Phakic posterior chamber IOLs

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Phakic posterior chamber IOLs

• Cells involved in crystalline lens and capsular
  bag opacification
• Evolution of designs of PPCIOLs
• Relevant aspects of fixation and sizing
• Sizing issue New studies
• Surgical implantation
• Relationship between cataract and myopia
• Cataractogenesis
• Specimens analyzed in our Center (Center for
  Research on Ocular Therapeutics and Biodevices
  and Magill Research Center for Vision Correction,
  Storm Eye Institute, MUSC)
• Mechanisms
• Review of the literature
• Classification of cataracts after phakic IOL
  implantation?

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Third generation Staar ICL
Courtesy Paul Koch, MD, Koch Eye Surgicenter,
Inc., Warwick, RI, USA
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Third generation Staar ICL
Courtesy Paul Koch, MD, Koch Eye Surgicenter,
Inc., Warwick, RI, USA
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Case of A. Chayet, MD, Mexico (ICL
capsulorhexis)
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ICL Pigment Deposition/Dispersion
Case of R. Gerl, MD, Germany
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Phakic posterior chamber IOLs

• Cells involved in crystalline lens and capsular
  bag opacification
• Evolution of designs of PPCIOLs
• Relevant aspects of fixation and sizing
• Sizing issue New studies
• Surgical implantation
• Relationship between cataract and myopia
• Cataractogenesis
• Specimens analyzed in our Center
• Mechanisms
• Review of the literature
• Classification of cataracts after phakic IOL
  implantation?

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Jimenez-Alfaro I, et al. Ophthalmology 2001
  10890-99
• (20 eyes age 27-40 years myopia 9.0 to -19.5
  D follow-up 16.5
• 5.1 months)
• Anterior chamber reduction (9-12)
• Central endothelial cell density decrease (not
  progressive)
• Increase of the aqueous flare (50)
  stabilization above preoperative values
• Progressive decrease of crystalline lens
  transmittance
• Contact ICL-iris in all eyes
• Peripheral contact ICL-crystalline lens (60)
• Central contact ICL-crystalline lens (15)
• Changes in ICL axis (10)

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Surgical trauma -possible cataractogenetic
  effects of the NdYAG laser
• -accidental contact of the anterior capsule
  during different surgical steps
• Intermitent microtraumas -increased crystalline
  curvature during accommodation
• -rotation of the phakic lens
  postoperatively
• Increase in the overall lens size throughout life

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Constant trauma
• (contact phakic lens-anterior capsule)

central
periphery
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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Continuous disruption of the
• blood-aqueous barrier
• (subclinical inflammation)
• Caused by
• -friction iris/phakic lens
• -ciliary sulcus fixation
• Effects on the
• -crystalline lens transmittance
• -corneal endothelium

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Crystalline lens metabolic
• and nutritional disturbances
• Caused by
• -subclinical inflammation
• -blockage of normal circulation
• of the aqueous humor

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Phakic posterior chamber IOLs

• Cells involved in crystalline lens and capsular
  bag opacification
• Evolution of designs of PPCIOLs
• Relevant aspects of fixation and sizing
• Sizing issue New studies
• Surgical implantation
• Relationship between cataract and myopia
• Cataractogenesis
• Specimens analyzed in our Center
• Mechanisms
• Review of the literature
• Classification of cataracts after phakic IOL
  implantation?

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Review of the literature (1996-2001)
• -21 studies
• -Fyodorov early lenses, Chiron-
• Adatomed, ICL

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Fechner PU et al. Posterior chamber myopia lenses
  in phakic eyes. J Cataract Refract Surg 1996
  22178-182
• -Chiron-Adatomed silicone lens
• -69 eyes of 37 patients
• -Anterior subcapsular opacities in 8/45 eyes
  (17.8)
• -1 to 2 years postoperatively
• -No space between phakic lens and natural lens

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Zaldivar R, et al. Posterior chamber phakic
  intraocular lens for myopia of -8 to -19
  diopters. J Refract Surg 1998 14294-305
• -Staar ICL
• -124 myopic eyes
• -2 eyes with opacities present preoperatively (no
  evolution)
• - 1 eye with a peripheral anterior subcapsular
  opacity developed in the region of the peripheral
  laser iridotomy

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Trindade F, Pereira F. Cataract formation after
  posterior chamber phakic intraocular lens
  implantation. J Cataract Refract Surg 1998
  241661-1663
• -Staar ICL
• -1 case report
• -Cataract 6 months postoperatively
• -59-year-old woman
• -Contact ICL-anterior capsule in the midperiphery
  (UBM)
• -Anterior subcapsular opacity in the central,
  noncontact area

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Pesando PM, et al. Posterior chamber collamer
  phakic intraocular lens for myopia and hyperopia.
  J Refract Surg 1999 15415-423
• -Staar ICL
• -19 myopic eyes
• -15 hyperopic eyes
• -Anterior subcapsular opacity developed 24 hours
  after surgery

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Kaya V, et al. Phakic posterior chamber plate
  intraocular lenses for high myopia. J Refract
  Surg 1999 15580-585
• -Fyodorov lens
• -34 myopic eyes
• -1 case of nuclear cataract
• -52-year-old male, with 2 nuclear sclerosis
  preoperatively

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Fink AM, et al. Cataract development after
  implantation of the Staar collamer posterior
  chamber phakic lens. J Cataract Refract Surg
  1999 25278-282
• -Staar ICL
• -Case report (36 and 40-year-old patients)
• -Anterior subcapsular opacities 10-14 months
  postoperatively in 3 of the 4 eyes
• -Opacities appeared superiorly and progressed
  involving the optical zone
• -Satisfactory central ICL vault in all of the
  cases (slit-lamp and UBM)

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Menezo JL, et al. Posterior chamber phakic
  intraocular lenses to correct high myopia A
  comparative study between Staar and Adatomed
  models. J Refract Surg 2001 1732-42
• -12 myopic patients
• -ICL in one eye and Chiron-Adatomed in the other
• -Anterior subcapsular cataract 25 with ICL
  after 19-21 months 33.3 with silicone lens
  after 9-16 months
• -No space between phakic lens and natural lens

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Incidence of cataract varies considerably
• Chiron-Adatomed 0-52.9
• ICL 0-25
• -Definition cataract x opacity
• -Variation of age and follow up period
• -Implantation of different (successive) models
  in the same study

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Standardization of the studies
• -Describe parameters of NdYAG laser iridotomies
• -Note any intraoperative trauma to the anterior
  capsule
• -Follow up period of at least 1 year
• -Evaluation of the relationship of the phakic
  lens with anatomic structures (slit-lamp, UBM,
  Scheimpflug camera)

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Cataractogenesis after phakic posterior chamber
intraocular lens implantation

• Standardization of the studies (cont.)
• -Development of an accurate method to choose the
  IOL size
• -Evaluation of subclinical inflammation with
  laser flare meters
• -Evaluation of explanted phakic lenses and
  histopathological analysis of adjacent tissues
• -Description of the evolution of the anterior
  subcapsular opacity

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Phakic posterior chamber IOLs

• Cells involved in crystalline lens and capsular
  bag opacification
• Evolution of designs of PPCIOLs
• Relevant aspects of fixation and sizing
• Sizing issue New studies
• Surgical implantation
• Relationship between cataract and myopia
• Cataractogenesis
• Specimens analyzed in our Center
• Mechanisms
• Review of the literature
• Classification of cataracts after phakic IOL
  implantation?

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Progression of the cataracts

• Peripheral opacities, non progressive (personal
  communications)
• Superior opacity, with progression involving the
  optical zone (Fink AM, et al. Cataract
  development after implantation of the Staar
  collamer posterior chamber phakic lens. J
  Cataract Refract Surg 1999 25278-282)

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Classification systems

• Based on standard retroillumination photographs
  and the total area of the opacities
• -Lens Opacities Classification System (LOCS III)
• -Wilmer system
• -Oxford system

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Classification systems

• Sophisticated systems combining high-resolution
  digital retroillumination imaging with image
  analysis systems, allowing objective
  documentation and quantitative measurement (as
  for PCO)
• -Pande MV, Ursell PG, Spalton DJ, et al.
  High-resolution digital retroillumination imaging
  of the posterior lens capsule after cataract
  surgery. J Cataract Refract Surg 1997
  231521-1527
• -Tetz MR, Auffarth GU, Sperker M, et al.
  Photographic image analysis system of posterior
  capsule opacification. J Cataract Refract Surg
  1997 231515-1520

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Classification of cataracts after phakic IOL
implantation?
-Peripheral (area) -Paracentral (area)
-Central (area)
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Thank you!