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Phakic IOL Overview
António Marinho, MD PhDAntónio Marinho, MD PhD
Departamento de Cirurgia RefractivaDepartamento de Cirurgia Refractiva
Hospital ArrábidaHospital Arrábida
Porto PortugalPorto 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
Myopia - Subjective Refraction
– 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
WHEN PHAKIC IOLs ?
INCLUSION CRITERIASpecific
Anterior chamber anatomy (AC depth and AC size)
Endothelium profile
Iris shape Pupil Size
Perfect Surgery
AC DepthAC Depth
Bad Selection
Endothelial Decompensation
Shallow AC
AC SIZE (OCT)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 SelectionAC 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 5.0mmARTISAN 5.0mm Iris-Claw phakic IOL
PMMA
5.0 mm O.Z.
Available for myopia,
hyperopia (-23.00 to
+12.00) and
astigmatism( +/-)
ARTISAN 6.0mmARTISAN 6.0mm Iris-Claw phakic IOL
PMMA
6.0 mm O.Z.
Available for myopia
(-2.00 to –15.00)
2 side ports Main incision Fill AC with visco Introduce and
rotate the IOL Enclavation of iris
tissue Iridectomy Suture
Artisan Surgery
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
ARTIFLEXARTIFLEX 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 ResultsBCVA>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)
YES(-2.00/-23.00)
YES(-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 criteriaPIOLs
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 ResultsConclusions
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