SELECTION of PATIENTS
PIOLs
António Marinho, MD PhD
Departamento de Cirurgia Refractiva
Hospital Arrábida
PORTO PORTUGAL
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?


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

Mínimal Age
– 18 years

exceptions
– anisometropia
– Stable refraction in the last
18 months

Above 50 years
– low ametropia

LASIK
– high ametropia

CLE
INCLUSION CRITERIA
General
Stable refraction
 No intraocular diseases (diabetes
without retinopathy and well controlled
glaucoma are relative
contraindications,but any history of
UVEITIS is absolute contraindication)
 Ectatic disorders of the cornea are NOT
contraindications

INCLUSION CRITERIA
Specific

Anterior chamber anatomy (AC depth
and AC size)

Endothelium profile

Iris shape

Perfect Surgery
Pupil Size
Anterior chamber depth
AC depth (central)
 > 2.80mm (endothelium to natural lens)

Higher IOL power may need deeper AC
(see Ophtec tables)
 Importance of critical distance

How to measure the AC depth
?

US biometer (not precise)
Orbscan
 Scheimpflug (Pentacam)


OCT (Visante,SL-OCT)
How to evaluate the AC ?

US Biometer (not precise)

Orbscan

OCT (Visante,SL-OCT)
AC DEPTH (OCT)
Implantation simulation
Anterior chamber size
Angle to angle distance (AC phakic
IOLs)
 Sulcus to sulcus distance (ICL)
 Not important for iris-fixated IOLs (“one
size fits all)

How to measure AC Size ?

White to white (caliper,Orbscan,IOL
master)---- not reliable

OCT (good to angle, but not to sulcus
to sulcus)
AC SIZE (OCT)
Iris shape

Avoid convex iris

Most important in Hyperopia (clearance)

Possibility of posterior synechia
Preop ACD too small <2,8mm
Iris = convex
Posterior Synechia
Pupil Size


Mesopic pupil
<6.0mm
Artisan 5mm
Mesopic Pupil
<7.0mm
 Artisan 6mm
Artiflex/Acrysof/ICL

Glare and halos
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)

Endothelium Profile
Endothelial Cell Count

Before Surgery (inclusion criteria)

3 months after (shows surgical trauma)

Yearly afterwards (if important decrease
EXPLANT)
Perfect Surgery
Atraumatic Surgery
 Use cohesive viscoelastic
 Center the IOL with the pupil (recheck
at the end) – Artisan/Artiflex
 Take all the visco out
 Attention to post-op medication

WHICH PIOL?

Angle- supported ?

Posterior chamber ?

Iris- supported ?
PIOLs Which ?
Acrysof,Artisan,Artiflex,ICL
PRL