Phakic IOL Overview

António Marinho, MD PhDAntónio Marinho, MD PhD

Departamento de Cirurgia RefractivaDepartamento de Cirurgia Refractiva

Hospital ArrábidaHospital Arrábida

Porto PortugalPorto Portugal

DEFINITION

REFRACTIVE SURGERY

To change in a permanent way the refractive power of the eye

How to achieve this goal ?

Change the corneal power (PRK,LASIK)

Change the power of the lens (RLE)

Introduce a new refractive surface (Phakic IOL)

Why Phakic IOLs?

Phakic IOL’s are ideal for high ametropias because:

High predictability even in very high ametropias

Stability of refraction Preserve accomodation No loss (usually gains) of lines of BSCVA

Myopia - Subjective Refraction

– under - 7D : LASIK– above -7D: Phakic IOL– Main Factor : Pachymetry

Hyperopia - Cycloplegic Refraction

– under + 3D : LASIK– above + 4D: Phakic IOL– Main factor: Keratometry

Age Mínimal Age

– 18 years exceptions

– anisometropia

– Stable refraction in the last 18 months

Above 50 years– low ametropia

LASIK

– high ametropia CLE

WHEN PHAKIC IOLs ?

INCLUSION CRITERIASpecific

Anterior chamber anatomy (AC depth and AC size)

Endothelium profile

Iris shape Pupil Size

Perfect Surgery

AC DepthAC Depth

Bad Selection

Endothelial Decompensation

Shallow AC

AC SIZE (OCT)AC SIZE (OCT)

Endothelium Profile

Endothelial cell count: 21 to 25 years 2800 cells/mm 26 to 30 years 2650 cells/mm 31 to 35 years 2400 cells/mm 36 to 45 years 2200 cells/mm > 45 years 2000 cells/mm Endothelial cell shape (avoid high

polymagatism)

Endothelial Cell Count

Before Surgery (inclusion criteria)

3 months after (shows surgical trauma)

Yearly afterwards (if important decrease EXPLANT)

ACRYSOF

Hydrophpbic Acrylic IOL

4 point angle fixation 6.0 mm Optic -6.00/-16.50 4 sizes

(12.5,13.0,13.5 and 14.0mm)

Size SelectionAC Diameter

(mm)Model

11.25 – 11.75 L12500

11.76 – 12.25 L13000

12.26 – 12.75 L13500

12.76 – 13.25 L14000

Acrysof Surgery

Introduce the IOL in the cartridge (diving position)

2.6 mm incision Inject the IOL into

the eye (past pupil) NO iridectomy No suture

ANGLE SUPPORTED AC PIOLs

Angle to angle distance very important

Size of the IOL is critical

Contact with the angle and iris root

May be close to endothelium

Far away from lens

Rotation

Rotation

Peripheral synaechiae

ARTISAN 5.0mmARTISAN 5.0mm Iris-Claw phakic IOL

PMMA

5.0 mm O.Z.

Available for myopia,

hyperopia (-23.00 to

+12.00) and

astigmatism( +/-)

ARTISAN 6.0mmARTISAN 6.0mm Iris-Claw phakic IOL

PMMA

6.0 mm O.Z.

Available for myopia

(-2.00 to –15.00)

2 side ports Main incision Fill AC with visco Introduce and

rotate the IOL Enclavation of iris

tissue Iridectomy Suture

Artisan Surgery

ARTIFLEX

Iris-claw phakic IOL

PMMA haptics Silicone (foldable

optic) 6.00mm One size fits all

TORIC ARTIFLEX

Myopia -1.00 to -14.50

Cylinder -1.00 to -7.50

Two models (axis at 180º and 90º)

Sphere + Cylinder < -14.50

ARTIFLEXARTIFLEX 2 side ports Main incision (3.2mm) Fill AC with visco Introduce and rotate

the IOL Enclavation of iris

tissue Iridectomy No Suture

IRIS SUPPORTED PIOLs

One size fits all No angle touch Close contact with

the iris (grasp) Safe distance from

the endothelium Far away from the

lens

Not Perfect Surgery….

Decentration is always a surgeon’s fault

These lenses are always centered regardless of the pupil

Luxation of the IOL(traumatic or spontaneous)is due to weak grasp

Bad Selection

Posterior Synaechia

Convex Iris

Shallow AC

IOL DEPOSITS

Rare Disappear

spontaneouly after 3 months in most cases

May need steroid treatment (exceptionally)

Related to surgical manipulation

Posterior Chamber PIOLs

ICL V4c

The NEW ICL V4 c has a tiny central hole in the middle of the optic

NO iridectomy is needed

ICL Surgery

Load the ICL in the cartridge

2 side ports (12 and 6) Main incision (temporal) Introduce IOL in AC Place IOL behind the

iris Constricit the pupil Iridectomy (if not YAG

before)

Posterior Chamber PIOLs

Sit on sulcus (ICL) or “float” in aquous humour (PRL)

“Vault” (the space between ICL and lens) is crucial and depends on the IOL size

Close contact with the lens

Very far away from the endothelium

Size matters…..

Short ICL: Decentration and small vault Long IOL: Excessive vault

If there is no vault…

Anterior subcapsular cataract (less frequent as the surgical technique and sizing devices get better)

Refractive ResultsBCVA>20/40

Artisan 93.9% (518 eyes)

ICL 94.7% (331 eyes)

Cachet 100% (113 eyes)

Refractive Results Safety

PIOL GAIN LOSS

Artisan 43.5 % 1.2% ICL 40.6% 0% Cachet 27.3% 0%

AVAILABILITY

Acrysof Artisan Artiflex ICL

Myopia YES(-6.00/-16.50)

YES(-2.00/-23.00)

YES(-2.00/-14.5)

YES(-3.0/-23.00)

Hyperopia NO YES(+2.0/+12.0)

NO YES(+3.0/+23.0)

Astigmatism(Toric)

NO YES (+/-) YES(-) YES (+/-)

Inclusion criteriaPIOLs

Acrysof Artisan Artiflex ICL

AC Depth >2.80mm >2.80mm > 3.00mm >2.80mm

AC Size Very Important(OCT)

One size fits all

One size fits all

Very important (W/W ????)

Iris configuration

Not important Avoid convex iris

Avoid convex iris

Not important

Pupil Size <7.0mm <6.0mm <7.0mm <7.0mm

Endothelium Profile

Normal Normal Normal Normal

PIOLs Surgery Overview

Acrysof Artisan Artiflex ICL

Pupil Miosis Miosis Miosis Mydriasis

Side Port 1 (?) 2 2 2

Incision 2.6mm 5.2/6.2mm 3.2mm 3.2mm

Visco Cohesive Cohesive Cohesive Cohesive

Iridectomy /Iridotomy

NO YES YES YES/ NO

Suture NO YES NO NO

Refractive ResultsConclusions

All Phakic IOLs have GREAT refractive results

Most eyes gain lines The KEY to select a phakic IOL are not

the refractive results ,but the complications