Update on Phakic IOLS
Alaa El-Danasoury, MD, FRCS
Medical Director
Chief, Refractive Surgery Service
Magrabi Hospitals & Centers
AAO - Chicago, 2010
Financial Disclosure
Consultant for
 Nidek
 STAAR Surgical
AAO - Chicago, 2010
Why P-IOLs? 1993 - 2010
1993: We thought
2010: We know
LASIK
P-IOLS

Predictable in all errors

P-IOLs more predictable

Relatively safer

New safer P-IOLs designs

One procedure fits all errors

LASIK limitations

Outcome measure: VA

Other measures: Quality…

Patients preferred LASIK

Surgeons prefer P-IOLs
AAO - Chicago, 2010
Attempted vs Achieved Correction - 12
Mos
n = 79 eyes; SE: -6.0 to -12.0 D
14.0
Overcorrected
Achieved
12.0
10.0
P-IOL (n=40)
LASIK (n=39)
8.0
Undercorrected
6.0
4.0
P > 0.1
4.0
6.0
8.0
10.0
Attempted
AAO - Chicago, 2010
12.0
14.0
P-IOLs Vs LASIK
UCVA at 12 Months
Percent of Eyes
100
80
60
IOL
LASIK
40
20
0
20/20 or better 20/30 or better 20/40 or better 20/60 or better
P < 0.05
AAO - Chicago, 2010
Uncorrected Visual Acuity (UCVA)
P-IOLs Vs LASIK
Loss & Gain of SCVA
Percent of Eyes
70
60
50
40
IOL
30
LASIK
20
10
0
-2
-1
0
1
2
Lines of Spectacle-corrected Visual Acuity (SCVA)
AAO - Chicago, 2010
3
P-IOLs Vs LASIK
Patient Preference (36 pat: P-IOL / LASIK)
What is the main reason for your preference?
P-IOL:

Better quality of vision
23/26 (88.5%)
LASIK:

Easier procedure

Cosmetic
7/8 (87.5%)
1/8 (12.5%)
AAO - Chicago, 2010
Indications of P-IOLs:


1.
2.
3.
4.
5.
High Refractive errors
Special Indications:
Stable &/or stabilized KC
Suspicious corneas
Thin corneas
After Corneal grafts
Patients Preference
AAO - Chicago, 2010
Avaiable Phakic IOL Designs:
1.
2.
3.
Angle supported Phakic IOLs:
Iris fixated Phakic IOLs:
Posterior Chamber phakic IOLs
AAO - Chicago, 2010
Available Phakic IOL Designs:
Angle supported Phakic IOLs:
I.
•
Only available is Acrysof Cachet (Alcon)
Iris fixated Phakic IOLs:
II.
•
•
Artisan / Verisyse (Ophtec / AMO)*
Artiflex / Veriflex ((Ophtec / AMO)
Posterior Chamber phakic IOLs
III.
•
•
ICL and Toric ICL (STAAR)*
PRL (Ciba Vision)
* FDA Approved
AAO - Chicago, 2010
I.
Angle Supported P-IOLS (Acrysof
Cachet)
Advantages
1.
Easy to implant
2.
Foldable material (small incision)
3.
Fast rehabilitation
AAO - Chicago, 2010
Acrysof Cachet
AAO - Chicago, 2010
Angle Supported P-IOLS
Disadvantages
1.
2.
3.
4.
Endothelium cell damage (older designs were withdrawn
for the market; Alcon Acrysof Cachet is recently
introduced and carries the promise of less endothelial
damage)
Possible Anterior chamber angle damage
Pupil Ovalization
Sizing is critical
• A small lens will move in the anterior chamber
• A large lens will induce angle damage and pupil ovalization
AAO - Chicago, 2010
II- Iris-Fixated P-IOLs
AAO - Chicago, 2010
Iris Enclavation

Artisan lens is fixed to
the Iris by enclavating
a fold of iris tissue in
the claw mechanism of
the haptic
AAO - Chicago, 2010
Iris Fixated lens
Advantages
1.
2.
3.
Best centration (manually centered over the
pupil)
Further from the endothelium (compared to
the anterior chamber lenses)
Long track records with relative safety
AAO - Chicago, 2010
Iris Fixated lens
Disadvantages
PMMA rigid lenses:
 Large incision = Surgical induced astigmatism &
Slow recovery
 small optic (5 mm) for high myopia and Toric
lenses
 Cosmetic (PMMA material reflects light in certain
positio of gaze)
Foldable design:
• Critical enclavation
• Occasional inflammation
AAO - Chicago, 2010
III. Posterior Chamber Lenses
ICL and Toric ICl are the most commonly used
 ICL has FDA approval
 Toric ICL is pending ICL approval

AAO - Chicago, 2010
ICL - Advantages
1.
2.
3.
4.
5.
6.
Implanted through small incision
Fast recovery
Cosmetically the best (cannot be seen in the eye)
Large effective optical zone
Toric design is available to correct astigmatism
Can be easily removed through the same small
incision
AAO - Chicago, 2010
ICL: Advantages
Cosmetically the Best
AAO - Chicago, 2010
ICL Advantages:
Toric Design
AAO - Chicago, 2010
ICL vault
AAO - Chicago, 2010
ICL Sizing issues



High Frequency US studies
Vaulting: 300 to 1000 um
Sizing; W-W is good enough
VuMax, Sonomed
Artemis II, Ultralink
Courtesy; David Brown, MD
AAO - Chicago, 2010
Courtesy, Erik Mertens, MD
ICL & TICL - Disadvantages

Sizing issues is not yet finalized:
• W-W is good enough
• High frequency US can improve the sizing in 5% of cases
• Forgiveness of the lens sue to the material & position

ICL induced Cataract
• 0.3 to 0.5%
• Related to the age at the time of surgery and lens power
AAO - Chicago, 2010
Conclusion

P-IOLs are mandatory for safe refractive surgery
practice

Many available designs passed the test of time

In Continuous development & improvement to reach
highest possible safety standards
AAO - Chicago, 2010
THANK U!!
AAO - Chicago, 2010