Transcript CONCLUSIONS - Sociedade Portuguesa de Oftalmologia

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)
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Change the power of the lens (RLE)
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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 ?
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
Myopia
- Subjective Refraction
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Age

Mínimal Age
– under - 7D : LASIK
– above -7D: Phakic IOL
– Main Factor : Pachymetry
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Hyperopia
- Cycloplegic Refraction
– under + 3D : LASIK
– above + 4D: Phakic IOL
– Main factor: Keratometry
– 18 years

exceptions
– anisometropia
– Stable refraction in the last
18 months
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Above 50 years
– low ametropia

LASIK
– high ametropia

CLE
INCLUSION CRITERIA
Specific
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Anterior chamber anatomy (AC depth
and AC size)
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Endothelium profile
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Iris shape
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Perfect Surgery
Pupil Size
AC Depth
Bad Selection
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Endothelial
Decompensation
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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)
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Endothelial Cell Count
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Before Surgery (inclusion criteria)
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3 months after (shows surgical trauma)

Yearly afterwards (if important decrease
EXPLANT)
ACRYSOF
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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)
11.25 – 11.75
11.76 – 12.25
12.26 – 12.75
12.76 – 13.25
Model
L12500
L13000
L13500
L14000
Acrysof Surgery
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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

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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.
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Available for myopia,
hyperopia (-23.00 to
+12.00) and
astigmatism( +/-)
ARTISAN 6.0mm
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Iris-Claw phakic IOL
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PMMA
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6.0 mm O.Z.
Available for myopia
(-2.00 to –15.00)
Artisan Surgery
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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)
 6.00mm
 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
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ARTIFLEX
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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
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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….
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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
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Posterior Synaechia
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Convex Iris
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Shallow AC
IOL DEPOSITS
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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
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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
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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
Size matters…..
Short ICL: Decentration and small vault
 Long IOL: Excessive vault

If there is no vault…
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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
Artisan
 ICL
 Cachet

GAIN
43.5 %
40.6%
27.3%
LOSS
1.2%
0%
0%
AVAILABILITY
Acrysof
Artisan
Artiflex
ICL
Myopia
YES
YES
YES
(-6.00/-16.50) (-2.00/-23.00) (-2.00/-14.5)
YES
(-3.0/-23.00)
Hyperopia
NO
YES
(+2.0/+12.0)
NO
YES
(+3.0/+23.0)
Astigmatism
(Toric)
NO
YES (+/-)
YES(-)
YES (+/-)
Inclusion criteria
PIOLs
Acrysof
Artisan
Artiflex
ICL
AC Depth
>2.80mm
>2.80mm
> 3.00mm
>2.80mm
AC Size
Very
Important
(OCT)
One size fits
all
One size fits
all
Very
important
(W/W ????)
Iris
configuration
Not important
Avoid convex
iris
Avoid convex
iris
Not important
Pupil Size
<7.0mm
<6.0mm
<7.0mm
<7.0mm
Endothelium
Profile
Normal
Normal
Normal
Normal
PIOLs Surgery Overview
Acrysof
Artisan
Artiflex
ICL
Pupil
Miosis
Miosis
Miosis
Mydriasis
Side Port
1 (?)
2
2
2
Incision
2.6mm
5.2/6.2mm
3.2mm
3.2mm
Visco
Cohesive
Cohesive
Cohesive
Cohesive
Iridectomy
/Iridotomy
NO
YES
YES
YES/ NO
Suture
NO
YES
NO
NO
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
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