1. INTRACORNEAL LENS 29 years Follow Up N – No Financial Interest Head of the Oftalmic Department Medical School Maimonides University Director of the Clinica Oftalmologica de Alta Complejidad Buenos Aires - Argentina Prof. Dr. Horacio M. Soriano hsoriano@fibertel.com.ar

2. Intracorneal Lens History Introduced in 1949 by Jose Barraquer Barraquer JI.Queratoplatica Refractiva.Estudios e informaciones Oftalmologicas.1949;2:10. Continued by Bowen in 1961 Bowen, S. F., Jr., et al: Intracorneal Lens: Experimental Study, Proc Mayo Clin... Study, Thesis, University of Minnesota Graduate School, Minneapolis, 1961. Belau and col. in 1964 J W Belau, PGDyer, JAOgle, KNHenderson, JW. Correction of ametropia with intracorneal lenses: an experimental study. Arch Ophthalmol. 1964;72:541–547. Dohlman in 1967 Dohlman CH, Refojo MF,Rose J.Synthetic polymers in corneal surgery:glyceryl methacylate.Arch Ophthalmol. 1967;177:52-58 and Choyce in 1968. Choyce P.The present status of intracameral and intracorneal implants.Can J Ophth.1968;3:295-311. Introduced in 1949 by Jose Barraquer Barraquer JI.Queratoplatica Refractiva.Estudios e informaciones Oftalmologicas.1949;2:10. Continued by Bowen in 1961 Bowen, S. F., Jr., et al: Intracorneal Lens: Experimental Study, Proc Mayo Clin... Study, Thesis, University of Minnesota Graduate School, Minneapolis, 1961. Belau and col. in 1964 J W Belau, PGDyer, JAOgle, KNHenderson, JW. Correction of ametropia with intracorneal lenses: an experimental study. Arch Ophthalmol. 1964;72:541–547. Dohlman in 1967 Dohlman CH, Refojo MF,Rose J.Synthetic polymers in corneal surgery:glyceryl methacylate.Arch Ophthalmol. 1967;177:52-58 and Choyce in 1968. Choyce P.The present status of intracameral and intracorneal implants.Can J Ophth.1968;3:295-311.

3. Keratorefractive surgery limits are determined by corneal physiology. To nourish the cornea, lachrymal film provides oxygen and the acuose humor aminoacids, carbonic hydrates and lipids. Intrastromal implant must be sufficiently permeable to water, glucose and other essential nourishing elements to allow normal corneal physiology maintenance, be place deep in stroma perfectly centered and his diameter less than 5 milimeters.

4. In 1981 ICLE made of PMMA and silicon were implanted in 20 rabbits. With diameters ranging from 4 to 6 mm and different implantation depth. Observation period varied between 1 to 10 months. Central corneal ulceration in all cases after a period of 2 to 12 weeks with ICLE expulsion. Bowman membrane absence and limited blinking maybe responsible for bad results. Animal Experimentation RABBITS

5. In 1983, Siloxanyl-alkyl- metacrilato copolymers with silicon ICLE were implanted in 10 cats. 4 to 5 mm diameters implants with K 42.5 D were placed in the deepest stroma. Corneal incision was made at 1.5 mm of superior limbus in three cases. At 2.5 mm in the rest of them. In all cases excellent tolerance for more than 2 years. Animal Experimentation CATS

6. Surgical Technique and Clinical Experimentation Topical anesthesia. Visual axis mark. Lineal incision at 2.5 mm from superior limbus, at 80% of central pachymetry, 4.5 to 6mm length. Corneal pocket prepared in deep stroma. ICL implant and suture. ICL was implanted in 4 patients. Implants of Siloxan-alkyl-metacrilato copolymer with silicon and Fluoroperm 60 were used. Diameter: 4.5 and 5 mm K: Between 42 and 43 D. Only one patient could be follow for 29 years

7. 24 years, male Evolution of refraction 1986 : BCVA 20/60 with - 0.50 + 2.50 / 135° 1989 : BCVA 20/40 with + 0.50/130 1994 : BCVA 20/30 with +0.75/85 1994 : Central corneal herpes 1995 : Corneal herpes recidivate 1995 : Herpes cured. BCVA with no change 2002 : BCVA 20/30 -1 -1 / 180° 2011 : BCVA 20/30 with -1-2/90.The lens appears with an horizontal fracture in the middle (trauma?) 2014 : BCVA 20/40 with -1.50-2/100. Central haze !!! Actual axial length is 33,17mm Clinical Experimentation OD: Refraction – 8.0 pre op VA 20/200. Optical Corneal Pachymetry 600 On November 7, 1985 OD ICL implant, -20D, 5 mm. diameter, K 43 D

8. 24 years, male OD: Refraction - 8 pre op VA 20/200 Surgery was performed on November 7, 1985 OD ICL implant, -20D, 5 mm. diameter, K 43 D 10 years after surgery and despite having suffered a corneal herpes, corneal transparency and vision remain unchanged. 17 years after surgery we could make a topography that showed a central flattening and ultrasonic pachimetry was coincident with optical pachimetry. Corneal transparency and vision remained unchanged. 26 years later control is performed and lens sows a central horizontal fracture with no discomfort or changes in vision ( trauma ? ) 29 years after surgery decreased vision and ligth haze is observed because of the lens breakage Clinical Experimentation Evolution

9. 410 597 595 593 590 Post Surgical PachimetryPost Surgical Topography Clinical Experimentation CASE 1 ( 2002 ) Central pachimetry show how deep lies the intracorneal lens BCVA 20/30 Refraction : -1.0 – 1.0 / 180

10. Clinical Experimentation Broken lens ( 2011 ) VA : 20/30 Refraction : -1.0 – 2.0 / 90

11. Clinical Experimentation Central haze ( 2014 ) VA : 20/40 Refraction : -1.50 – 2.0 / 100

12. ICL tolerance has been excellent for 29 years. Vision remains stable until the last tree years wen appears the fracture. This break we estimate is responsible for the appearance of haze, changes in topography and consequent decrease visual acuity. We assume that the rupture may have been caused by a trauma that the patient does not remember, increased fragility of the lens or the combination of both. Siloxan-alkyl-metacrilato copolymer with silicon and Fluoroperm 60 was the best option at this time. Watching the current development of this surgical option and new materials available we belived that our experience confirms the excellent prospects of this refractive method. Conclusion