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

2. DEFINITION REFRACTIVE SURGERY
To change in a permanent way the refractive power of the eye

3. 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)

4. 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

5. 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

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

7. AC Depth

8. Bad Selection
Endothelial Decompensation
Shallow AC

9. AC SIZE (OCT)

10. Endothelium Profile Endothelial cell count:
21 to 25 years cells/mm
26 to 30 years cells/mm
31 to 35 years cells/mm
36 to 45 years cells/mm
> 45 years cells/mm
Endothelial cell shape (avoid high polymagatism)

11. Endothelial Cell Count
Before Surgery (inclusion criteria)
3 months after (shows surgical trauma)
Yearly afterwards (if important decrease EXPLANT)

12. 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)

13. 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

14. 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

15. 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

16. Rotation

17. Rotation

18. Peripheral synaechiae

19. ARTISAN 5.0mm Iris-Claw phakic IOL PMMA 5.0 mm O.Z.
Available for myopia, hyperopia ( to ) and astigmatism( +/-)

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

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

22. ARTIFLEX Iris-claw phakic IOL PMMA haptics Silicone (foldable optic)
One size fits all

23. TORIC ARTIFLEX Myopia -1.00 to -14.50 Cylinder -1.00 to -7.50
Two models (axis at 180º and 90º)
Sphere + Cylinder <

24. ARTIFLEX 2 side ports Main incision (3.2mm) Fill AC with visco
Introduce and rotate the IOL
Enclavation of iris tissue
Iridectomy
No Suture

25. 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

26. 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

27. Bad Selection
Posterior Synaechia
Convex Iris
Shallow AC

28. IOL DEPOSITS Rare Disappear spontaneouly after 3 months in most cases
May need steroid treatment (exceptionally)
Related to surgical manipulation

29. Posterior Chamber PIOLs

30. ICL V4c
The NEW ICL V4 c has a tiny central hole in the middle of the optic
NO iridectomy is needed

31. 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)

32. 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

33. Size matters….. Short ICL: Decentration and small vault
Long IOL: Excessive vault

34. If there is no vault…
Anterior subcapsular cataract (less frequent as the surgical technique and sizing devices get better)

35. Refractive Results BCVA>20/40
Artisan % (518 eyes)
ICL % (331 eyes)
Cachet % (113 eyes)

36. Refractive Results Safety
PIOL GAIN LOSS
Artisan % %
ICL % %
Cachet % %

37. 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(-)

38. 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

39. 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

40. 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