this study was approved by the institutional ethics committee , and informed consent was obtained from all patients .
the patients were aged 666 years including 10 males and 1 female . in five patients ,
trauma was caused by a blunt injury , and six patients had a penetrating injury .
iris injuries included five sphincter tears , one iridodialysis , and six partial iris defects within a quadrant ; all patients had varied pupil dilation .
primary lens injuries presented as lens luxation in three cases , lens opacities / capsular rupture in seven cases , and the absence of a lens in one case .
initial surgery consisted of corneal / scleral wound repair , lensectomy or lens extraction , and anterior or pars plana vitrectomy .
the secondary surgery permitted the reconstruction of the injured iris and the implantation of an iris - claw iol .
the interval between the two surgeries was from 5 days to 3 years with a mean of 3 months .
corneal endothelial cell count ( cecc ) , iol master calculation , and optical coherence tomography ( oct ) examination data were collected before and after surgery .
iris reconstruction consisted of iridodialysis repair / sphincter tear repair ( or iris defect repair ) and pupil reconstruction . if an iridodialysis coexisted with a sphincter tear ( or iris defect ) , iridodialysis repair should be processed first and later followed by sphincter tear repair ( or iris defect repair ) .
clinical data in 11 patients with iris - lens injuries iridodialysis was first repaired by starting a scleral tunnel incision at 23 mm posterior to the limbus around the site of the iridodialysis [ fig .
the ac was maintained by inserting a 20-gauge infusion cannula in the inferior temporal quadrant .
a 10-prolene suture within a 25-gauge needle was introduced from a small corneal incision through the dialyzed iris root and out to the scleral tunnel [ fig .
next , the thread was pulled out , and the needle was drawn into the ac to place additional sutures at 12-mm intervals ( running mattress suture ) .
the extraocular thread was passed through the mattress suture loops one by one until the entire iridodialysis was closed [ fig .
finally , the two threads were tied together , and the knot was buried under the scleral tunnel [ fig .
ruptured sphincter or partial defected iris was then reconstructed by passing a curved needle with a 10 - 0 prolene suture through the ruptured iris from a limbal incision out to the opposite limbus [ fig .
1f ] ; and the two threads were tied externally with a siepser slipknot [ fig . 1 g and h ] .
the iris - claw iol ( ophtec bv , groningen , the netherlands ) , held by specially designed forceps , was slowly inserted into the ac and was horizontally fixed at mid - periphery of the iris with an enclavation needle ( or 25-gauge needle ) through a side limbal incision [ fig .
1i ] . iris reconstruction combined with iris - claw intraocular lens implantation in case # 1 .
a 28-year - old male patient was injured by a ruler and resulted in pupil dilation , iridodialysis , and sphincter tear ( a ) .
iridodialysis was repaired first ( b - d ) , followed by sphincter tear repair ( e - h ) and iris - claw intraocular lens implantation ( i ) about 0.5% levofloxacin and tobradex eye drops were given postoperatively .
the follow - up period was scheduled at 1 and 2 weeks ; 1 , 3 , and 6 months ; and once a year .
final examinations included visual acuity ( va ) , iop , iris and pupil status , iol position , cecc , and oct .
uncorrected va ( ucva ) in all of the injured eyes before combined surgery was  20/1000 .
postoperatively , a significant increase in ucva and best - corrected va ( bcva ) of 20/66 or more was obtained in six ( 6/11 , 55% ) cases and nine ( 9/11 , 82% ) cases , respectively [ table 2 ] .
there was only one case ( case # 6 ) with bcva of 20/200 , most likely due to the presence of a 7-mm scar on the cornea .
anatomical recovery following iris reconstruction and iris - claw iol implantation was also significant [ fig . 2 ] .
after combined surgeries , the irises were reshaped , and the pupils became smaller ( irregular in five cases , round in six cases ) .
iris atrophy and depigmentation around the claw enclavation sites or iris suture sites were noted in several cases [ fig . 2 ] .
pre- and post - operative anterior segment photographs ( case # 1 , # 2 , and # 9 ) . a dilated pupil with a sphincter tear (
( b , d , and f ) a well - positioned iris - claw intraocular lens fixated on the anterior surface of the repaired iris , with a round or smaller pupil postoperatively . figure a and b , c and d , and e and f represent case # 1 , # 2 , and # 9 , respectively visual outcomes in 11 patients with combined surgery pre- and post - operative ceccs during follow - up periods varied in cases . except for an increased postoperative cecc in the injured eye of case # 2 , the remaining injured eyes exhibited a decreased postoperative ceccs compared to the preoperative ceccs .
pre- and post - operative corneal endothelial cell counts in 11 patients ( cells / mm ) oct images of the posterior segment in 10 cases exhibited no remarkable changes pre- and post - operatively . in one case ,
the cystoid macular edema ( cme ) disappeared spontaneously after combined surgery ( case # 2 ) .
only one patient , a 6-year - old boy , had a loose knot with a slightly dilated pupil , but his iris - claw iol was well - positioned ( case # 3 ) .
the two most popular and efficient methods for iris repair are most likely the siepser slipknot to repair sphincter tear ( or iris defect ) and the mattress suture to repair iridodialysis .
this method 's outstanding advantage is that the knot can be tied extraocularly by sliding two opposite sutures in a way that results in minimal disturbance to the ruptured iris .
the modified running mattress suture method that we described here for iridodialysis repair simply used a 25-gauge needle with a 10 - 0 prolene suture [ fig .
1c ] . the needle tip can grasp as little iris root as possible , fixing to the sclera , and thus helps to restore the natural , round structure of a pupil .
moreover , a running mattress suture can save surgical time with only one knot left . in our series
, successful anatomical results were achieved after iris reconstruction including 11 cases with siepser slipknots and one case with a running mattress suture . with varied periods of follow - up ,
only a 6-year - old boy had a loose knot with a slightly dilated pupil ; however , his iris - claw iol was still at a stable position ( case # 3 ) .
surgical experience demonstrated that the two iris reconstruction procedures both obtain excellent anatomical and cosmetic outcomes [ fig . 2 ] .
implantation of an iol in an aphakic eye without capsular support is technically complicated and varies based on patient age , iris and pupil statuses , as well as surgeons ' preferences .
suspension of a scleral or sulcus - fixated pciol is most likely the most frequently used surgical technique , particularly since modified novel procedures have been introduced .
the advantages of this type of procedure are a natural position , lack of corneal endothelial cell decompensation , and lack of pressure , which could rupture the iris or pupil .
dick and augustin suggested that sulcus - fixated pciols remained the preferred procedure to correct aphakia in eyes without capsular support that had a significant loss of iris tissue from surgery or trauma .
however , transscleral fixated iol is a time - consuming operation , and short- or long - term complications , such as tilting or decentering of the iol , suture erosion , or iol dislocation may happen in certain cases . an alternative to a pciol is an aciol , which is simpler and more convenient and is recommended for the treatment of those with aphakic eyes .
an aciol needs the angle of the ac as support and is easy to insert ; however , there is the possibility of endothelial cell loss and pupil deformation . because ocular trauma mostly occurs in young patients , long - term aciol placement in this group of patients may not be favored .
many reports have shown the implantation of an iris - claw iol is simple , safe , and efficient for short - term or long - term use .
the advantages of the iris - claw iol are that insertion is easy , no suture is needed for fixation , it is reversible , and there is little corneal endothelial cell loss .
this technique has been considered as a good option in the absence of capsular support , for example , as an alternative method for iol implantation with a complicated posterior capsule ruptured during cataract surgery or for traumatic aphakic eyes . in our literature search , we have not found reports about iris reconstruction combined with iris - claw iol implantation applied to traumatic aphakic eyes .
sminia et al . reported a long - term outcome of artisan iris - claw iol implantations in five aphakic eyes without capsular support following a penetrating ocular trauma .
the bcva at the last follow - up was 20/40 or better in four eyes .
a report from neuhann et al . described a 3-year - old boy who presented with a perforating corneal injury and an extensive iris dialysis in his right eye .
the child had a lensectomy , iridectomy , and vitrectomy with an implantation of an artisan iol fixed to some iris remnants , but the child developed an extensive noninflammatory fibrous membrane in the ac , which subsequently needed explantation .
theoretically , iris - claw iol was meant to be used in patients with a normal pupil or a normal iris because they could experience inconvenient symptoms when the pupil size exceeds the diameter of the iris - claw iol , such as halos , blurred vision , or further laceration , or unknotting of a suture could happen when inappropriately applied to a ruptured iris .
however , our clinical data showed that iris - claw iol implantation combined with iris reconstruction in traumatic aphakic eyes had significant results .
the iris - claw iols in all of the cases were well - fixed on the anterior surface of the repaired iris .
none of the patients developed such complications as tilting or decentering of the iol , corneal endothelial cell decomposition , or a dislocation of the iris - claw iol .
whether the sutured iris is sufficiently strong to support an iris - claw iol is our consideration , for example , unknotting of the suture or dislocation of the iris - claw iol .
our 1.14.2 years of follow - up demonstrated the sutured iris remained well - shaped , except in one child who had a loose knot , but his iol remained in the proper position without dislocation .
the 11 patients , both children and adults , maintained their regular daily activities after surgery .
we assume the iris - claw iol may not interfered with the sutured iris ; nevertheless , this proper positioned iol may strengthen the sutured iris against mechanical force .
although the result showed a decreased postoperative ceccs compared to preoperative ones in injured eyes , and a decreased ceccs in injured eyes compared to control eyes , neither decompensation nor postoperative corneal edema was observed in any of the cases after an average of 3 years follow - up period . a corneal scar and
the measuring technique may have contributed to the cecc drop from preoperative 1449 cells / mm to postoperative 899 cells / mm in a 66-year - old male ( case # 5 ) . comparing with dr .
budo ' criteria for cecc in an iris - claw iol implantation , there was another case ( case # 2 ) in our series with preoperative cecc below 2100 cells / mm ; however , it increased to 2203 cells / mm after surgery .
therefore , for traumatic iol implantation , preoperative cecc should be evaluated along with other conditions , such as corneal edema or corneal scarring . because we do not know whether the ceccs will increase or further decrease in the future or whether the reduced ceccs are due to the trauma or surgery , long - term follow - up is needed .
evidence from other reports indicates that iris - claw iol implantation was safe for corneal endothelial cells .
concluded that this iol did not result in a significant loss of endothelial cell density after observing 765 eyes implanted with an artisan iris - claw phakic iol .
sminia et al . performed an 11-year follow - up study of five children with penetrating eye injuries who received an iris - claw iol implantation , in which preoperative ceccs in three cases varied from 1349 to 1972 cells / mm , and none of the patients developed corneal edema or decompensation after the long - term follow - up . the reason that iris - claw iols implantation in traumatic aphakic eyes is quite safe for corneal endothelial cells is most likely related to a deeper ac or a safe distance from the corneal endothelial cells to the surface of the iris - claw iol after cataract removal . moreover
, a viscoelastic intraoperatively injected agent may also contribute to the protection of the corneal endothelial cells .
there were no remarkable changes found on macular octs in 10 of the 11 cases before or after combined surgery .
only one cme , in case # 2 , occurred after a primary lensectomy and anterior vitrectomy , but it spontaneously disappeared after the secondary combined surgery .
none of the 11 cases with cme demonstrated that the combined surgery did not disturb the macula .
hirashima et al . studied iris - claw aciol for the treatment of subluxated lenses in 15 patients with marfan syndrome and found that none of them developed cme .
sminia et al . also had a similar result after an 11-year follow - up study of five children with penetrating eye injuries with an iris - claw iol implantation .
overall , our results demonstrate iris reconstruction combined with iris - claw iol implantation is a safe and efficient procedure due to the good visual outcomes , well - reconstructed iris and pupil , well - positioned iris - claw iols , and minimal complications .
it may be a good option for the iris injury in an aphakic eye without capsular support . because of the relatively small sample size and relatively short follow - up period , the long - term efficiency and safety of the combined surgery need to be further evaluated .
cecc , suture knot , iris and pupil characteristics , and iris - claw iol position should be the major focus of the follow - up study .
 aim : to study the efficiency and safety of iris reconstruction combined with iris - claw intraocular lens ( iol ) implantation in the patients with iris - lens injuries.settings and design : retrospective , noncomparable consecutive case series study.materials and methods : eleven patients ( 11 eyes ) following iris - lens injuries underwent iris reconstructions combined with iris - claw iol implantations . clinical data , such as cause and time of injury , visual acuity ( va ) , iris and lens injuries , surgical intervention , follow - up period , corneal endothelial cell count , and optical coherence tomography , were collected.results:uncorrected va ( ucva ) in all injured eyes before combined surgery was equal to or < 20/1000 . 
 within a 1.14.2-year follow - up period , a significant increase , equal to or better than 20/66 , in ucva was observed in six ( 55% ) cases , and in best - corrected va ( bcva ) was observed in nine ( 82% ) cases . 
 postoperative bcva was 20/40 or better in seven cases ( 64% ) . 
 after combined surgery , the iris returned to its natural round shape or smaller pupil , and the iris - claw iols in the 11 eyes were well - positioned on the anterior surface of reconstructed iris . 
 no complications occurred in those patients.conclusions:iris reconstruction combined with iris - claw iol implantation is a safe and efficient procedure for an eye with iris - lens injury in the absence of capsular support . 
Materials and Methods
Results
Discussion
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