Long-term Study of Artisan Phakic Intraocular Lens Implantation for the Correction of Moderate to High Myopia

Phakic intraocular lens: Two-year results and comparison of endothelial cell loss with iris-fixated intraocular lenses

PURPOSE

To evaluate the efficacy, safety, and stability of a foldable angle-supported Acrysof Cachet phakic intraocular lens (pIOL) to correct moderate to high myopia and compare endothelial cell loss after iris-fixated Artisan and Artiflex pIOL implantation.

SETTING

University Eye Clinic Maastricht, the Netherlands.

DESIGN

Retrospective observational study.

METHODS

Foldable angle-supported pIOL implantation for myopia ranging from -6.0 to -16.5 diopters (D) was done. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, spherical equivalent (SE), and adverse events were documented preoperatively and 6 months and 1 and 2 years postoperatively. Endothelial cell loss after implantation of the foldable angle-supported pIOL and iris-fixated pIOLs was compared 6 months and 1 and 2 years postoperatively.

RESULTS

There were 158 eyes. The UDVA was equal to or more than 20/25 in 95% of eyes at 1 and 2 years postoperatively. The mean SE was -0.17 D ± 0.43 (SD) 2 years postoperatively. One patient developed pupil ovalization, resulting in explantation of the pIOL from both eyes. Acute endothelial cell loss in the foldable angle-supported pIOL group was -3.2% ± 0.7%, significantly higher than after iris-fixated pIOL implantation. Chronic endothelial cell loss from 6 to 24 months after surgery was -3.8% ± 0.7%. At the 2-year follow-up, the chronic endothelial cell loss in the foldable angle-supported pIOL group was not different than with iris-fixated pIOLs (P > .05).

CONCLUSIONS

The foldable angle-supported pIOL effectively corrected moderate to high myopia. However, acute surgical endothelial cell loss was significantly higher than with iris-fixated pIOLs.

FINANCIAL DISCLOSURE

Dr. Nuijts is a consultant to Alcon Laboratories, Inc., Théa Pharma GmbH, and ASICO LLC; he has received study grants from Acufocus, Inc., Alcon Laboratories, Inc., Carl Zeiss Meditec AG, Ophtec BV, and Physiol S.A. No other author has a financial or proprietary interest in any material or method mentioned.

Long-Term Comparison of Posterior Chamber Phakic Intraocular Lens With and Without a Central Hole (Hole ICL and Conventional ICL) Implantation for Moderate to High Myopia and Myopic Astigmatism: Consort-Compliant Article

The study shows a promising next-generation surgical option for the correction of moderate to high ametropia. Hole implantable collamer lens (ICL), STAAR Surgical, is a posterior chamber phakic intraocular lens with a central artificial hole. As yet, however, no long-term comparison of the clinical results of the implantation of ICLs with and without such a hole has hitherto been conducted. A prospective, randomized, controlled trial was carried out in order to compare the long-term clinical outcomes of the implantation, in such eyes, of ICLs with and without a central artificial hole.Examinations were conducted of the 64 eyes of 32 consecutive patients with spherical equivalents of -7.53 ± 2.39 diopters (D) (mean ± standard deviation) in whom implantation of a Hole ICL was performed in 1 eye, and that of a conventional ICL was carried out in the other, by randomized assignment. Before 1, 3, and 6 months, and 1, 3, and 5 years after surgery, the safety, efficacy, predictability, stability, intraocular pressure, endothelial cell density, and adverse events of the 2 surgical techniques were assessed and compared over time.The measurements of LogMAR uncorrected and corrected distance visual acuity 5 years postoperatively were -0.17 ± 0.14 and -0.24 ± 0.08 in the Hole ICL group, and -0.16 ± 0.10 and -0.25 ± 0.08 in the conventional ICL group. In these 2 groups, 96% and 100% of eyes, respectively, were within 1.0 D of the targeted correction 5 years postoperatively. Manifest refraction changed by -0.17 ± 0.41 D and -0.10 ± 0.26 D occurred in from 1 month to 5 years in the Hole and conventional ICL groups, respectively. Only 1 eye (3.1%), which was in the conventional ICL group, developed an asymptomatic anterior subcapsular cataract.Both Hole and conventional ICLs corrected of ametropia successfully throughout the 5-year observation period. It appears likely that the presence of the central hole does not significantly affect these visual and refractive outcomes.

TRIAL REGISTRATION

UMIN000018771.

Iris-fixated phakic intraocular lens implantation to correct myopia and a predictive model of endothelial cell loss

PURPOSE

To report long-term results of Artisan phakic intraocular lens (pIOL) to correct myopia and to propose a model predicting endothelial cell loss after pIOL implantation.

SETTING

Quinze-Vingts National Ophthalmology Hospital, Paris, France.

DESIGN

Retrospective, interventional case series.

METHODS

Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and central endothelial cell count (ECC) were determined before and at yearly intervals up to 5 years after pIOL implantation. Linear model analysis was performed to present a model that describes endothelial cell loss as a linear decrease and an additional decrease depending on postoperative loss.

RESULTS

A total of 49 patients (68 eyes) implanted with pIOLs from January 2000 to January 2009 were evaluated. The mean preoperative and final spherical equivalent (SE) were -13 ± 4.10 and -0.75 ± 0.74 diopters (D), respectively. The mean preoperative and final central ECC were 2629 ± 366 and 2250 ± 454 cells/mm(2), respectively. There were no intraoperative complications for any of the eyes. One eye required surgery for repositioning the pIOL, and 1 eye required pIOL exchange for postoperative refractive error. The model predicted that for patients with preoperative ECC of 3000, 2500, and 2000 cells/mm(2), a critical ECC of 1500 cells/mm(2) will be reached at 39, 28, and 15 years after implantation, respectively.

CONCLUSIONS

Implantation of the pIOL was an effective and stable procedure after 5 years of follow-up. The presented model predicted EC loss after pIOL implantation, which can assist ophthalmologists in patient selection and follow-up.

FINANCIAL DISCLOSURE

The authors report no conflict of interest.

Implantable Collamer Lens for Myopia: Assessment 12 Years After Implantation

PURPOSE

To evaluate the long-term refractive and visual stability and the risks related to the implantation of Implantable Collamer Lens (ICL; STAAR Surgical, Monrovia, CA) phakic intraocular lens (PIOL) for myopia.

METHODS

This retrospective, consecutive, cumulative clinical study was performed in a group of 144 eyes implanted with ICL PIOL for myopia. Only the cases with clinical data available 12 years after the implantation were included in the series. Corrected distance visual acuity (CDVA), uncorrected distance visual acuity, spherical equivalent, refractive astigmatism, endothelial cell density, ICL vaulting, and postoperative complications were analyzed.

RESULTS

Mean spherical equivalent refraction was -16.90±4.26 diopters (D) preoperatively and -1.77±1.93 D 12 years postoperatively. Mean CDVA at the first and last visit were 0.31±0.19 logMAR and 0.22±0.22 logMAR, respectively (Mann-Whitney U test, P<.001). Twelve years postoperatively, 8.9% of eyes had lost more than two lines of CDVA. The incidence of clinically relevant cataracts (13.88%) was significantly linked to the use of the V3 model ICL (chi-square test, P=.007). During the follow-up period, a significant reduction in PIOL vaulting was observed (Kruskal-Wallis test, P<.05), and the mean endothelial cell density decreased by 19.75%.

CONCLUSIONS

The ICL PIOL provided good refractive outcomes and stability in the long term. The incidence of cataracts is low when the latest models of this PIOL are used.

Visual acuity improvement in adult amblyopic eyes with an iris-fixated phakic intraocular lens: long-term results

PURPOSE

To evaluate the effect of implantation of iris-fixated phakic intraocular lenses (pIOLs) (Artisan) in adult amblyopic eyes.

SETTING

Optical Express, London, United Kingdom.

DESIGN

Retrospective case series.

METHODS

The study analyzed data from 5 years of follow-up of amblyopic eyes that were implanted with iris-fixated pIOLs and had a preoperative corrected distance visual acuity (CDVA) of 6/15 or worse. Visual acuity, refraction, endothelial cell count, and complications were assessed.

RESULTS

Data for 103 eyes were analyzed as 2 groups. Group 1 comprised 82 eyes with myopia or myopic astigmatism, and Group 2 contained 21 eyes with hyperopia or hyperopic astigmatism. The mean preoperative sphere in Group 1 was -13.42 diopters (D) ± 5.62 (SD) with a mean cylinder of -2.35 ± 1.75 D. In Group 2, the mean sphere and cylinder were +6.77 ± 1.91 D and -2.63 ± 2.43 D, respectively. The mean CDVA improved from 0.51 ± 0.15 logMAR to 0.34 ± 0.16 logMAR (P<.001) in Group 1 and from 0.54 ± 0.17 logMAR to 0.46 ± 0.14 logMAR in Group 2 (P<.005). The safety index was 1.48 in Group 1 and 1.19 in Group 2. The efficacy index was 1.21 in Group 1 and 1.00 in Group 2. The mean gain in CDVA was statistically significantly greater in Group 1 (0.17 ± 0.14 logMAR) than in Group 2 (0.08 ± 0.11 logMAR). Two or more lines of CDVA were gained by 48.8% of eyes in Group 1 and by 19.0% of eyes in Group 2.

CONCLUSION

The iris-fixated pIOL was a safe and effective option for improving visual acuity in adult amblyopic eyes.

FINANCIAL DISCLOSURE

Dr. Schallhorn is a consultant to Abbott Medical Optics, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

[Scheimpflug photography for the examination of phakic intraocular lenses]

BACKGROUND

High myopia phakic intraocular lenses (IOL) have become an established means of surgical correction for high ametropia. Scheimpflug photography is one of the methods which are frequently applied for postoperative examination of the implants.

MATERIAL AND METHODS

Results from published studies employing Scheimpflug photography for examination of anterior chamber angle-fixated, iris-fixated and sulcus-fixated phakic IOLs were evaluated.

RESULTS

In several published studies Scheimpflug photography was used to examine the position of the implant and opacification of the crystalline lens. The results provided valuable evidence for the improvement of phakic IOL design.

CONCLUSION

Scheimpflug photography offers an easy to use, rapid non-contact examination of phakic IOLs.

Corneal endothelial cell density after vitrectomy with silicone oil for complex retinal detachments

PURPOSE

To evaluate the endothelial cell density changes in eyes with silicone oil tamponade after vitrectomy for complex rhegmatogenous retinal detachment.

METHODS

A prospective controlled study with 81 eyes with complex rhegmatogenous retinal detachment undergoing vitrectomy and silicone oil tamponade. Fellow eyes that fulfilled specific inclusion criteria served as controls. Endothelial cell density (in cells per square millimeter), coefficient of variance (standard deviation per mean cell area × 100), percentage of hexagonal cells, and corneal thickness were documented preoperatively and compared with values obtained at 3, 6, and 12 months postoperatively. For the purpose of the study analysis, all study eyes were divided into 5 groups, according to their lens status during the follow-up.

RESULTS

High endothelial cell density loss was found in Group 3, (eyes that underwent an additional phacoemulsification procedure) and Group 4 (eyes that underwent lens and/or intraocular lens removal during the follow-up) at 12 months with a mean cell loss of 19% and 39%, respectively (P < 0.001).

CONCLUSION

An intact natural or artificial lens-iris diaphragm may provide a protective barrier against corneal endothelial cell damage from long-term silicone oil tamponade.

Comparison of surgically induced astigmatism following iris-claw PIOL insertion with scleral, limbal, or corneal incisions

PURPOSE

To compare surgically induced astigmatism (SIA) based on incision site and evaluate the clinical results and astigmatic stability of iris-claw phakic intraocular lens (Artisan lens; Ophtec BV, Groningen, Netherlands) implantation.

METHODS

Eighty-five eyes of 53 patients with myopia who underwent Artisan lens implantation with a 6.2-mm incision and follow-up of 6 months were retrospectively observed. SIA was assessed using keratometric astigmatism at 6 months postoperatively for the incision sites of the sclera, limbus, and cornea, and the efficacy, safety, predictability, and astigmatic stability were also calculated.

RESULTS

SIA obtained using Naeser's polar method (KP[90]SIA) was -0.48 ± 0.35 for scleral incisions, -0.99 ± 0.35 for limbal incisions, and -1.14 ± 0.54 for corneal incisions. Corresponding net astigmatism values, as calculated with KP(90)SIA and KP(135)SIA, were 0.70 ± 0.48 (177°), 1.04 ± 0.37 (175°), and 1.21 ± 0.57 (1°), respectively, with SIA increasing the nearer the incision was to the cornea center. Six months after surgery, the efficacy index was 1.03 and the safety index was 1.08. Ninety-eight percent of patients were within 1.50 diopters of attempted refraction.

CONCLUSIONS

The values of SIA after Artisan lens insertion showed significant differences among three incision locations, despite the absence of significant differences in preoperative steep corneal axis astigmatism values at the incision locations. It would be applicable for refractive surgery in the aspect of minimizing astigmatism after surgery.

Changes in the accommodation-convergence relationship after the Artisan phakic intraocular lens implantation for myopic patients

Purpose

To evaluate the change of accommodation-convergence parameters after implantation of Artisan phakic intraocular lens (PIOL).

Methods

Prospective study for the patients with the Artisan PIOL implantation was performed. A total of 37 patients (3 males and 34 females) enrolled the study. Preoperatively, convergence amplitude, the stimulus accommodative convergence per unit of accommodation (AC/A) ratio and the near point of convergence (NPC) were evaluated. After the Artisan PIOL implantation, the identical evaluations were repeated at 1 week, 1, 3, and 6 months after the surgery.

Results

Mean age was 24.3 ± 4.8 years old, and preoperative refractive error was -8.92 ± 4.13 diopters (D). After the implantation, mean refractive errors significantly decreased to within ±1.00 D, and noticeable complications were not found. The convergence amplitude and the stimulus AC/A ratio increased 1 month after the surgery, but progressively stabilized afterward to near preoperative values. NPC didn't show any significant change over follow-up period up to 6 months.

Conclusions

These results regarding implantation of the Artisan PIOL revealed the increase of accommodation-convergence relationship within first 1 month after the surgery, but progressive stabilization was noted during follow-up periods.

Eight-year follow-up of posterior chamber phakic intraocular lens implantation for moderate to high myopia

PURPOSE

To assess the long-term clinical outcomes of Implantable Collamer Lens (Visian ICL; STAAR Surgical) implantation for moderate to high myopia.

DESIGN

Retrospective observational case series.

METHODS

This study evaluated 41 eyes of 41 patients with myopic refractive errors of -4.00 to -15.25 diopters (D) who underwent ICL implantation and routine postoperative examinations. Before surgery, and 1 and 6 months and 1, 4 and 8 years after surgery, we assessed the safety, efficacy, predictability, stability, and adverse events of the surgery.

RESULTS

The safety and efficacy indices were 1.13 ± 0.27 and 0.83 ± 0.36. At 8 years, 68.3% and 85.4% of the eyes were within 0.5 and 1.0 D, respectively, of the targeted correction. Manifest refraction changes of -0.32 ± 0.73 D occurred between 1 month and 8 years. The mean endothelial cell loss from preoperative levels was 6.2% at 8 years. Two eyes (4.9%) developed clinically significant symptomatic cataract during the follow-up period. Simultaneous lens extraction and phacoemulsification with IOL implantation was successfully performed in these 2 eyes.

CONCLUSIONS

According to our experience, ICL implantation was overall good in measures of safety, efficacy, predictability, and stability for the correction of moderate to high myopia during the 8-year observation period, suggesting its long-term viability as a surgical option for the treatment of such eyes.

Myopic regression after phakic intraocular lens implantation and LASIK

PURPOSE

In myopia, biometry including the axial length is important, along with the refractive data. We compared the rates of myopic regression 3 years after phakic intraocular lens (pIOL) implantation and laser in situ keratomileusis (LASIK) after matching the preoperative axial length in highly myopic eyes of Japanese patients.

METHODS

This retrospective nonrandomized study included 133 eyes of 84 patients with myopia exceeding -6.00 diopters (D) who underwent implantation of two iris-fixated pIOLs (pIOL group, 66 eyes/46 patients) or myopic LASIK (LASIK group, 67 eyes/38 patients) who were followed for more than 3 years postoperatively. The patient age, preoperative refraction, and preoperative axial length were matched between the study groups.

RESULTS

There were no significant differences preoperatively between the groups in age, intraocular pressure, refraction, keratometry, or axial length. The mean regression values after 3 years compared with the 1-month postoperative refractions were -0.12 ± 0.47 (SD) D in the pIOL group and -0.82 ± 0.69 D in the LASIK group (p < 0.001). The differences in the mean regression rates between 1 and 12 months, 12 and 24 months, and 24 and 36 months of follow-up were, respectively, 0.09 ± 0.38 D, -0.11 ± 0.35 D, and -0.11 ± 0.30 D in the pIOL group and -0.57 ± 0.84 D, -0.24 ± 0.47 D, and 0.00 ± 0.53 D in the LASIK group (p < 0.001, p = 0.07, p = 0.15, respectively).

CONCLUSIONS

There was a significant difference in myopic regression 3 years postoperatively between the groups matched for preoperative axial length in Japanese patients. This result has the potential to elucidate myopia in the future.

Preoperative anterior segment optical coherence tomography as a predictor of postoperative phakic intraocular lens position

PURPOSE

To evaluate anterior segment optical coherence tomography (AS-OCT) in the preoperative simulation of postoperative iris-fixated phakic intraocular lens (pIOL) position in the anterior chamber.

SETTING

Farabi Eye Research Center, Department of Ophthalmology, Tehran University of Medical Sciences, Tehran, Iran.

DESIGN

Case series.

METHODS

Using AS-OCT, the pIOL position was simulated preoperatively in 2 ways and compared with the actual postoperative pIOL position. For preoperative evaluations, the simulator was placed on the posterior pigmented epithelium of the iris. Then, the simulation was performed with the simulator placed in the middle of the iris tissue. The following distances were measured: from the center of the pIOL to the endothelium, from the edge of the pIOL to the endothelium, and from the posterior surface of the pIOL to the crystalline lens.

RESULTS

The study examined 26 eyes (16 patients). Although all distances in both simulation methods (except the lens vault in the first method of simulation) were highly correlated (all P<.009), only the results with the simulator placed in the middle of the iris tissue were not statistically different from the corresponding postoperative measurements (P=.209 and P=.564 for distance from endothelium to the center and the pIOL edge, respectively).

CONCLUSIONS

Using the pIOL template of the AS-OCT system for preoperative simulation of iris-fixated pIOLs improved the criteria for patient selection for implantation of these pIOLs. The simulator should be placed in the middle of the iris tissue for preoperative simulation.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Implantation of phakic intraocular lens in 3 patients with oculocutaneous albinism

We present 3 cases with oculocutaneous albinism in which a high refractive error was optically corrected by implantation of an Artisan iris-fixated phakic intraocular lens, with a follow-up of 8 to 14 years.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Iris-fixated phakic intraocular lens implantation after retinal detachment surgery: long-term clinical results

PURPOSE

To assess the efficacy and safety of iris-fixated phakic intraocular lens (pIOL) implantation to correct myopia in eyes with previous retinal detachment (RD) surgery.

SETTING

Department of Ophthalmology, Soonchunhyang University College of Medicine, Seoul, South Korea.

DESIGN

Retrospective case series.

METHODS

Patients having pIOL implantation in both eyes were enrolled. Eyes that had scleral buckling or encircling (RD group) and healthy fellow eyes (non-RD group) were evaluated over a 6-year follow-up. The corrected distance visual acuity (CDVA), endothelial cell density (ECD), intraoperative complications, and long-term complications were safety outcomes. Uncorrected distance visual acuity (UDVA), predictability, and stability of refraction were efficacy outcomes.

RESULTS

The study comprised 34 eyes (17 patients). The mean postoperative CDVA and ECD were not significantly different between groups, and no patient lost CDVA. The rate of transient intraocular pressure spike was significantly higher in the RD group (P=.043). After 3 years and 6 years, the mean postoperative UDVA was 0.06 logMAR ± 0.09 (SD) and 0.08 ± 0.10 logMAR, respectively, in the RD group and 0.04 ± 0.08 logMAR and 0.04 ± 0.09 logMAR, respectively, in the non-RD group (P=.518 and P=.478, respectively). The rate of eyes within ±0.50 diopter of the desired refraction and the postoperative refraction was not significantly different between groups. No eye had vitreoretinal changes requiring secondary surgical intervention.

CONCLUSION

Iris-fixated pIOL implantation corrected the myopic refractive error in patients who had scleral buckling or encircling surgery for RD with a high degree of efficacy, safety, and long-term stability.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Changes in higher-order aberrations after iris-fixated phakic intraocular lens implantation

PURPOSE

To evaluate surgically induced changes in corneal, internal, and ocular higher-order aberrations (HOAs) after phakic intraocular lens (PIOL) implantation and compare them between two PIOLs with different pupillary diameters.

METHODS

Twenty-three eyes with an Artisan PIOL (Ophtec BV, Groningen, The Netherlands) (Artisan group) and 30 eyes with an Artiflex PIOL (Ophtec BV) (Artiflex group) were retrospectively evaluated. The corneal, internal, and ocular HOAs and refractive data were recorded preoperatively and 6 months postoperatively. The root mean squares (RMSs) of the total HOAs from the third- to sixth-order Zernike coefficients were calculated. The RMSs of the third- and fourth-order coefficients represented coma-like aberrations (S3) and spherical-like aberrations (S4), respectively. The main outcome measures were the differences in the parameters among the groups with different pupillary diameters.

RESULTS

The mean postoperative spherical equivalents decreased from -11.84 ± 4.90 to -0.16 ± 0.40 diopters and -9.78 ± 3.20 to -0.09 ± 0.26 diopters in the Artisan and Artiflex groups, respectively. With the 4- and 5-mm pupillary diameters, the postoperative internal and ocular spherical aberrations (Z4(0)) were significantly lower in the Artiflex group than in the Artisan group (4 mm, P = .002, .024; 5 mm, P = .004, .022, respectively). With the 6-mm pupillary diameter, there were no significant postoperative differences in any parameter measured between groups; both groups had positive spherical aberration values.

CONCLUSIONS

The postoperative ocular spherical aberrations were positive after Artisan and Artiflex implantation. The postoperative ocular spherical aberration was greater in the Artisan group, possibly due to differences in the SAs of both PIOLs.

[Transient visual deterioration by exposure to cold, phacic anterior chamber lens and forme fruste keratoconus. How can this be explained?]

This article reports on a 41-year-old male patient with forme fruste keratoconus and intolerance to contact lenses. An iris-supported intraocular lens was inserted in this eye with initially satisfactory results. During wintertime the patient coached a team of biathletes even in very low temperatures and/or windy conditions and after 2-3 h experienced a deterioration of vision in this eye. The contralateral eye with a contact lens never gave any such problems in this cold environment. Several factors might be responsible for this deterioration of vision. A very low outside temperature with or without wind induces evaporation of the tear fluid resulting in a more viscous lipid content than in warm conditions. A thin cornea facilitates faster cooling of the aqueous humor and less warming of the aqueous humor due to a deep anterior chamber where the warming iris is more distant from the cornea and partially covered by the optic and haptic of the implanted lens both of which have low heat transmission and slower exchange of the aqueous humor via the small peripheral iridotomy in comparison to the pupil which is covered by the implanted lens. Populations, such as Inuits and Mongolians who permanently live in cold environments, have developed shallow anterior chambers during evolution which protects the cornea from the cold due to the reduced distance from the warming iris to the cornea. In retrospect the implantation of a refractive lens into the posterior chamber would probably have been the better choice in this particular patient constellation.

Artisan iris-fixated toric phakic intraocular lens for the correction of high astigmatism after deep anterior lamellar keratoplasty

We report the refractive correction of high astigmatism in one eye of a 23-year-old woman following deep anterior lamellar keratoplasty (DALK) using an Artisan iris-fixated, toric, phakic intraocular lens (IOL). One year after implantation, uncorrected and corrected distance visual acuities were both 20/25, refraction was -1.00 D cylinder, and the endothelial cell count was 1827 cells/mm(2). Iris-fixated phakic IOLs are not recommended for every postkeratoplasty patient with high refractive error; however, this procedure can offer good outcomes in carefully selected cases of previous DALK.

Artiflex Toric foldable phakic intraocular lens: short-term results of a prospective European multicenter study

PURPOSE

To evaluate the short-term efficacy, predictability, stability, and safety of the foldable Artiflex Toric phakic intraocular lens (pIOL; Ophtec) for the correction of myopia with astigmatism.

DESIGN

Prospective, nonrandomized multicenter study.

METHODS

One hundred fifteen eyes of 73 patients were implanted with an Artiflex Toric pIOL. Mean implanted spherical and cylindrical powers were -7.10 ± 2.70 diopters (D) and -2.14 ± 0.80 D, respectively. Total follow-up was 6 months. Outcome parameters included uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), subjective manifest refraction (used for vector analysis), intraocular pressure, and endothelial cell density (ECD).

RESULTS

At 6 months, 99.0% of eyes had a UCVA of ≥20/40, and 81.8% of eyes were ±0.5 D of the intended refraction. In 74.5% postoperative UCVA was equal to or better than preoperative BSCVA; 2 eyes lost 2 or more lines of BSCVA postoperatively because of the development of synechiae. In 75.5% of eyes the remaining cylinder was ±0.5 D. There was a significant decrease in ECD after 3 months (4.8% ± 11.9%), with no additional decline between 3 and 6 months. There were few complications, except for the incidence of pigment and nonpigment precipitates (14.8% and 12.2%, respectively at 6 months). Mean misalignment was 0.6 ± 1.5 degrees (range 0-8).

CONCLUSIONS

The Artiflex Toric pIOL effectively and safely corrects myopia and astigmatism in the short term, with stable and predictable visual results after 6 months, when strict inclusion criteria are applied. Deposition of pigment and nonpigment precipitates on the pIOL warrants further investigation.

AcrySof phakic angle-supported intraocular lens for the correction of high to extremely high myopia: one-year follow-up results

AIM

To assess the safety, efficacy and predictability of the AcrySof phakic angle-supported intraocular lens (IOL) (Alcon Inc., U.S.A.) for correction of high-to-extremely high myopia in adults.

METHODS

In this prospective study performed in Tianjin Medical University Eye Center & College of Optometry, Tianjin, China, 25 eyes of 13 patients were implanted with AcrySof phakic angle-supported IOLs and followed for 1 year postoperatively. Preoperative manifest refractive sphere was (-12.08±2.44) diopters (D) and cylinder was (-1.35±0.62)D. Visual acuity, predictability and stability of manifest refraction spherical equivalent (MRSE), adverse events, and endothelial cell density were analyzed during 1-year of follow-up.

RESULTS

After 1 year of follow-up, no eyes lost≥1 line (best spectacle-corrected visual acuity)BSCVA; an uncorrected visual acuity (UCVA) of 20/20 or better was achieved in 60% of eyes; 100% had an UCVA of 20/40 or better; a BSCVA of 20/30 or better was achieved by 100% of eyes; 84% had a BSCVA of 20/20 or better. The overall mean percentage change in endothelial cell density 1 year after surgery was (-0.27±3.60)%. Two eyes (8%) had increased intraocular pressure (IOP) on the day of surgery. No pupil ovalization, pupillary block, or retinal detachment events were observed.

CONCLUSION

After 1 year of follow-up, the implantation of AcrySof phakic angle-supported IOL is proved to be safe, effective and predictable with minimal complications in patients with high-to-extremely high myopia. Due to the limitation of visiting time, long-term of clinical investigation is necessary to verify the safety and efficacy of this IOL.

Foldable iris-fixated phakic intraocular lens implantation for the correction of myopia: two years of follow-up

Purpose:

To evaluate the safety, efficacy and potential risks of Artiflex foldable iris-fixated phakic intraocular lens (pIOL) implantation for the management of myopia.

Materials and Methods:

Seventy-eight eyes of 40 consecutive patients with a mean spherical refraction of –11.70 ± 3.77 diopters (D; range –5.50 to –17.5 D) were included in this prospective, noncomparative, interventional case series. Main parameters assessed were uncorrected visual acuity (UCVA), best-spectacle corrected visual acuity (BSCVA), corneal topography (Orbscan II, BauchandLomb, Rochester, NY, USA), manifest and cycloplegic refractive errors, endothelial cell density (ECD) and applanation tonometry.

Results:

After 2 years, BSCVA was 20/40 or better in 82% of the eyes and UCVA was 20/40 or better in 84% of the eyes. After 1 month, 1 year, and 2 years, 51.3% (37 of 72 eyes), 58.9% (46 of 78 eyes) and 76.0% (38 of 50 eyes) of eyes gained 1 line or more of BSCVA, respectively. Compared to preoperative values, the mean endothelial cell loss was 2.6% at 1 month, 4.9% at 1 year and 7.4% at 2 years. Pigmented or non-pigmented precipitates were observed in17 eyes (21.7%) which were treated with topical corticosteroids. At the second postoperative year, pigmented precipitates persisted in nine eyes. However, this was not associated with a loss of BSCVA.

Conclusion:

The implantation of Artiflex pIOL is an effective surgical option for the management of high myopia. The most common complication observed within 2 years of follow-up was accumulation of pigmented precipitates with no effect on the final BSCVA.

Transient myopic shift after phakic intraocular lens implantation

Three patients presented with spontaneous myopic shift 6 weeks to 6 months after implantation of the Artiflex phakic intraocular lens (pIOL). The corrected distance visual acuity (CDVA) was maintained in all cases. Cyclopentolate drops successfully reverted the myopic shift in all cases; however, 2 cases required surgical reenclavation of the pIOL haptics to achieve long-term refractive stability. At the last follow-up, all patients had returned to emmetropia, with uncorrected distance visual acuities of 20/20. A slight decrease in objective optical quality was observed. No eye lost a line of CDVA. In 1 eye, optical coherence tomography scans showed slight posterior positioning of the pIOL. These cases show that spontaneous myopic shift is a potential complication of iris-claw pIOL implantation. That cyclopentolate drops and/or reenclavation of the haptics were effective in reverting the situation suggests a mechanical mechanism related to iris and ciliary body dynamics.

FINANCIAL DISCLOSURE

Dr. Güell is a consultant to Ophtec. No author has a financial or proprietary interest in any material or method mentioned.

Refractive lens exchange versus phakic intraocular lenses

PURPOSE OF REVIEW

To review the evidential basis of current practice in refractive lens exchange (RLE) vs. phakic intraocular lens (pIOL).

RECENT FINDINGS

Visual outcomes after pIOLs are better than RLE. With RLE, there still remain risks of retinal detachment, cystoid macular oedema, glare, halos and posterior capsule opacification. With pIOLs, risks include pigment dispersion, cataract formation, glaucoma and inflammation. The decision to choose between either is broadly based on age and type of refractive error, and the choice follows thorough evaluation and counselling taking into consideration patient's needs and expectations.

SUMMARY

With advancing technology, newer IOL models for RLE and phakic correction are becoming available. pIOLs provide better visual outcomes for distance correction and currently do not provide near-vision correction possible with RLE.

Collagen crosslinking and toric iris-claw phakic intraocular lens for myopic astigmatism in progressive mild to moderate keratoconus

PURPOSE

To report the long-term results of combined collagen crosslinking (CXL) and toric phakic intraocular lens (pIOL) implantation to correct myopic astigmatism in patients with progressive mild to moderate keratoconus.

SETTING

Instituto de Microcirugia Ocular, Barcelona, Spain.

DESIGN

Case series.

METHODS

From November 2006 to July 2009, CXL was performed in eyes with proven progressive keratoconus. Once refraction and topography stabilized, toric Artiflex/Artisan pIOL implantation was performed to correct residual myopic astigmatism. A complete ophthalmologic examination, including manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, biomicroscopy, tonometry, fundoscopy, keratometry, corneal tomography, and central endothelial cell count (ECC), was performed before each procedure and postoperatively at 3 months and at yearly intervals up to 5 years. Main outcome measures were accuracy and stability of the spherical equivalent (SE) and cylinder, keratometry, UDVA (efficacy), CDVA (safety), central ECC, and complications.

RESULTS

The median follow-up in the 9 patients (17 eyes) was 36.9 months ± 15.0 (SD). The median interval between CXL and pIOL implantation was 3.9 ± 0.7 months. Fourteen eyes (82%) were within ± 0.50 diopter (D) of the attempted SE correction and 13 eyes (76%) were within ± 1.00 D of the attempted cylinder correction. The mean difference in simulated keratometry between preoperatively and the last follow-up was 0.17 ± 0.45 D (range -0.55 to 1.45 D). The postoperative UDVA was 20/40 or better in 16 eyes (94%). No eye lost lines of CDVA. No significant decrease in central ECC occurred (P>.05).

CONCLUSION

Combined CXL and toric iris-claw pIOL implantation effectively and safely corrected myopic astigmatism in progressive mild to moderate keratoconus.

FINANCIAL DISCLOSURE

Dr. Güell is a consultant to Ophtec. No other author has a financial or proprietary interest in any material or methods mentioned.

Hypermotility of an iris-fixated anterior chamber phakic intraocular lens due to nontraumatic iris laxity

PURPOSE

Permanent immovability of phakic intraocular lenses (pIOLs) for the correction of high myopia is crucial in avoiding injury to the corneal endothelium and maintaining visual acuity. Unstable position of iris-fixated pIOLs due to traumatic or nontraumatic disenclavation of the haptic has been described previously.

METHODS AND RESULTS

We report a different mechanism of repeated excessive implant motility in both eyes of a young woman who developed late nontraumatic elongation of the iris fibers to which an iris-claw pIOL was fixated. This led to increased motility of the pIOLs with blinking causing mild iritis. Subsequent bilateral successful re-enclavation to other iris fibers ameliorated these symptoms. After 2.5 years, these iris fibers, too, were elongated, causing excessive movements of the pIOLs and consecutive endothelial cell loss necessitating removal of the pIOLs. The etiology of this iris fiber laxity remains unclear.

CONCLUSIONS

Surgeons should be aware of this rare potential complication.

Rigid iris-fixated phakic lens implantation for high myopia: novel trapezoidal corneal versus scleral incisions

PURPOSE

To compare refractive performance of implantation of an iris-fixated phakic intraocular lens (PIOL) through a novel trapezoidal corneal and a scleral tunnel incision.

METHODS

Sixty-nine eyes selected to undergo PIOL implantation were randomly assigned to 1 of 2 groups: 5.2-mm trapezoidal corneal incision (TCI), 34 eyes; 5.2-mm scleral tunnel incision (STI), 35 eyes. Visual acuity, refraction, corneal astigmatism, tonometry, and endothelial cell density were recorded preoperatively and postoperatively. Surgically induced astigmatism (SIA) was calculated using vector analysis.

RESULTS

No intraoperative complications were noted. One day after surgery, the quantity of cells in the anterior chamber was significantly lower in TCI group than in STI group (p=0.019). The percentage of eyes with uncorrected visual acuity (UCVA) of ≥20/25 was 41.2% for TCI and 17.1% for STI; the difference was statistically significant (p=0.03), but not thereafter. The mean corneal astigmatism was significantly lower in the TCI group than in the STI group (p=0.01) 3 months postoperatively and subsequently. No significant between-group difference in SIA was found during the follow-up. There was no significant difference in best-corrected visual acuity and endothelial cell loss between groups, postoperatively.

CONCLUSIONS

The TCI and STI techniques are comparable in terms of safety and induction of astigmatism for the rigid iris-fixated PIOL implantation. However, the TCI is easy to perform and provides a faster visual recovery and lower postoperative corneal astigmatism compared with the STI.

Management of corneal endothelial decompensation caused by iris-fixated phakic intraocular lenses with descemet stripping automated endothelial keratoplasty

PURPOSE

To describe 2 cases of corneal decompensation after iris-fixated phakic intraocular lens (pIOL) implantation requiring Descemet stripping automated endothelial keratoplasty (DSAEK).

MATERIALS AND METHODS

Case reports and literature review.

RESULTS

Two cases of corneal decompensation after pIOL implantation are reported. The average age at presentation was 52 years (range: 37 to 67 years) in 2 women. The mean presentation time of corneal decompensation after pIOL implantation was 29 months (range: 22 to 36 months). Both the affected eyes required pIOL explantation and DSAEK to treat corneal decompensation. One patient (1 eye) had concurrent cataract surgery to maximize visual rehabilitation. The mean follow-up after DSAEK surgery was 14 months (range: 12 to 16 months). The best-corrected visual acuity was 20/50 (range: 20/40 to 20/60) at the last follow-up.

CONCLUSIONS

Despite a good safety profile for iris-fixated pIOLs, some patients may still develop corneal decompensation after implantation. We report a pair of cases with corneal decompensation severe enough to warrant endothelial transplantation and pIOL explantation, with and without concomitant cataract surgery.

Corneal endothelium after refractive surgery

The endothelium is vital to the health and optical clarity of the human cornea. The safety of procedures to correct refractive errors depends on preservation of an intact corneal endothelium. Disease states and genetic and environmental factors affect the corneal endothelium; an unstable corneal endothelium can impact the success of refractive surgery. Technological advances and recent laboratory findings have improved the ability to assess the endothelium. The status of the corneal endothelium after laser in situ keratomileusis, photorefractive keratectomy, phakic intraocular lenses, and adjuvants to these treatments has been the topic of numerous clinical trials. Safety guidelines for refractive surgery procedures should be followed to minimize deleterious effects on the corneal endothelium.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

Artiflex phakic intraocular lens implantation after corneal collagen cross-linking in keratoconic eyes

PURPOSE

To evaluate the safety, efficacy, and stability of the Artiflex (Ophtec BV) foldable anterior iris-claw phakic intraocular lens (PIOL) following corneal collagen cross-linking (CXL) in select cases of progressive keratoconus.

METHODS

This prospective, comparative study, conducted between March 2007 and June 2008, involved 11 eyes with progressive keratoconus. Inclusion criteria were progressive keratoconus (Amsler-Krumeich classification grades I and II) with no corneal opacities, corneal thickness >450 μm, endothelial cell count >2500 cells/mm(2), anterior chamber depth >3.2 mm, spherical equivalent refraction >4.50 diopters (D) (with a cylinder component <2.00 D), and no other treatment for keratoconus other than contact lens. Each patient underwent CXL in the keratoconic eye with implantation of the Artiflex IOL 6 months thereafter. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and refraction and topographic profiles were examined at 1, 6, and 12 months after the CXL procedure.

RESULTS

All eyes achieved UDVA of 0.3 logMAR or better. Final spherical and cylindrical error ranged from 0 to -1.50 D and 0 to -1.75 D, respectively. No eyes lost lines of preoperative CDVA. Statistically significant reductions in mean maximum (2.14 D, P<.001) and minimum (1.17 D, P=.02) keratometry values were present 12 months after the CXL procedure. No complications were observed.

CONCLUSIONS

Combined CXL and Artiflex implantation was a safe and effective treatment in this subset of eyes with progressive keratoconus. Good results in terms of visual acuity, postoperative residual refractive error, and keratometry values were identified.

Late onset secondary cataract following implantation of an iris-fixated phakic intraocular lens

PURPOSE

To report a case of bilateral late onset anterior cortical cataract following implantation of an iris-fixated phakic intraocular lens (pIOL).

METHODS

Single observational case report.

RESULTS

Three and a half years following uncomplicated consecutive implantation of iris-fixated pIOL in both eyes, anterior cortical cataract changes inferiorly emanating from the site of enclavation of the lens in the right eye were noted. By 7 years after implantation, anterior cortical cataract changes were seen emanating from the enclavation sites superiorly and inferiorly in both eyes. These cataracts did not cause any loss of corrected distance visual acuity.

CONCLUSIONS

This case demonstrates that a potential complication of an iris-fixated pIOL is late onset secondary cataract formation.

Pediatric phakic intraocular lens surgery: review of clinical studies

PURPOSE OF REVIEW

To report on the accumulating peer-reviewed data of phakic intraocular lens (pIOL) implantation in the pediatric population. I evaluate and compare the published peer-reviewed articles for the reported efficacy and complications of phakic intraocular lens implantations in children for correction of clinically significant high refractive errors.

RECENT FINDINGS

Multiple studies have shown the relevancy and effectiveness of pIOL implantation as an alternative surgical management for highly significant pediatric ametropia in selective patients who are noncompliant with medical treatment.

SUMMARY

In the management of clinically significant severe pediatric ametropic and/or anisometropic myopia or hyperopia and in the event of nonadherence to traditional medical treatment, phakic anterior chamber IOL implantation is currently considered an effective modality of treatment. Long-term follow-up of pediatric patients following pIOL implantation is necessary. Future clinical trials should focus on children of various age groups to assess the variables of visual acuity gain or loss, stereopsis, contrast sensitivity, high-order aberrations, corneal physiology, and long-term complications to accurately and properly address the safety and efficacy of the type of and the best time for pIOL implantation in treatment and/or prevention of amblyopia in children.

Collagen copolymer toric posterior chamber phakic intraocular lens in eyes with keratoconus

PURPOSE

To assess the safety, efficacy, stability, and predictability of collagen copolymer toric phakic intraocular lens (pIOL) implantation to correct myopia and astigmatism in eyes with keratoconus.

SETTING

Fernández-Vega Ophthalmological Institute, Oviedo, Spain.

METHODS

This prospective study comprised keratoconic eyes that had implantation of a toric Intraocular Collamer Lens. Uncorrected (UDVA) and corrected (CDVA) distance visual acuities, refraction, and postoperative complications were evaluated 1, 3, 6, and 12 months postoperatively.

RESULTS

Preoperatively, the mean spherical equivalent in the 30 eyes (21 patients) was -5.38 diopters (D) +/- 3.26 (SD) (range -13.50 to -0.63 D) and the mean cylinder, -3.48 +/- 1.24 D (range -1.75 to -6.00 D). At 12 months, 86.7% of the eyes were within +/-0.50 D of the attempted refraction and all eyes were within +/-1.00 D. For the astigmatic components J0 and J45, 83.3% of eyes and 86.7% of eyes, respectively, were within +/-0.50 D. The mean Snellen UDVA was 0.81 +/- 0.20 and the mean CDVA, 0.83 +/- 0.18; CDVA was 20/40 or better in 29 eyes 96.7% of eyes and 20/25 or better in 22 eyes (73.3%). No eyes lost more than 2 lines of CDVA; 29 eyes (96.7%) maintained or gained 1 or more lines. The efficacy index was 1.07 and the safety index, 1.16. There were no complications or adverse events.

CONCLUSIONS

The results confirm that toric ICL implantation is a predictable, effective procedure to correct ametropia in eyes with keratoconus. Predictability and stability were achieved early and remained fairly stable up to 12 months.

Late-onset nontraumatic dislocation of anterior chamber phakic intraocular lens

Long-term stability of the position of phakic intraocular lenses (pIOLs) is important in maintaining visual acuity as well as avoiding injury to the local tissues. We report a case of late nontraumatic dislocation of an iris-fixated pIOL, with subsequent successful repositioning.

Anterior chamber depth is significantly decreased after scleral buckling surgery

OBJECTIVE

Myopic patients have an increased risk for the development of a rhegmatogenous retinal detachment (RRD). Currently, myopic patients have the choice to undergo correction of their refractive error by the implantation of a phakic intraocular lens (pIOL). After pIOL implantation, progressive endothelial cell loss may result if the anterior chamber is too shallow. Because scleral buckling (SB) surgery for treatment of an RRD may in itself result in a decreased anterior chamber depth (ACD), this may become an important issue not only for the retinal surgeon who is faced with a patient who has both an RRD and a pIOL, but also for the refractive surgeon who should consider the potential problems of the implantation of pIOL in an eye that has previously undergone SB surgery. The goal of this study was to evaluate how long changes in ACD persist after SB procedures in patients with RRD.

DESIGN

Prospective case series.

PARTICIPANTS

Thirty-eight eyes with a primary RRD treated by SB using an encircling element and a radial or segmental buckle; 31 fellow eyes served as controls.

METHODS

Anterior chamber depth (in the horizontal meridian) and axial length were measured preoperatively and at 1 week and 1, 3, 6, 9, and 12 months postoperatively with an anterior optical coherence tomography method and an IOLMaster (Carl Zeiss Meditec, Jena, Germany), respectively.

MAIN OUTCOME MEASURES

In all 38 eyes, ACD was significantly reduced compared with preoperative levels up to 9 months after SB surgery.

RESULTS

Anterior chamber depth returned to normal at 1 year after surgery. Axial length was significantly enlarged during the whole follow-up period. No significant differences were found between the use of radial or segmental buckles.

CONCLUSIONS

Anterior chamber depth may remain decreased after SB for a longer time period than previously reported.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.