Departamento de Cirurgia Refractiva Phakic IOL Overview António Marinho, MD PhD Departamento de Cirurgia Refractiva Hospital Arrábida Porto 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

WHEN PHAKIC IOLs ? Age Myopia - Subjective Refraction Hyperopia 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

INCLUSION CRITERIA Specific Anterior chamber anatomy (AC depth and AC size) Endothelium profile Iris shape Pupil Size Perfect Surgery

AC Depth

Bad Selection Endothelial Decompensation Shallow AC

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 Selection AC 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 5.0mm Iris-Claw phakic IOL PMMA 5.0 mm O.Z. Available for myopia, hyperopia (-23.00 to +12.00) and astigmatism( +/-)

ARTISAN 6.0mm Iris-Claw phakic IOL PMMA 6.0 mm O.Z. Available for myopia (-2.00 to –15.00)

Artisan Surgery 2 side ports Main incision Fill AC with visco Introduce and rotate the IOL Enclavation of iris tissue Iridectomy Suture

ARTIFLEX Iris-claw phakic IOL PMMA haptics Silicone (foldable optic) 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

ARTIFLEX 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 Results BCVA>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) (-2.00/-23.00) (-2.00/-14.5) (-3.0/-23.00) Hyperopia NO (+2.0/+12.0) (+3.0/+23.0) Astigmatism (Toric) YES (+/-) YES(-)

Inclusion criteria PIOLs Acrysof Artisan Artiflex ICL AC Depth >2.80mm > 3.00mm AC Size Very Important (OCT) One size fits all Very important (W/W ????) Iris configuration Not important Avoid convex iris Pupil Size <7.0mm <6.0mm Endothelium Profile Normal

PIOLs Surgery Overview Acrysof Artisan Artiflex ICL Pupil Miosis Mydriasis Side Port 1 (?) 2 Incision 2.6mm 5.2/6.2mm 3.2mm Visco Cohesive Iridectomy /Iridotomy NO YES YES/ NO Suture

Refractive Results Conclusions 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