule rupture, and microscopic hyphema. Ten days after the immediate primary-repair surgery, aspiration of the lens secondary to traumatic cataract was performed. Four months later, a black diaphragm intraocular lens was implanted. Postoperatively, the best corrected visual acuity was 20/20 in both eyes. Multifocal spectacles were prescribed to provide the near and far vision required for the patient's job. Normal intraocular pressure and acceptable photophobia were noted during the 18-month follow-up.

A 56-year-old man complaining of decreased visual acuity in his left eye visited the emergency room 1 hour after blunt trauma. Slitlamp examination showed no visible iris tissue. The corneal wound at 5 o'clock was sharp, and Seidel was negative. In the right eye, there was a main clear corneal incision (CCI) at 11 o'clock and an opposite CCI (OCCI) to correct corneal astigmatism at 5 o'clock in the left eye. Anterior chamber inflammation and hyphema resolved 4 weeks after the trauma. The intraocular lens and capsular bag were intact, and the corrected distance visual acuity returned to 20/25. To our knowledge, this is the first report of traumatic iris expulsion through a 3.0 mm OCCI. An OCCI may seal better than a main CCI, which is used in cataract surgery, because the OCCI is not used during the cataract procedure. However, surgeons should be aware of the risk for postoperative wound dehiscence associated with the OCCI.

An aphakic patient with severe chronic hypotony had an alternative treatment of a traumatic cyclodialysis cleft: a 3-port pars plana vitrectomy, cryotherapy of the cleft, and fluid-gas exchange with subsequent supine positioning. The therapeutic principle was mechanical apposition of the detached ciliary muscle to the scleral spur by the gas bubble and scar induction by cryotherapy. Intraocular pressure increased to within normal ranges, and visual acuity improved over a 15 month follow-up.

Purpose To report the intraoperative performance and postoperative outcomes in microphthalmic eyes of infants younger than 1 year having bilateral cataract surgery. Setting Iladevi Cataract & IOL Research Centre, Ahmedabad, India. Methods This prospective observational study excluded eyes with ocular trauma, inflammation, posterior persistent fetal vasculature causing stretching of the ciliary processes or tractional retinal detachment, aniridia, or chorioretinal coloboma. Intraoperative observations included the rate of peripheral extension of the anterior capsule tear, intraoperative iris prolapse/trauma, and posterior capsule tear. All eyes were left aphakic. Postoperative observations included visual outcome, posterior synechias, visual axis obscuration (VAO), and glaucoma. Results The study evaluated 42 eyes of 21 infants. The mean age at surgery was 4.0 months ± 2.6 (SD) and the mean follow-up, 25.6 ±11.3 months. Surgery was performed using the limbal approach in 30 eyes (71.4%) and by pars plicata lensectomy in 12 eyes (28.6%). In the limbal group, 3 eyes (10.0%) had an incomplete anterior capsulorhexis, 2 eyes (6.7%) had iris trauma, and 2 eyes (6.7%) had peripheral extension of the posterior capsulectomy edge. At the final follow-up, visual acuity remained stable in 4 eyes (9.5%) and was improved in 38 eyes (90.5%). The complications were posterior synechias in 15 eyes (35.7%), glaucoma in 13 eyes (30.9%), and VAO in 7 eyes (16.7%). Conclusion The results suggest that good visual outcomes can be obtained in microphthalmic patients with bilateral congenital cataract after early surgical intervention, with an acceptable rate of serious postoperative complications.

Purpose To evaluate the safety and efficacy of several different Morcher iris diaphragms in the treatment of partial or complete aniridia. Setting Jules Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Methods This ongoing prospective single-site nonrandomized interventional clinical trial was designed to evaluate Morcher iris diaphragm models 50D, 50F, 96S, and 96F. Safety measures included changes in best corrected visual acuity (BCVA), surgical complications, adverse events, and postoperative interventions. Efficacy measures included changes in best corrected glare visual acuity and changes in daytime and nighttime glare sensitivity, measured by questionnaire responses. Results Thirteen patients (13 eyes) completed a 1-year follow-up. Regarding safety, there was a statistically significant improvement in median BCVA of 2 Snellen lines ( P = .002). One patient lost 2 letters of BCVA on the 20/20 line. There were 2 adverse events. One was minor bleeding during a posterior synechialysis that resolved without intervention. The second was piggyback intraocular lens decentration from worsening zonular dialysis in an eye with a trauma history. One postoperative intervention was the repositioning of a 50D ring. Regarding efficacy, there was a statistically significant median improvement in best corrected glare acuity of 10 Snellen lines ( P ≤.001). Subjective daytime glare improved 5 questionnaire scale points ( P = .004), and nighttime glare sensitivity improved 3 scale points ( P = .001). Conclusion Morcher iris diaphragms were relatively safe and very effective in reducing the light and glare sensitivity associated with partial or complete aniridia.

Purpose To assess the safety and efficacy of implantation of prosthetic iris devices in patients with albinism. Setting Private practice, Cincinnati, Ohio, USA. Methods This retrospective noncomparative case series comprised 13 eyes of 8 patients with diminished pigment epithelium of the iris secondary to albinism. All eyes had anterior segment surgery with intraocular lens (IOL) and prosthetic iris device implantation. Eleven eyes received an endocapsular-type iris reconstruction implant (Morcher aniridia interdigitating rings), and 2 eyes (1 patient) received a combined iris–IOL device (Ophtec model 311). The visual acuity, subjective glare reduction, postoperative anatomical outcomes, and intraoperative or postoperative complications were reviewed. Results All eyes achieved the desired anatomic result. The best corrected visual acuity improved in 8 of 13 eyes, remained stable in 3 eyes, and decreased in 2 eyes. Glare and photophobia improved subjectively in 6 of 8 patients, remained unchanged in 1 patient, and increased in 1 patient after implantation of an artificial iris diaphragm. There were no intraoperative or postoperative complications. Conclusions Implantation of prosthetic iris devices appears to be useful in the management of patients with iris deficiency secondary to albinism. The procedure was safe and particularly effective in reducing glare and photophobia in most patients.

A 45-year-old man with retinitis pigmentosa experienced total aniridia in the left eye due to direct blunt trauma 2 years after uneventful bilateral phacoemulsification via a 3.5 mm clear corneal incision. Ultrasound biomicroscopy (UBM) of the left eye revealed no missing or stretched zonular fibers extending from the ciliary body to the anterior capsule, a few iris root remnants, a normal ciliary body, an in-the-bag acrylic intraocular lens, and Descemet's membrane dehiscence at the corneal tunnel through which the iris extruded. The eye recovered 20/25 visual acuity after 1 week. Transient hyphema and a rise in intraocular pressure were recorded. This is the first report of traumatic aniridia 2 years after phacoemulsification with UBM evidence of undamaged zonular apparatus. A UBM examination may be clinically helpful, especially when blood prevents accurate slitlamp examination of the anterior segment.

We report a 50-year-old patient who had secondary implantation of an aphakic Artisan (Ophtec) intraocular lens (IOL) that was placed vertically in the anterior chamber. The patient had had a perforating injury to the cornea that required corneal wound repair, lensectomy, and anterior vitrectomy. Because of the localized traumatic aniridia, the Artisan IOL could not be placed horizontally. Three months after surgery, the best corrected visual acuity was 0.9 and there were no complications.

A 30-year-old man with bilateral congenital aniridia presented with a subluxated cataract in the right eye. He wore a soft contact lens for aphakic correction in the fellow eye after lensectomy for a subluxated cataract. We performed pars plana lensectomy and vitrectomy with implantation of a transscleral ciliary sulcus fixated posterior chamber intraocular lens in the right eye. Good postoperative visual acuity was obtained.

We present 2 pseudophakic patients who had traumatic episodes that resulted in total expulsion of the iris without disturbing the intraocular lens (IOL). Because of intolerable glare, each patient was managed by reopening the fibrosed capsular bag and implanting 2 multi-finned prosthetic iris devices through a small incision, leaving the IOL in place. Following surgery, glare was no longer present and excellent visual acuity was maintained. We believe these are the first pseudophakic patients with traumatic total aniridia to be managed by this approach.

A case is presented that illustrates selective disinsertion and extrusion of iris tissue after blunt trauma without damage to the intraocular lens (IOL). This was an observational case report of a single patient treated as an inpatient using topical steroids and antiglaucoma drugs. Progress was monitored by tonometry and slitlamp examination. Total absence of iris tissue was discovered after resolution of hyphema with restoration of vision. Absence of iris tissue was confirmed on gonioscopy and fundoscopy. The IOL was found undisplaced and intact in the capsular bag, and visual function was restored. The insertion of foldable IOLs through self-sealing small-incision cataract sections confers protection to the globe in the face of blunt trauma in 2 ways. The self-sealing cataract section acts as a release valve during the compressive phase and allows extrusion of the disinserted iris tissue, whereas the flexible IOL absorbs the impact and prevents disruption of surrounding tissues.

Purpose To determine the efficacy and safety of surgical implantation of artificial iris–lens diaphragm in patients with anatomic or functional iris deficiencies, aphakia or cataract. Setting Svyatoslav Fyodorov MNTK Eye Microsurgery, Cheboksary, Russia. Methods Twenty eyes of 19 consecutive patients with combined iris and lens pathology of traumatic or congenital etiology were identified for an interventional noncomparative case series. The newly proposed model of an elastic iris–lens diaphragm with a colored haptic and additional support elements was implanted using various fixation approaches. Results Fifteen eyes (75%) experienced improvement in corrected visual acuities. The best spectacle-corrected visual acuity (BSCVA) in 2 eyes did not change, while the uncorrected visual acuity (UCVA) in these eyes increased. There were 3 eyes in which BSCVA deteriorated with no change or even slight improvement in UCVA. All patients were satisfied with the cosmetic results of the surgery and reported a decrease in glare and photophobia. There was 1 intraoperative complication of vitreous hemorrhage. Postoperatively, 2 cases of hyphema, 1 case of ciliochoroidal detachment, 4 eyes with exaggerated immediate postoperative reaction, and 1 eye with persistent low-grade cyclitis were observed. In 1 eye, there was persistent intraocular pressure rise. One eye showed signs of cystoid macular edema. No iris–lens diaphragm decentrations and no new or extensions of old retinal detachments were seen during the follow-up period. Conclusions Artificial iris–lens diaphragm implantation effectively improved postoperative outcomes by correcting aphakia, reducing glare disability, and addressing cosmetic issues faced by iris-deficient, and aphakic or cataract patients. Although the iris–lens diaphragm appears to be safe, long-term results must be clarified in studies with longer follow-up and a larger patient population.

Purpose: To evaluate the efficacy of secondary black diaphragm intraocular lens (IOL) implantation in aphakic eyes with traumatic aniridia and previous pars plana vitrectomy (PPV). Setting: Shandong Eye Institute and Hospital, Qingdao, China. Methods: This retrospective study comprised 15 aphakic eyes with aniridia and no vitreous that had implantation of a secondary black diaphragm IOL 6 to 72 months after PPV. The PPV was performed as a result of trauma to the posterior segment. Before implantation of the IOL, all patients had reduced visual acuity from aphakia and intolerable glare from aniridia. Eyes were aphakic as a result of previous extracapsular cataract extraction (1 eye), lens extrusion during trauma (3 eyes), or simultaneous cataract lensectomy during PPV (11 eyes). Significant iris defects were present, with 9 eyes being aniridic after the injury. The mean follow-up was 17 months (range 3 to 34 months). The postoperative visual acuity, intra- ocular pressure (IOP), endothelial cell density, IOL centration, and intraocular inflammation were monitored. Results: All 15 eyes had improved visual acuity and marked glare reduction after IOL implantation. No major IOL decentration was seen. Five patients had increased IOP 3 to 5 days after IOL implantation; 3 were known to have secondary glaucoma from trauma before surgery and their IOP was controlled preoperatively (< 21 mm Hg) with timolol 0.5% eyedrops. The other 2 patients had normal- appearing angles, and 1 was diagnosed with hemolytic glaucoma after IOL insertion. Postoperative elevated IOP was controlled by timolol eyedrops (4 eyes) or selective laser trabeculoplasty (1 eye). Hyphema was seen in 1 patient on the first day after IOL implantation, but no further bleeding was noted. Vitreous hemorrhage was seen the first day after IOL insertion in 2 patients. One resolved without sequelae; the other required vitreous washout. Retinal detachment and cystoid macular edema did not occur in any patient. Conclusions: Black diaphragm IOL implantation can be considered in eyes with coexisting aphakia and aniridia and without vitreous. Intraoperative IOP regulation is crucial in vitrectomized eyes to prevent complications such as expulsive hemorrhage. In general, visual function was better after IOL insertion as a result of better visual acuity and glare reduction. Although this IOL appears to be safe, long-term results must be assessed in studies with a longer follow-up and a larger study group.

Purpose To report the unusual finding of intraoperative fragility of the anterior capsule in some patients with congenital aniridia and determine the histopathologic etiology of this finding. Setting Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods Anterior lens capsule specimens were obtained from aniridic and nonaniridic patients during cataract surgery. The intraoperative behavior of each capsule was noted, after which the specimens were submitted for histopathologic evaluation. Results All anterior capsule specimens from the nonaniridic patients were of normal thickness. Some, but not all, anterior capsule specimens from the aniridic patients were remarkably thin. Thin capsules were associated with extreme intraoperative fragility. Conclusion Greater awareness of anterior capsule fragility in some aniridic patients may reduce the risk of capsule complications and lead to safer surgical outcomes.

Congenital aniridia represents a spectrum of diseases involving multiple ocular structures and occurs in 1 in 64 000 to 1 in 96 000 people. Affected individuals may have glaucoma, cataract, and aniridic keratopathy. A form called congenital aniridia variant also exists in which severe limbal stem cell deficiency coexists with mild macular hypoplasia and subtle iris abnormalities of stromal atrophy, ectropion uveae, and corectopia. Keratolimbal allograft is effective for the treatment of aniridic keratopathy due to limbal stem cell deficiency. Considerations for cataract surgery in patients with aniridia have been outlined. However, after keratolimbal allograft, the cataract surgeon must be mindful of additional complexities. We have experience with 32 patients (41 eyes) who had phacoemulsification and intraocular lens (IOL) implantation a mean 18.7 months (range 3 to 50 months) after keratolimbal allograft surgery. We found that even though the keratolimbal allograft was well healed and the epithelium healthy, stromal haze, atrophic iris remnants, corectopia, and poorly dilated pupils could be present. To optimize visualization in these eyes and in eyes with congenital aniridia variant, trypan blue and iris hooks are used (Figure 1). Ideally, the main wound is placed posterior to the limbus, midway between the anterior and posterior keratolimbal allograft edges andmidway between the segment junctions (Figure 2). In eyes with aniridia or congenital aniridia variant, the anterior capsule is

Early iris prostheses were made of black irradiated poly(methyl methacrylate) (PMMA) or another acrylic (Perspex) in light blue, brown, or green. While functional results were excellent, cosmesis was lacking. Two currently available iris prostheses are the (1) CustomFlex (HumanOptics AG), which is made of silicone and customized to match a photograph of the residual, fellow, or desired iris, and the (2) IrisMatch (Morcher GmbH), a clear PMMA implant with an annular opaque film applied to a 9.0 mm diaphragm and optic. It is available in 45 colors, achieved by pixilated specks of black and primary colors. With iris prosthesis implantation, we recommend vital staining of the capsule. Visualization of the capsulorhexis margin becomes difficult during insertion

Purpose: To determine the efficacy and safety of surgical implantation of prosthetic iris devices in patients with anatomic or functional iris deficiencies. Setting: Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods: Twenty-five patients were enrolled in an interventional prospective noncomparative case series. Twenty-eight eyes had prosthetic iris diaphragm implantation for traumatic iris defects, congenital aniridia or iris coloboma, herpetic iris atrophy, surgical iris loss, or ocular albinism. Prosthetic iris implantation was performed with phacoemulsification and intraocular lens (IOL) implantation in 20 eyes, secondary IOL implantation in 6 eyes, and IOL exchange in 1 eye. A single pseudophakic eye with disabling glare secondary to traumatic aniridia had secondary prosthetic iris implantation alone. The surgical ease of insertion, intraoperative and postoperative complications, postoperative anatomic results, visual acuity, and subjective glare reduction were evaluated. Results: Patients were followed postoperatively for a mean of 10.2 months (range 1.4 to 25.7 months). All eyes achieved the desired anatomic result. Visual acuity was improved in 22 of 28 eyes (79%), unchanged in 5 eyes, and worsened by a single line in 1 eye. Patients were surveyed postoperatively to determine the change in glare disability. The severity of glare disability was subjectively improved in 23 of 24 patients (96%) who responded to the survey. Intraoperative complications included 3 fractured implants as well as an incomplete or torn capsulorhexis in 3 eyes. Postoperative complications included transient hypotony in 2 eyes, mild persistent inflammation in 1 eye, and macular edema followed by a retinal detachment in 1 eye with recent severe trauma. Conclusions: Implantation of prosthetic iris devices improved postoperative outcomes by reducing glare disability and, in selected cases, by correcting aphakia. Although operating on traumatized, congenitally aniridic, or uveitic eyes presents special challenges, implantation of prosthetic iris devices appears to be a safe and effective method for reducing the ubiquitous glare in patients with iris deficiency.

A 38-year-old man sustained a left eye injury after being attacked by a mynah bird. Ocular examination revealed a beak-shaped, full-thickness corneal laceration with total aniridia in the left eye. No other ocular injury was observed, and the lens and posterior segment remained normal over the subsequent 3 months. A penetrating keratoplasty was planned for visual restoration.

Originally, the open poly(methyl methacrylate) (PMMA) capsular tension ring (CTR) was designed to compensate for zonular defects or to stretch the posterior capsule in highly myopic eyes not receiving an intraocular lens (IOL). We address the variety of subsequent designs, applications, and techniques that have evolved. With pre-existing or intraoperative zonular defects, a standard CTR may be inserted before or at any time during cataract removal to maintain or re-establish an extended capsular diaphragm. For profound zonular dialysis or weakness, a CTR was designed for scleral fixation. Capsular tension rings with integrated tinted sector shields have been developed to compensate for sector iris colobomas or aniridia. The CTR has also been used as a measuring gauge for in vivo quantification of capsule dimensions and postoperative capsular shrinkage. The CTR has improved control during primary posterior capsulorhexis and prevented oval distortion along the lens axis postoperatively. During combined cataract and vitreous surgery, a CTR prevents capsule damage and provides undisturbed peripheral visualization before IOL implantation. Capsular tension rings may also influence capsule opacification formation. A special band-shaped CTR with sharp edges was developed to inhibit lens epithelial cell migration and avoid capsulorhexis-optic contact.

Traumatic aniridia and aphakia occurred in the left eye of a 22-year-old man who had had Artisan (Ophtec) phakic intraocular lens (IOL) implantation. Aniridia was probably the result of the relatively large wound used to implant the nonfoldable IOL. Although the eye had severe traumatic damage, vision was recoverable through a 2-stage procedure of vitrectomy and subsequent scleral suture fixation of an iris-diaphragm IOL.

We present the first reported case of traumatic aniridia as an isolated injury after blunt trauma to an eye that had phacoemulsification through a corneal tunnel. This case provides insight into the properties of the self-sealing corneal tunnel and possible advantages that it may confer on the eye.

Endoscopic laser cycloablation can be effective in treating glaucoma. The Micro probe endoscopic laser permits excellent visualization of the ciliary processes. However, the surgeon can not simultaneously view through the probe and see the probe's location in the eye through the surgical microscope. An iris adhesion with the probe led to total aniridia in the case reported. Having an assistant watch the operative monitor or devising a system that allows the surgeon to watch both monitors could prevent this complication.