INTRAOCULAR
CONTACT
LENS
HKMA Structured CME Program
John Chang, MD
Director of Guy Hugh Chan Refractive Surgery Centre
Hong Kong Sanatorium and Hospital
9 August 2007
LASIK is not the best option
for every patient
• Dioptre removal/optical zone &
quality of vision trade-off
• Large pupils
• Dry eyes
• Steep / flat corneas
• « Funny corneas » / Keratoconus
• Thin corneas
We all have those patients !
Phakic IOLs
Advantages
– Preserves Corneal topography.
– No induced aberrations
– => Better quality of vision
– High predictability.
– Stable refractive outcome.
– Safe in eyes with suspicious corneas.
– Removable
– Minimal capital expenses.
Introduction
• Posterior Chamber Sulcus Fixated Lens
• Version 4
• Myopia -3.00 D to > -20.00 D
• Hyperopia +3.00 D to +17.00 D
Loading the ICL
• The ICL is marked to ensure proper orientation in the
eye as it unfolds
Lower left
Leading
right
Alignment
Marks
Clear Corneal Incision
• Temporal, clear corneal incision orients best to iris
plane
Video - ICL Injection
ICL Positioning
• Use the paracentisis
Video: ICL Positioning
• Rotate using the
edge of the lens or
on the haptic
“body”
• OK to use
footplates
73 Eyes
Since 6th May 2002
• Age
:
23 to 47
• Mean age
:
34.33 ± 6.37 yrs
• Male
:
12
• Female
:
36
Pre-Op MRSE
• Range
:
-7.00 D to -24.75 D
• Mean
:
-14.38 ± 3.45 D
Follow up
• 1 day, 1 week, 1 month, 3 month, 6 month,
and 1 year and beyond
• Dilated slit lamp & fundus exam (DFE) for all eyes at 6 months
• Range:
2 weeks to 43.8 months
• Mean:
15.9 months
Predictability of Refraction
Planned Refraction
• Within ± 0.50 D
:
45
(61.6 %)
• Within ± 1.00 D
:
59
(80.8 %)
Post-Op UCVA
Those eyes with 20/20 or better Pre-Op BCVA
20/15
19
(48.7 %)
20/20 or better
31
(79.5 %)
20/25 or better
36
(92.3 %)
20/40 or better
39
(100.0 %)
Worse than 20/40
0
(0 %)
Total
39
Stability of refraction
Mean MSE at each follow up
2
-0.23 -0.1
Diopter
-2
-0.1
-0.19
-0.3
-0.14
-0.39
-6
mean MSE
-10
-14
-14.38
-18
pre-op
1 wk
1m
3m
6m
Follow up time
12 m
18 m
24 m
Safety
Pre- vs Post- BCVA
gained 2 or more lines
14
(19.2 %)
gained 1 line
39
(53.4 %)
no change
18
(24.7 %)
lost 1 line
2
(2.7 %)
Lost > 1 line
0
(0%)
Lost 1 line
• Age:
39 M
• Pre-op MRSE:
-10 D
20/20
• Post-op MRSE:
+0.13 D
20/25
• Follow up:
1 month
Patient complaint of difficulty with reading and elected to
have ICL removed despite near VA J2 after 1 month.
Lost 1 line
• Age:
39 F
• Pre-op MRSE:
-13.88 D
20/15
• Post-op MRSE:
-0.50 D
20/20
• Follow up:
14.9 months
Post-op BCVA varied between follow up visits from 20/15
to 20/20. No other complication was noted.
Complications
Out of 73 eyes:
• 1 (1.4 %) ICL size too small – observe
• 1 (1.4 %) brow ache for 2 months
• 1 (1.4 %) ICL removed after 1 month ( pt didn’t like it)
39 year old male, c/o near vision problem
MRSE at 1 month: +0.13 D
• 1 (1.4 %) overcorrect by +1.5 D (VD not at 12mm)
Complications
• 1 eyes (1.4 %) complained of seeing extra light from P.I.
• 17 eyes (23.3 %) developed transient IOP rise within 2
month post op;
– range 23 to 30 mmHg;
– all controlled by timolol;
– all resolved by 1 month;
– only 3 eyes in 2006, all other before 2005
Complications
• 2 eyes (2.7 %) developed ASC
Mean pre-op MSE
-9.28 D
-11.25 D
MSE at last visit
-3.00 D 20/20
-1.25 20/20
UCVA
20/150
20/25
ACD
3.2
3.18
WTW
11.5
11
Lens type
ICM125V4
ICM115V4
Comment
onset at 20 month
onset 13 days, visually
significant at 18
months
Early result: Toric ICL
25 eyes (since June 2004)
•
•
•
•
Age range:
Mean age:
M:F
Mean follow up:
23 to 44
32.0 ± 6.8 yrs
4 : 14
7.5 ± 4.4 months
(range 1.4 to 18.8 months)
Early result: Toric ICL
Mean ICL power:
Sphere
Cylinder
-18.44 ± 3.22 D
+3.68 ± 1.20 D
Pre-op
Post-op
Mean sphere
-13.85 ± 3.20 D
-0.20 ± 0.51 D
Mean cylinder
+2.95 ± 1.07 D
+0.64 ± 0.47 D
Mean MSE
-12.36 ± 3.06 D
+0.03 ± 0.34 D
Early result: Toric ICL
Post-op mean MSE at each follow up
4
Diopter
0
0.36
0.21
0.18
0.03
-0.06
-4
mean MSE
-8
-12
-12.36
-16
pre-op
1 wk
1m
3m
Follow up
6m
12 m
Early result: Toric ICL
Cumulative post-op BCVA and UCVA
20/20 or better pre-op BCVA
100.00%
80.00%
60.00%
Post-op UCVA
Post-op BCVA
40.00%
20.00%
0.00%
20/15
20/20
20/25
20/30
20/40
Advantages
ICL vs LASIK
• No / Minimal night vision problems
• Stability /Faster recovery.
• Correct much higher ranges of myopia (-3.0 D to -20.0 D)
• Also correct hyperopia (+3.0 D to +17.0 D)
• Reversible
• No ectasia
Advantages
ICL vs LASIK
• 2 patients had ICL in one eye (-19 D, -17 D) and LASIK
in the other eye(-14 D, -13 D)
• Higher myopia in the eyes with ICL
• Both patients report better quality vision with ICL
despite the higher myopia
• Stability – no initial overcorrection.
Advantages
ICL vs ACIOL
• No endothelial cell loss, no AC reaction
• Small self-sealing incision
-No/less induced astigmatism
• No need to pre-cut flap in bioptics
• Can correct astigmatism at the same time
-(LRI or Toric ICL)
The Verisyse anterior-chamber Lens
Picture from www.gutsehen.de/gfx/iol_verisyse.jpg
Disadvantages
• Clinically significant ASC 1.3%*
• Sizing can be difficult, Orbscan not always reliable
• Glaucoma? Pigment dispersion?
• Expensive
• 2 Procedures: Laser P.I. First (uncomfortable), then
lens implantation
*5 year follow up US FDA MICL Clinical Trial – in press
Conclusion
• ICL and Toric ICL results very encouraging
• Transient IOP rise 2° to Occucoat?
• Accuracy as good / better than LASIK for high myopia
• Much better immediate and long term stability than
Lasik.
• Technically not difficult (Avg surgery time 25 mins)
• No / Minimal night vision problems
• Short learning curve –easier than Phaco
What if one develops a
cataract extraction leads to
immediate presbyopia?
Multi-Focal IOL
*Diagrams from AMO
Refractive IOL - Array
*Diagrams from AMO
*Diagrams from AMO
*Diagrams from AMO
*Diagrams from AMO
*Diagrams from AMO
Adjustment by
human eye
to Multi-Focal IOL
*Diagrams from AMO
Basic Theory
• Diffractive MIOL - Tecnis MF
near focus
*Diagrams from AMO
far focus
*Diagrams from AMO
TecnisMF
Array
ReZoom
near
focus
*Diagrams from AMO
far
focus
Patients
No. of
patients
No. of eyes
Mean age
Range
Array
59
95
54 + 11.9
35 to 85
ReSTOR
27
43
65 + 9.7
50 to 84
TecnisMF
130
179
59 + 13.3
7 to 87
Refraction
Array
ReSTOR
TecnisMF
-10.00
-0.60
-6.18
±7.9
±3.07
±5.29
+7.75 to -31.25
+4.00 to -6.75
+5.63 to -18.00
Postop mean
MRSE (D)
-0.22
-0.26
0.04
STD
±1.01
±0.68
±0.57
+2.38 to -6.63
+1.00 to -2.00
+2.00 to -2.25
Preop mean
MRSE (D)
STD
Range
Range
3 IOLs Comparison
Cumulative Postop UCVA
100
90
Percentage %
80
70
60
Array
ReSTOR
TecnisMF
50
40
30
20
10
0
20/15
20/20
20/25 20/30 20/40
VA (Snellen)
20/50 <20/60
3 IOLs Comparison
Percentage %
Cumulative Postop BCVA
100
90
80
70
60
50
40
30
20
10
0
Array
ReSTOR
TecnisMF
20/15 20/20 20/25 20/30 20/40 20/50 <20/60
VA (Snellen)
Safety
Preop vs Postop BCVA: Gain / Loss
45
40
Percentage %
35
30
25
Array
ReSTOR
TecnisMF
20
15
10
5
0
gain > 2 lines gain 2 lines
gain 1 line
no change
loss 1 line
Change in BCVA (Snellen)
loss >1 line
3 IOLs Comparison
100
Cumulative Postop Near UCVA
90
Percentage %
80
70
60
Array
ReSTOR
TecnisMF
50
40
30
20
10
0
J1
J2
J3
J5
Near VA
J7
>J7
Questionnaire
Night glare*
Halo*
Satisfaction#
Array
1.51 (32%)
1.68 (36%)
3.72 (92%)
ReSTOR
1.03 (21%)
1.47 (30%)
3.77 (87%)
TecnisMF
1.88 (44%)
1.99 (44%)
3.70 (93%)
* the higher the score, the more the severity (from 0-5)
# the higher the score, the higher the satisfaction (from 0-5)
(%) percentage of eyes had score ≥3
TecnisMF Questionnaire
% of time spectacles are required
0%
<50%
>50%
Reading
100%
0
0
(including newspaper, books, documents)
Near tasks
100%
0
0
(including SMS, watch, etc)
Distance
100%
0
0
1 patient requires spectacles for computer
Mix and Match- Early result
Spectacles dependence
Ave. Time Spent
Yes
No
Distance
----
0%
100%
Reading
2.8 hr
0%
100%
Computer
5.2 hr
0%
100%
All patients are 100% of time
SPECTACLES FREE
Thank You