1. 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　

2. 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

3. 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

4. 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

5. 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
-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%

6. 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

7. 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 / 51.1
-15.1
4.0 -
86.7

8. 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): ± 4.2 y.o.
　　・Age at cat. operation in high myopia: 56.8 ± 10.0 y.o.
　　・Average age at cat. operation: ± 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 ）
第61回　日本臨床眼科学会　 8

9. 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

10. 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.

11. 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 ’s ’s ’s
第61回　日本臨床眼科学会　 11

12. 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.