Phakic%20IOL%20Overview

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Phakic IOL Overview

• António Marinho, MD PhD
• Departamento de Cirurgia Refractiva
• Hospital Arrábida
• Porto Portugal

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DEFINITION

• REFRACTIVE SURGERY
• To change in a permanent way the refractive
  power of the eye

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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)

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Why Phakic IOLs?

• Phakic IOLs 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

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WHEN PHAKIC IOLs ?

• 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

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INCLUSION CRITERIASpecific

• Anterior chamber anatomy (AC depth and AC size)
• Endothelium profile
• Iris shape Pupil Size
• Perfect Surgery

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AC Depth
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Bad Selection

• Endothelial Decompensation
• Shallow AC

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AC SIZE (OCT)
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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
• gt 45 years 2000 cells/mm
• Endothelial cell shape (avoid high polymagatism)

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Endothelial Cell Count

• Before Surgery (inclusion criteria)
• 3 months after (shows surgical trauma)
• Yearly afterwards (if important decrease EXPLANT)

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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)

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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

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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

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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

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Rotation
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Rotation
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Peripheral synaechiae
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ARTISAN 5.0mm

• Iris-Claw phakic IOL
• PMMA
• 5.0 mm O.Z.
• Available for myopia, hyperopia (-23.00 to
  12.00) and astigmatism( /-)

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ARTISAN 6.0mm

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

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Artisan Surgery

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

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ARTIFLEX

• Iris-claw phakic IOL
• PMMA haptics
• Silicone (foldable optic)
• 6.00mm
• One size fits all

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TORIC ARTIFLEX

• Myopia -1.00 to -14.50
• Cylinder -1.00 to -7.50
• Two models (axis at 180º and 90º)
• Sphere Cylinder lt -14.50

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ARTIFLEX

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

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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

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Not Perfect Surgery.

• Decentration is always a surgeons fault
• These lenses are always centered regardless of
  the pupil
• Luxation of the IOL(traumatic or spontaneous)is
  due to weak grasp

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Bad Selection

• Posterior Synaechia
• Convex Iris
• Shallow AC

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IOL DEPOSITS

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

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Posterior Chamber PIOLs
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ICL V4c

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

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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)

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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

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Size matters..

• Short ICL Decentration and small vault
• Long IOL Excessive vault

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If there is no vault

• Anterior subcapsular cataract (less frequent as
  the surgical technique and sizing devices get
  better)

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Refractive ResultsBCVAgt20/40

• Artisan 93.9 (518 eyes)
• ICL 94.7 (331 eyes)
• Cachet 100 (113 eyes)

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Refractive Results Safety

• PIOL GAIN LOSS
• Artisan 43.5 1.2
• ICL 40.6 0
• Cachet 27.3 0

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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 (/-)
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Inclusion criteriaPIOLs
Acrysof Artisan Artiflex ICL
AC Depth gt2.80mm gt2.80mm gt 3.00mm gt2.80mm
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 lt7.0mm lt6.0mm lt7.0mm lt7.0mm
Endothelium Profile Normal Normal Normal Normal

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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
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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