ASCRS 2008, Chicago Assessment of a triple procedure in patients with ICL-induced cataracts 　　~ICLTM removal, phacoemulsification and 　　　 intraocular.

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ASCRS 2008, Chicago Assessment of a triple procedure in patients with ICL-induced cataracts 　　~ICLTM removal, phacoemulsification and 　　　 intraocular lens implantation Daisuke Aizawa,MD Kazutaka Kamiya,MD Tetsuya Ikeda,MD Kimiya Shimizu,MD 有水晶体眼内レンズ挿入眼におけるレンズ摘出および白内障同時手術 Kitasato Univ. School of Medicine,JAPAN 第61回　日本臨床眼科学会　

Introduction ICLTM implantation has advantages over LASIK Kitasato University School of Medicine Introduction ICLTM implantation has advantages over LASIK in high myopic correction. （ Aizawa et.al. APSCRS 2007） On the other hand, cataracts are among the complications of this procedure. We assessed the triple procedure of ICL removal, PEA and IOL implantation. 第61回　日本臨床眼科学会　 2

Kitasato University School of Medicine Objects & Methods 10 eyes of 8 patients (6 eyes of male, 4 eyes of female) Age (at ICL implantation time) 46.9 ± 2.8 (37～57) y.o. Pre-op refraction -15.1 ± 5.8 (-10.4～-24.0) D Axial length 29.3 ± 1.9 (26.1～32.0) mm ICL type Ver. II: 9 eyes, Ver. IV: 1 eye Period (implant to extraction) 4.0 ± 2.1 (1.6～8.1) years Age (when ICL extraction) 51.1 ± 4.2 (45～62) y.o. IOL MasterTM was used for axial length measurement. （SRK-T） Operation ・Topical anesthesia ・ICL extraction via 3 mm temporal corneal incision ・PEA+IOL through the same incision

Results 1 Visual acuity * * * 1.05 1.10 0.81 0.73 Visual acuity 0.73 Kitasato University School of Medicine Results 1 Visual acuity * 1.05 1.10 0.81 0.73 Visual acuity 0.73 0.68 0.31 * Safety index = 1.51 Efficacy index = 0.93 BSCVA UCVA 0.02 * 　P＜0.001 （Wilcoxon signed rank test） Before ICL After ICL Cataract After ICL removal implantation implantation formation and IOL implantation 第61回　日本臨床眼科学会　 4

Results 2,3 Predictability, Manifest refraction (SE) Kitasato University School of Medicine Results 2,3 Predictability, Manifest refraction (SE) Predictability Manifest refraction (SE) 6 overcorrection 5 -1.6 -2.0 -2.9 Achieved (D) 4 Achieved (D) 3 Manifest refraction (D) 2 -15.1 1 undercorrection 0 1 2 3 4 5 6 -25 Attempted (D) Attempted (D) Before ICL After ICL Cataract After ICL removal implantation implantation formation and IOL implantation < ±0.5D： 80% < ±1.0D： 90%

Results 4,5 IOP, Endothelial cell density Kitasato University School of Medicine Results 4,5 IOP, Endothelial cell density IOP Endothelial cell density 20 3000 2555 2526 2296 IOP (mmHg) Corneal endothelial cell density (cells/㎜2） 13.2 13.5 12.9 * N.S. Cell loss 9.1% * 　P＜0.01 　　（Wilcoxon signed rank test）（Wilcoxon signed rank test） Before ICL Cataract After ICL removal implantation formation and IOL implantation Before ICL Cataract After ICL removal implantation formation and IOL implantation 第61回　日本臨床眼科学会　 6

implant’n/extraction Kitasato University School of Medicine Results 6 Vaulting (ICL to lens) Ages at implant’n/extraction Pre-op refraction（D） ICL tenure of use (years) version Vaulting （μm） Cataract type 53 / 55 -10.4 2.4 Ⅱ 148.8 nuclear 37 / 44 -10.8 7.4 171.7 44 / 46 -13.0 2.1 ant’r, subcapsular -12.0 2.2 48 / 51 -17.8 2.8 -16.4 3.4 46 / 48 -14.4 1.6 262.7 53 / 56 -24.0 2.7 102.6 44 / 52 -16.0 8.1 181.0 57 / 62 -18.5 5.4 Ⅳ Mean 46.9 / 51.1 -15.1 4.0 - 86.7

Assessment 1 Cataract type Kitasato University School of Medicine Assessment 1 Cataract type Nuclear cataract (7 eyes) → common in high myopia ・Age at ICL removal (present study): 51.1 ± 4.2 y.o. 　　・Age at cat. operation in high myopia: 56.8 ± 10.0 y.o. 　　・Average age at cat. operation: 63.4 ± 8.9 y.o. 　　 high myopia occur cat. earlier　　　　　　　 Anterior subcapsular cat. (3 eyes) → suspected ICL-induced 　　・after crystalline lens exposure to ICL 　　・ as a nutritional disturbance as changes in the dynamic state of aqueous humor （Shimizu JSCRS 2007）（Trinidade F et al. J Cataract Refract Surg. 1998）（K.Fujisawa et al ; Graefes Arch Clin Exp Ophthalmol. 2006 ）第61回　日本臨床眼科学会　 8

Assessment 2 Lens Version & Cataract Type Kitasato University School of Medicine Assessment 2 Lens Version & Cataract Type ・version II: anterior-subcapsular (3 eyes / 9 patients) nuclear (6 eyes / 9 patients) ・version IV: nuclear (1 eye / 1 patient) Version IV lenses have higher vaulting. We consider that is the reason why ASC is unlikely. Ver.Ⅱ Ver.Ⅲ Ver.Ⅳ Optical zone larger Vaulting: +0.17mm 第61回　日本臨床眼科学会　 9

Assessment 3 Predictability (error < ±1.0D) Kitasato University School of Medicine Assessment 3 Predictability (error < ±1.0D) Predictability of cataract surgery (%) 90% 90.5% * IOL master, (SRK-T) 60-80% ** IOL master, (SRK-T, Double-K method) (Iida et. al. JSCRS 2006) high myopic eye ICL Implanted eye LASIK eye *** IOL master, (SRK-T) (Shimizu et.al. JSCRS 2007) * ** *** Predictability of IOL power calculation in ICL implanted eyes is almost equal to that in unoperated high myopic eyes without any specific calculation method.

Accommodation and Pseudo-accommodation Kitasato University School of Medicine Assessment 4 Changes in accommodation Cataract occurs earlier in high myopia. Pseudo-accommodation is greater in IOL eyes in high myopia. In high myopic eyes in patients in their 50s, breadth of accommodation and pseudo-accommodation after cataract surgery and implantation with ICLs are approximately the same.　　　　　　 Accommodation and Pseudo-accommodation ICL implanted eyes high myopic eyes regular eyes Pseudo-accommodation (D) Accommodation and （Shimizu, JSCRS 2007） 20’s 30’s 40’s 50’s 第61回　日本臨床眼科学会　 11

Kitasato University School of Medicine Conclusions Cataracts occurred frequently in elderly persons and in cases of old type ICL implantations. Even if cataracts are formed, the ICL can be removed easily, IOL power can be calculated enough predictably, no decrease in area of distinct vision, and good visual performance is maintained.