PHAKIC IOL’S ( pIOL’S ) IN CORRECTING HIGH MYOPIA By: H.R. ZIAI MD. Esfand 1391 Isfahan

HISTORY 1950s : First ideas formed 1988 : Angle supported PMMA, ZB5M & MA20, by Bikoff But : Discontinued because of complications ( corneal edema, iritis,… )

HISTORY 1988 : First phakic iris – clawed IOL introduced for myopia by Worst 1998 : Artisan – Worst by OPHTEC Then changed it’s name to Artisan – Verysise and it’s flexible form to Artiflex

HISTORY 1987: First PC pIOL or sulcus support pIOLs introduced : - Phakic Refractive Lens ( PRL ) by CIBA VISON. And then : - Implantable Contact Lens ( ICL ) or Implantable Collamer Lens ( ICL ) - Collamer is a copolymer of hema ( 99% ) and porcine collagen ( 1% )

CLASSIFICATION OF pIOLS Ant.Chamber pIOLS ( AC pIOLS) - Angle supported 1) PMMA 2) Foldable - Iris – Clawed 1)PMMA 1)Foldable Post.Chamber pIOLS ( PC pIOLS ) (or sulcus supported ) \\\

INDICATIONS High Myopia - Myopia > to D - Stromal bed < 300µ after laser ablation - Keratometry < 34-36D after laser ablation

FDA Approval for Artisan/Artiflex - Myopia : to D - Ast. < 2.5 D - Age > 21 y - ACD > 3.2 mm

FDA Approval for ICL : - Myopia : to D - Ast.< 2.50 D - Age y - ACD > 3.00 mm

High Hyperopia - Keratometry > 50 D after laser ablation - Available pIOLS : ICL : Up to D Artisan : Up to

- Laser ablation is the Tx of choice for Ast. up to 4.00 – PIOLS are available too. High Ast.

CONTRAINDICATIONS - Any intraocular pathology ( Cat., Glaucoma, NVI, Uveitis, … ) - ↓ ACD - ↓ Diameter

ADVANTAGS OF pIOLS - Rang of correction >> Laser - Easy technique ( Like Cat. Surgery ) - Less expensive instruments than Laser - Removable - No ↓ in contrast sensitivity even : ↑ Compared with spectacle -More predictable

DISADVANTAGES OF pIOLS - All intraocular risks - Large incision ( in PMMA types ) - Limitation in hyperopia due to small ant. segment - Irreversible complication

PRE-OP EVALUATION - Power of IOL - Diameter of IOL for angle or sulcus supported IOLs - ACD - Specular microscopy - Optic size in correlation to scotoptic pupil size - All other rutin evaluation before cat. surgery

Cont. But : Main challenge in angle or sulcus supported pIOLs is : “ Sizing IOL diameter” Through Angle-to-angle And ciliary sulcus diameter

Cont. For angle supported pIOLS – 1.00 mm add to w-to-w measured manually or by orbscan, although not always correct. - Use of OCT/UBM

Cont. Note: If diameter measured horizontally the lens must implanted horizontally; if implanted vertically, it causes Decenteration, Ovalization, Iritis, Glaucoma.

Cont. For PC pIOLS ( sulcus supported ) - Add 0.50 – 1.00 mm to horizontal W-W - New ultrasound techniques like Artemis & UBM

ANGLE SUPPORTED pIOLS Surgical Technique (important points) -Incision, mm (based on type ) - Sup. approach ( more common ) - Retrobulbar avoided ( glob perforation ) - IOL dialled to the best pupil-optic matching

Cont. - Surgical PI - OVD irrigated meticulously - Pilo 2 ( useful, but may decentered pupil

Complications - Haloes and Glare : more com complication ( 20 % ) more in 1th year, but : ↓ over time - Pupil ovalisation ( 7-22% ) ( if oversized ) - Iris retraction and atrophy

Cont. Endothelial cell damage: -Surgical trauma - Presence of IOL % in 1th year and less in next years Too small size : ↑ damage

Cont. - ↑ IOP - Transient, 2’ to OVD - Topical CS - Pupilary block - Uveitis : 4.5% - Usually transient, 2’ to iris manipulation - In over sized IOL, may chronic, causing glaucoma cat., PAS, Iris damage, …

Cont. - Cataract - Less common than PC pIOL - Caused by trauma, uveitis - Age > 40 y at time of surgery - AL > 30 mm - RD : 3% If pIOL have additive risk for RD over the myopia??

Cont. Rare complications - Corneal decompensation - Urretis – Zavalia synd. - Malignant glaucoma - Endophthalmitis - Hyphema

IRIS FIXATED pIOLs General information of Artisan mm vault ( 0.8 mm distance between IOL & crystalin lens) - Diameter : 8.5 mm - Optic : 6.5 & 6.0 mm - Center :0.2 mm thickness

Indications ( FDA ) : - Myopia - Hyperopia - RE After PK - Sever anisometropia in children - Aphakia - KCN - Progressive high myopia in psudophakic children

Complications - Glare & haloes: 0-9% more in small optics ( 5mm ) and Large pupil ( > 5.5 mm ) - AC inflammation: 0.5% - Pigment dispersion : 2” to poor enclavation -Crystalin lens rise: like Hyeperopia ( Artiflex > Artisan ) because of step in optic- haptic junction

Cont. Endothelial cell loss - Intraoperative trauma ( main cause ) - more in first 6m post op. - ACD < 3.2 → ↑ risk Glaucoma - Usually transient - OVD, CS, pigment, inflammation

Cont. Cataract : 3% - NS - Age > 40 at implantation time →↑risk - AL > 30 mm →↑ risk Other complications - Hyphema - Intermittent myopic shift - RD

PC PIOLs ( SULCUS SUPPORTED ) - PRL : Silicon, hydrophobe - ICL : Hydrophyl, biocompatible, permeable

Complications -Glare & halos 8.4 %, ↓ over time -Flare ; 27%, Up to 2y -Cataract - The major concern – 3 % - Traumatic contact, metabolic disturbance - Ant. sub capsular

Cont. Pigment dispersion & deposition - Iris rubbing - ↑ Size ( ↑ Vault ) →↑ dispersion

Glaucoma - 2’ to pigment dispersion - Angle closure - Pupilary block ( if fibrin formed ) - ICL > PRL Decenteration : The most complication - Small size IOL, difficult problem - Even sometime dislocation into vitreous cavity

Note : In PC pIOL, vault is of critical importance - ↑ Vault → ↑ Pigment dispersion - ↓ Vault → ↑ Cataract

BIOPTICS Implantation of pIOL followed by Laser ablation - In case of extremely myopia, high Ast., lens power not available. - Safe and effective

FEW SELECTED POINTS - PIOLs have been used successfully for post PK Ast. - Artisan induces HOA less than APT because of reserving prolate shape of cornea. - Toric pIOL + CXL successfully have been used for correcting RE in mild to moderate KCN & PMD.

Cont. - AC pIOLs have been used for TX of children with sever myopic anysometropia ( > ) that resist or no cooperative for traditional amblyop therapy with encouraging results.

CONCLUSION Compared with corneal laser ablation, pIOLs are excellent in : - Predictability - Efficacy - Safety - Quality of vision

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