Prevalence of cataract after collagen copolymer phakic intraocular lens implantation for myopia, hyperopia, and astigmatism

Bilensectomy: Safety and Visual Outcomes in Angle-Supported, Iris-Fixated, and Posterior Chamber Phakic Intraocular Lenses

PURPOSE

To report the visual and refractive outcomes, intraoperative and postoperative complications, and main causes of bilensectomy in the different types of phakic intraocular lenses (pIOLs).

METHODS

This was a retrospective multicenter study that included 234 eyes of 185 patients that underwent bilensectomy. Patients were divided into three groups depending on the pIOL that was explanted (angle-supported, iris-fixated, or posterior chamber). The main reasons leading to the indication for bilensectomy, time elapsed between pIOL implantation and bilensectomy, intraoperative and postoperative complications, uncorrected and corrected distance visual acuity (UDVA and CDVA), and endothelial cell density loss 1 year after bilensectomy were evaluated.

RESULTS

There was a statistically significant improvement in UDVA and CDVA after bilensectomy in all groups. Cataract development was the main reason for bilensectomy, followed by significant endothelial cell density loss. Time between pIOL implantation and bilensectomy was significantly greater in eyes with an anterior chamber pIOL.

CONCLUSIONS

Bilensectomy outcomes in general are good. Iris-fixated lenses, particularly hyperopic, are more prone to intraoperative complications and endothelial cell loss than the other pIOLs models. The results show that bilensectomy is a safe and effective procedure with a relatively low rate of intraoperative and postoperative complications and acceptable refractive predictability. [J Refract Surg. 2023;39(3):128-134.].

EVO/EVO+ Visian Implantable Collamer Lenses for the correction of myopia and myopia with astigmatism

INTRODUCTION

Intraocular lens implantation in phakic eyes for the correction of refractive error is currently a widespread procedure. The EVO and EVO+ Visian Implantable Collamer Lenses (ICL) are two of the most prevalent lenses implanted. They incorporate a central orifice to avoid the need for iridotomy. The main difference between both ICL is the higher optical diameter zone provided by the EVO+, allowing a better quality of vision at night. This review aims to provide an overview of the current ICL models available for correcting myopia and myopic astigmatism.

AREAS COVERED

During the last decade, more than 100 scientific papers analyzing the performance of EVO and EVO+ lenses have been published. This review describes the objective visual performance achieved with the implantation of central hole ICL lenses and the subjective perception of the patients implanted with these lenses. In addition, the safety and the potential complications associated with undergoing an EVO and EVO+ ICL implantation have been addressed.

EXPERT OPINION

Refractive surgeons and candidates to undergo ICL implantation should be aware of the excellent safety and visual outcomes provided by the implantation of central hole ICL lenses. However, future research could address minor issues currently not resolved.

ICL Postimplantation Decentration and Tilt in Myopic Patients with Primary Iridociliary Cysts

Purpose

To observe the decentration and tilt of implantable collamer lens (ICL) as well as possible visual effects postimplantation in primary iridociliary cysts.

Methods

The present investigation was a retrospective cohort study. All 48 patients (91 eyes) who underwent ICL surgery at the Center of Refraction Surgery of Tianjin Medical University Eye Hospital between July 2018 and May 2020 were split into two groups based on the absence or presence of primary iridociliary cysts established by ultrasonic biological microscopy (UBM) examination. Intraocular pressure (IOP), corrected distance visual acuity (CDVA), uncorrected distance visual acuity (UDVA), anterior chamber angle (ACA), anterior chamber volume (ACV), and anterior chamber depth (ACD) were recorded preoperatively and postoperatively at 1, 6, and 12 months. Additionally, we performed an analysis of the ICL vault, decentration, and tilt using a rotating Scheimpflug Oculus Pentacam camera system at 1, 6, and 12 months after surgery.

Results

No serious complications were observed. Significant postoperative improvement (P < 0.05) of UDVA was established in the two studied groups; however, we did not observe statistically significant intergroup differences (P > 0.05) throughout the entire research period. In each group, the preoperative ACA, ACV, and ACD were statistically significantly reduced (P < 0.05), but no such decrease was established between their postoperative values (P > 0.05). We observed no statistical differences between both groups with regard to their values of IOP, ACA, ACV, ACD, ICL vault, ICL decentration, and tilt at 1, 6, and 12 months after surgery. Similarly, no statistically significant within-group correlation (P > 0.05) of the decentration of ICL and the tilt and the CDVA values was established.

Conclusion

No postimplantation effect of ICL with a central hole on vision was established in myopia patients with primary iridociliary cysts, within certain limits of ICL decentration and tilt values.

Vault-Correlated Efficacy and Safety of Implantable Collamer Lens V4c Implantation for Myopia in Patients with Shallow Anterior Chamber Depth

INTRODUCTION

The aim of the study was to evaluate efficacy and safety outcomes after implantation of the Visian Implantable Collamer Lens (ICL V4c) in myopia patients with shallow anterior chamber depth (ACD).

METHODS

This retrospective study followed 163 eyes of 94 patients for at least 24 months. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity, intraocular pressure (IOP), manifest refraction, vault, endothelial cell density (ECD), anterior chamber angle (ACA), anterior chamber volume, and the distance from the corneal endothelium to the central ICL (C-ICL) were measured during follow-ups. Spearman's correlation and logistic regression were used to identify variables correlated with changes in ECD and potential risk factors for ineffective outcomes, respectively.

RESULTS

All surgeries were performed safely. High IOP of 9 eyes and anterior capsular opacity of 5 eyes were observed. The last follow-up ACA had a significant difference between the high and normal IOP groups (p = 0.0003). The mean ECD and vault were 2,855.76 ± 270.82 cells/mm2 and 388.01 ± 135.28 μm at the last follow-up, respectively. The vault and C-ICL were significantly associated with ΔECD (all p < 0.05). Furthermore, the vault was most responsible for the ECD loss. Twenty-two eyes had unsatisfactory postoperative UDVA, and the low vault at the last follow-up was a significant risk factor for this ineffective outcome (p < 0.001, OR = 14.739).

CONCLUSIONS

ICL V4c implantation in patients with shallow ACD achieved stable visual outcomes. The vault is related to postoperative visual acuity and ECD loss, which needs to be paid attention during follow-up.

Posterior-Chamber Phakic Implantable Collamer Lenses with and without a Central Hole: A Comparative Study

Purpose

 This study aimed to compare the short-term outcome of implanting the Visian implantable collamer lens V4 ICL versus the Visian V4c ICL in patients with moderate and high myopia.

Patients and Methods

 This is a retrospective that was conducted on patients with moderate or high myopia who were scheduled for ICL implantation at our institution, Patients who underwent V4 ICL implantation with peripheral iridectomy were assigned to group A, and those who underwent V4c ICL implantation without peripheral iridectomy were assigned to group B. In group A, a preoperative peripheral iridectomy was performed. In group B, the patients received cycloplegic and dilating agents. The patients underwent a complete ocular examination preoperatively and during the follow-up visits that were conducted at 3, 6, and 12 months postoperatively.

Results

This study included 214 eyes from 107 patients; group A included 110 eyes, and group B included 104 eyes. Postoperatively, the UCVA and BCVA showed statistically significant improvement across the follow-up time points (p<0.001), with no significant difference between the two groups. No statistically significant difference was found between the two groups in the mean achieved correction or the residual refraction. Both groups showed a strong correlation between the target and the achieved correction, with R2 = 0.99 in the two groups. No significant difference was found between the two groups in the IOP across all time measures. However, the intraocular pressure showed a statistically significant postoperative increase in group A (p=0.004), and no significant change in group B (p=0.817). There was a downward slope in the vaults of both groups across time, with significant variation in the last follow-up measure compared to the 3-month measure in the two groups (p<0.001). No significant difference was found between the two groups across all time measures.

Conclusion

The current study adds new evidence concerning the feasibility, safety, and efficacy of ICL V4c implantation for the treatment of moderate and high myopia, with safer postoperative IOP.

Analysis of perioperative problems related to intraocular Implantable Collamer Lens (ICL) implantation

PURPOSE

To introduce a modified procedure of ICL implantation, to summarize the perioperative problems and their corresponding treatment after myopia correction with Implantable Collamer Lens (ICL), and to compare the difference of complications between the no-hole ICL and hole ICL.

METHODS

We searched all articles on ICL-related perioperative problems and their corresponding treatment in Scopus, Embase, PubMed and Web of Science databases for the last 22 years.

RESULTS

ICL implantation is safe, effective, stable and predictable in the correction of myopia, hyperopia and astigmatism, but can also cause a series of perioperative problems, including intraoperative and postoperative complications.

CONCLUSION

There are many kinds of complications related to ICL, but the common intraoperative and postoperative complications mainly include abnormality of arch height, abnormal position of ICL, loss of corneal endothelial cells and corneal decompensation, high intraocular pressure and secondary glaucoma, cataract and night vision symptoms. Compared with ICL without central pore, the incidence of complications such as loss of corneal endothelial cells and corneal decompensation, high intraocular pressure and secondary glaucoma and cataract was relatively lower in central hole ICL, while postoperative complications such as night vision symptoms were obvious.

Safety and anterior chamber structure of evolution implantable Collamer lens implantation with short white-to-white corneal diameters

Introduction

To evaluate the safety and anterior chamber structure of implantation of the Evolution (EVO) implantable Collamer lens (EVO-ICL) in patients with short white-to-white (WTW) corneal diameters.

Materials and methods

The study population was divided into two groups: the experimental group (34 eyes of 34 patients) with WTW corneal diameters of ≤10.6 mm and the control group (59 eyes of 59 patients) with WTW corneal diameters of >10.6 mm. The outcome measures included uncorrected distance visual acuity, corrected distance visual acuity, refractive power, intraocular pressure (IOP), anterior chamber angle, depth, volume, and vault.

Results

The safety indices of the experimental and control groups were 1.17 ± 0.30 and 1.12 ± 0.14, respectively (P > 0.05); the effectiveness indices were 1.16 ± 0.31 and 1.07 ± 0.17, respectively (P > 0.05). The simulation curves of the expected and actual corrections in the experimental and control groups were y = 0.9876x – 0.0927 and y = 0.9799x + 0.0343, respectively. There were no significant differences between the IOPs and anterior chamber structures of the two groups (P > 0.05). The average vaults of the experimental and control groups were 395.76 ± 155.32 and 389.49 ± 135.01 μm, respectively (P > 0.05).

Conclusion

EVO-ICL implantation in patients with short WTW corneal diameters (≤ 10.6 mm) was determined to be a safe, effective, and predictable method for correcting myopia. The changes in the anterior chamber structure were still within normal limits after the surgery, the IOP remained stable, and the ideal vault was achieved after the surgery.

Effects of tilt and decentration of Visian Implantable Collamer Lens (ICL V4c) on visual quality: an observational study

Background

The central hole of the Visian Implantable Collamer Lens (ICL V4c) provides a reference to observe its tilt or decentration. This study aimed to investigate the tilt and decentration effects of ICL V4c on visual quality after implantation.

Methods

A total of 135 eyes from 69 patients who underwent ICL V4c implantation were included in this study. Evaluation of uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and aberrations were performed 6-months postoperatively. The anterior segment parameters were collected using CASIA2 anterior segment-optical coherence tomography, tilt and decentration of ICL V4c were analyzed using MATLAB software. All patients received questionnaires to investigate the visual quality postoperatively.

Results

The safety and effectiveness were 1.18 ± 0.17 and 1.11 ± 0.18, respectively. No significant changes were observed regarding higher-order and spherical aberrations after the operation; however, coma and trefoil significantly increased compared to preoperative values. The average total decentration and tilt was 0.21 ± 0.12 mm and 2.54 ± 1.00°, respectively. Horizontal, vertical, and total values of tilt and decentration were not significantly associated with postoperative CDVA, UDVA, and aberrations. The most common visual symptom was halo, and 97.04% of patients had a satisfaction score ≥ 8. The total or horizontal tilt was significantly positively correlated with the frequency, severity, and bothersome scores from the questionnaires.

Conclusions

ICL V4c implantation can obtain high visual quality and patient satisfaction. Although the degree of tilt and decentration after ICL V4c implantation was small, a positive effect on subjective visual quality was observed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02499-4.

Determinants of Subjective Quality of Vision After Phakic Intraocular Lens Implantation

PURPOSE

To evaluate postoperative subjective quality of vision in patients who underwent Implantable Collamer Lens (ICL) (STAAR Surgical) implantation for correction of myopia and to identify potential predictive parameters.

METHODS

In this single-center cross-sectional study, a total of 162 eyes of 81 patients (58 women, 23 men) who underwent ICL implantation were analyzed. The Quality of Vision (QOV) questionnaire was used to assess patient-reported outcomes. Baseline characteristics (eg, age), treatment parameters (eg, surgical corrected refraction), and refractive (eg, residual refraction) and visual (eg, uncorrected distance visual acuity) outcomes were analyzed regarding their effect on QOV.

RESULTS

Mean age was 33.3 ± 7.0 years (range: 21 to 51 years) and mean preoperative spherical equivalent was -8.42 ± 2.49 diopters (D) (range: -3.25 to -14.38 D). After a mean postoperative follow-up period of 19 ± 14 months (range: 6 to 54 months), the safety index score was 1.23 ± 0.21 and the efficacy index score was 1.17 ± 0.22. The mean QOV scores were 35.5 ± 11.3, 32.2 ± 11.1, and 23.3 ± 16.1 for frequency, severity, and bothersomeness, respectively. The most frequently experienced symptoms were halos (90.1%) and glare (66.7%). Halos appeared in 66.7% of the patients "occasionally" and 5 of them (6.2%) experienced them "very often." Only 1 patient (1.2%) classified halos as "very bothersome." Patients older than 36 years reported visual symptoms more frequently (P < .05) and showed higher bothersomeness scores (P = .01).

CONCLUSIONS

Halos are the most commonly perceived long-term visual disturbance after myopic ICL implantation with a central hole. Visual symptoms can persist more than 6 months postoperatively, causing only minor disturbances in most cases. Older patients seem more prone to experiencing these symptoms. [J Refract Surg. 2022;38(5):280-287.].

Phaco with ICL in situ in a case of high hyperopia

Purpose

To describe a unique method of biometric calculation and surgical technique of phacoemulsification and posterior chamber intraocular lens (PCIOL) implantation with an implantable collamer lens (ICL) in situ; for a high hyperope with post – ICL cataract.

Observations

A patient with high hyperopia who underwent bilateral ICL implantation later developed cataract in both eyes. He underwent phacoaspiration of the cataract with ICL in situ and a standard power PCIOL implantation in the left eye. A unique method of PCIOL power calculation was later devised for the right eye by accounting for the residual refractive error of the eye and implanted by a similar surgical technique.

Conclusion and importance

Following cataract surgery with the ICL in situ, the patient had a residual refractive error of +3.00D in the left eye however had a minimal residual refractive error in the right eye. A new surgical method of PCIOL implantation after cataract extraction with an ICL in situ as well as the biometric calculation for a PICOL to be implanted with an ICL in situ was devised.

Accuracy of Intraocular Lens Calculation Formulas in Patients Undergoing Combined Phakic Intraocular Lens Removal and Cataract Surgery

PURPOSE

To investigate the prediction accuracy of intraocular lens (IOL) calculation formulas, and the impact of anterior chamber depth (ACD) and lens thickness (LT) measurement errors on IOL power calculation in patients undergoing combined phakic IOL (PIOL) removal and cataract surgery.

DESIGN

Retrospective, consecutive case series study.

METHODS

Thirty-six PIOL implanted eyes (12 anterior chamber PIOLs and 24 posterior chamber PIOLs [PC-PIOL]) undergoing cataract surgery were included. The prediction accuracy of new formulas (Barrett universal II, Emmetropia verifying optical, Kane, and Ladas super formula) and traditional formulas (Haigis, Hoffer Q, Holladay 1 and SRK/T) with or without Wang-Koch (WK) axial length (AL) adjustment was evaluated. The influence of ACD and LT measurement errors of IOLMaster 700 on refractive outcomes was also investigated.

RESULTS

The Kane and traditional formulas with WK AL adjustment had no significant systematic prediction error and displayed a smaller median absolute error, whereas the other formulas showed significant hyperopia shift (P < .05) and relatively lower prediction accuracy. The accuracy rate of IOLMaster 700 in measuring the ACD and LT was 100% in eyes with anterior chamber PIOL implantation, and 37.50% in the PC-PIOL subgroup. No significant difference was observed in refractive outcomes of formulas using correct and wrong parameters in the PC-PIOL subgroup (P > .05).

CONCLUSIONS

The Kane and traditional formulas with WK AL adjustment exhibited relatively higher prediction accuracy in patients who underwent combined PIOL removal and cataract surgery. The IOLMaster 700 displayed low accuracy in ACD and LT measurements for PC-PIOL implanted eyes, but showed negligible impact on IOL prediction accuracy.

Changes of ocular biometry in eyes with posterior chamber phakic intraocular lens implantation

OBJECTIVE

To evaluate changes in biometric variables and intraocular lens (IOL) calculation results after posterior chamber phakic IOL (PCPIOL) implantation.

METHODS

This retrospective, observational study included 65 eyes of 38 patients who underwent PCPIOL (EVO Visian ICL) implantation for correction of myopia. Prior to and a minimum of one year (mean 14.9 months) after EVO Visian ICL implantation, biometric variables and IOL calculation results were compared. Optical biometry, including anterior chamber depth, axial length, flat, steep, and mean keratometry values and IOL calculation results for the Holladay 2, Hoffer Q, Haigis, and SRK/T formulas were measured using the IOLMaster 700 SWEPT Source OCT biometer.

MAIN RESULTS

The mean anterior chamber depth decreased from 3.70±0.22mm to 3.34±0.39mm, the mean axial length increased from 26.61±1.61mm to 26.71±1.66mm, and the mean flat keratometry changed from 42.82±1.86 D to 42.73±1.83 D. These changes were statistically significant. The mean IOL power calculation also revealed a statistically significant decrease with all four formulas (ranging from 0.19 D to 0.30 D) after PCPIOL implantation.

CONCLUSIONS

Biometric variables and IOL calculation results showed statistically significant changes one year after EVO Visian ICL implantations. However, IOL power calculations yielded a decrease of less than 0.50 D, inducing much less refractive deviation in the spectacle plane; and the change was primarily related to an increase in AL measurements. IOL power calculations in eyes with EVO Visian ICL in situ provided satisfactory and reliable results.

Distribution of White-to-White Corneal Diameter and Anterior Chamber Depth in Chinese Myopic Patients

Purpose: To investigate the distribution of white-to-white (WTW) corneal diameter and anterior chamber depth (ACD) in Chinese myopia patients. Methods: This was a cross-sectional observational study conducted at five ophthalmic centers. Anterior segment biometry was performed in 7,893 eyes of the 7,893 myopic patients using Pentacam, and the WTW and ACD were recorded. The distribution patterns of WTW and ACD were evaluated and the correlation between WTW and ACD was analyzed statistically. Results: There were 4416 (55.95%) males and 3477 (44.05%) females. The age of the study population was 25.14 ± 5.41 years. Distribution of WTW was slightly positively skewed (Skewness = 0.0076, Kurtosis = 0.3944, KS P = 0.020) with a mean of 11.65 ± 0.38 mm and a 95% normal range of 10.91-12.39 mm. A significant difference in WTW was found among different myopia groups (P < 0.001). The ACD was normally distributed (Skewness = 0.899, Kurtosis = 0.027, KS P = 0.086). The mean ACD was 3.25 ± 0.26 mm and the 95% normal range of was 2.74-3.75 mm. A significant difference in ACD was also found among different myopia groups (P = 0.030). There was a significant correlation between WTW and ACD (r = 0.460, P < 0.001). Conclusions: In our study, 95% of the Chinese myopic patients had a WTW within 10.91-12.39 mm and an ACD within 2.74-3.75 mm. ACD and WTW were significantly different among different myopia, gender and age groups. WTW was positively correlated with ACD.

Safety of phakic intraocular collamer lens implantation in 95 highly myopic special-needs children

PURPOSE

To assess the safety of intraocular collamer lens (ICL) implantation in children with high ametropia by reporting rates and case specifics of perioperative and longer-term adverse events (AEs).
.

SETTING

St. Louis Children's Hospital at Washington University Medical Center, St. Louis, Missouri.

DESIGN

Retrospective case series.

METHODS

Clinical data were collated retrospectively for 95 special-needs children (160 eyes) implanted with a Visian ICL over the past 5 years. All surgeries were performed at St Louis Children's Hospital under brief general anesthesia. The mean follow-up period was 2.0 ± 1.4 years (range, 0.5 to 5.2).

RESULTS

The mean age at implantation was 9.3 ± 5.2 years (range, 1.8 to 25) and mean preoperative spherical equivalent refractive error was -11.20 ± 3.90 diopters (range, 4 to 22). 62 children (62/95, 65%) had a neurodevelopmental disorder. 3 eyes (3/160, 2%) reported minor AE, consisting of steroid-response ocular hypertension, which resolved with cessation of topical steroid drops. Endothelial cell loss averaged 8.1% over 2 years, comparable with that reported in ICL-implanted adults. The most common major AE (7 eyes [7/160, 4%]) was postoperative pupillary block, requiring revision of the peripheral iridotomy. 1 child (1 eye [1/160, 0.6%]) with self-injurious behavior required repair of a wound leak. 1 child (1 eye [1/160, 0.6%]) with Down syndrome developed a cataract 2.8 years after ICL surgery, and 1 child (1 eye [1/160, 0.6%]) with severe autism spectrum disorder experienced traumatic retinal detachment 1.2 years after implantation.

CONCLUSIONS

The most common major AE among the cohort with Visian ICL was pupillary block due to closure of the iridotomy. Overall, the AE rate was low in this higher risk, difficult-to-manage population of special-needs children.

Tuck-and-pull technique for posterior chamber phakic intraocular lens explantation

The tuck-and-pull technique was developed for practical and safe explantations of posterior chamber phakic intraocular lenses (PCPIOLs). In this technique, after the creation of a side port, viscoelastic (or OVD [ophthalmic viscosurgical device]) is initially injected behind the PCPIOL to widen the space between PCPIOL and the crystalline lens. The old incisions can be used after recent implantations rendering the enlargement of the main incision unnecessary. After additional OVD over and under the PCPIOL, the haptic is tucked by a chopper and pulled through the main incision with a single maneuver. The haptic is grasped by two suture forceps and explanted with a "hand-to-hand" maneuver. The tuck-and-pull technique provided high protection of the corneal endothelium, crystalline lens, anterior chamber structures, and the PCPIOL itself. This technique is a practical, easy, and safe approach for explantations of all PCPIOL types, whatever the reason for its explantation may be.

Bilateral Cataract Development and Pupillary Block Glaucoma Following Implantable Collamer Lens

Aim and objective

We report the first case of bilateral cataract formation and pupillary block glaucoma and high intraocular pressure (IOP) following implantable Collamer lens (ICL) implantation that resulted in advanced visual field loss.

Background

The patient who underwent bilateral ICL implantation can develop bilaterally elevated IOP and an anterior subcapsular cataract with altitudinal visual field defect.

Case description

A 38-year-old man with high myopia presented for routine follow-up status post bilateral phakic ICL placement. The visual acuity was reduced due to an anterior subcapsular cataract and elevated IOP in both eyes with advanced glaucomatous visual field defects. The patient was treated with topical glaucoma medications. The left eye underwent same-day phakic ICL explanation and cataract surgery to prevent further visual field loss.

Conclusion

Cataract and glaucoma are serious complications after phakic ICL implantation; therefore, regular postoperative monitoring may prevent advanced visual impairment.

Clinical significance

The use of a phakic intraocular lens for the correction of myopia may result in complications. As a measure is to reduce such complications, refractive surgeons preferred using phakic posterior chamber intraocular Collamer lens for the correction of myopia.

How to cite this article

Owaidhah O, Al-Ghadeer H. Bilateral Cataract Development and Pupillary Block Glaucoma Following Implantable Collamer Lens. J Curr Glaucoma Pract 2021;15(2):91–95.

Dynamic assessment of variations in pupil diameter using swept-source anterior segment optical coherence tomography after phakic collamer lens implantation

Purpose

To dynamically assess variations in pupil diameter induced by changes in brightness in myopic eyes implanted with an implantable collamer lens (ICL, STAAR Surgical) with a central port.

Methods

This prospective, observational single-center case series study comprised 65 eyes from 65 consecutive patients undergoing ICL implant. A modified commercially available swept-source Fourier-domain anterior segment optical coherence tomography (AS-OCT) device was used for imaging and performing dynamic pupillometry under changing light conditions before and after a mean follow-up interval of four months after surgery.

Results

Preoperative mean pupil size under photopic conditions was 3.38 ± 0.64 mm; after surgery, this increased to 3.48 ± 0.61 mm. Mean pupil size under scotopic light conditions was 5.72 ± 0.79 mm before surgery and 5.84 ± 0.77 mm postoperatively. The differences between preoperative and postoperative pupil diameter in miosis and mydriasis were 0.10 ± 0.44 mm (P = 0.078) and 0.12 ± 0.58 mm (P = 0.098), respectively. The scotopic pupil exceeded the optic zone of the implanted lens in 39 eyes (60%). The mean central vault value was 412 ± 177 μm under maximum miosis and 506 ± 190 μm under maximum mydriasis. We found a positive correlation between vault and differences in pupil diameter under all light conditions (P < 0.05).

Conclusion

Dynamic AS-OCT enables a very precise determination of the pupillary diameter in the iris plane. The changes in the pupil diameter under different light conditions after the implantation of an ICL are related to the postoperative vault.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40662-021-00262-2.

Changes in ocular parameters the crystalline lens after implantation of a collamer lens

CLINICAL RELEVANCE

Understanding changes in ocular anatomical parameters after intraocular lens implantation will allow a more accurate determination of dioptric power prior to surgery.

BACKGROUND

The crystalline lens position might change due to the implantation and removal of an implantable collamer lens (ICL) or toric implantable collamer lens (TICL). This study aimed to assess the effect of ICL implantation on position of the crystalline lens.

METHODS

This retrospective study was conducted on patients who underwent V4c ICL or V4c TICL implantation between March and September, 2018. Preoperative and post-operative (2 weeks, 3 months and 6 months) axial length, central corneal thickness, crystalline lens position, crystalline lens thickness and vault height were analysed. Multivariable linear regression was used to determine the variables associated with 6-month changes in lens position.

RESULTS

This study included 117 eyes of 117 patients. There were decreases in all vertical distance measures from the central corneal endothelium to the anterior and posterior crystalline lens capsule (all p > 0.05). The amount of reduction was related to the crystalline lens position before the operation and crystalline lens thickness after the operation (all p < 0.01). An error in anterior chamber depth and lens thickness may appear when the ICL/TICL is close to the crystalline lens.

CONCLUSION

Phakic intraocular lens implantation resulted in lens thickening and forward movement on day 1 post-operatively, which becomes stable within 6 months. Preoperative lens position and post-operative lens thickness were related to the amount of movement.

Bilateral Refractive Lens Exchange With Trifocal Intraocular Lens for Hyperopia in Patients Younger Than 40 Years: A Case-Control Study

PURPOSE

To evaluate visual outcomes, satisfaction, and spectacle independence in non-presbyopic hyperopic patients who underwent bilateral refractive lens exchange with a trifocal intraocular lens (IOL) and to compare them with presbyopic hyperopic patients.

METHODS

In this retrospective study, patients younger than 40 years underwent bilateral refractive lens exchange with a diffractive trifocal IOL (FineVision Micro F; PhysIOL SA) for hyperopia with at least 3 months of follow-up. A control group of patients older than 50 years was matched by axial length, sex, and follow-up. Safety, efficacy, predictability, patient satisfaction, and spectacle independence were evaluated.

RESULTS

One hundred thirty-three patients (average age = 36.94 ± 2.91 years; range = 21.50 to 40 years) were included in this study. After a mean follow-up of 8.83 ± 5.69 months (range = 2.75 to 77.63 months), the safety and efficacy indexes and predictability within ±1.00 diopters (D) were 1.02%, 0.98%, and 99.62%, respectively, which was not different from the control group (P > .05). No intraoperative complications were recorded. The only postoperative complication was posterior capsule opacification in 21 eyes (7.89%), which was similar to the control group (P > .05). Ninety-seven percent of patients in each group expressed that they were satisfied and all of them in each group reported that they did not use spectacles for distance, intermediate, or near vision.

CONCLUSIONS

Refractive lens exchange and trifocal IOL implantation for hyperopia in patients without presbyopia provided the same good visual outcomes as in presbyopic patients with a high rate of patient satisfaction and spectacle independence. [J Refract Surg. 2021;37(8):524-531.].

Occlusion of AquaPORT Flow in a Case of Toxic Anterior Segment Syndrome Following Implantable Collamer Lens Surgery Causing Severe Pupillary Block

PURPOSE

To present a case where following Implantable Collamer Lens (ICL) implantation the patient developed toxic anterior segment syndrome (TASS) with a subsequent pupillary block as a consequence of the occlusion of the AquaPORT (STAAR Surgical) flow hole.

METHODS

Case report and literature review.

RESULTS

A V4c toric ICL (STAAR Surgical) was implanted in the left eye of a 32-year-old woman. After 1 week, the lens was 15° off axis and uneventful lens alignment correction was performed. At postoperative day 1, an intraocular pressure (IOP) of 11 mm Hg and mild corneal edema were observed. At postoperative day 7, there was an uncorrected distance visual acuity of 20/800, an IOP of 44 mm Hg, diffuse corneal edema, and fibrin strands in the anterior chamber. TASS was diagnosed and topical steroids, cycloplegia, antiglaucoma drops, and oral acetazolamide were prescribed. At postoperative day 9, dispersed endothelial pigment with a fixed mid-dilated pupil were identified. Anterior segment optical coherence tomography showed strands of fibrin blocking the central ICL hole and angle closure. Pupillary block related to the fibrin occluding the AquaPORT hole consecutive to TASS was diagnosed. The patient underwent ICL removal, but had a persistent atonic, hyporeflexive pupil as a complication.

CONCLUSIONS

This case demonstrates that an AquaPORT hole may not be enough to prevent pupillary block in cases with postoperative intraocular inflammation, causing severe postoperative complications such as Urrets-Zavalia syndrome. Clinicians should consider this diagnosis in cases with corneal edema in the early postoperative period following AquaPORT ICL insertion. [J Refract Surg. 2020;36(12):856-859.].

Long-term assessment of crystalline lens transparency in eyes implanted with a central-hole phakic collamer lens developing low postoperative vault

PURPOSE

To assess long-term crystalline lens transparency in eyes implanted with phakic collamer intraocular lens (pIOL) with a central port and low postoperative vault for correction of myopia.

SETTING

Clinica Baviera, Madrid, Spain.

DESIGN

Retrospective cross-sectional single-center study.

METHODS

Using a noninvasive Fourier-domain swept-source anterior segment optical coherence tomography system, shifts in myopic and astigmatic myopic eyes implanted with a pIOL with vaulting lower than 100 μm in miosis and more than 4 years of follow-up were dynamically evaluated. Main outcome measures were pIOL dynamic vault (vault interval and vault range [VR]), crystalline lens density, and anterior subcapsular lens opacities. Crystalline lenses were examined under slitlamp microscopy, and lens density was evaluated using quantitative Scheimpflug images. Scheimpflug images were compared with those of a control group comprising eyes that were candidates for pIOL implantation.

RESULTS

The study population comprised 24 eyes from 16 patients previously implanted with a pIOL (5.82 ± 0.9 years) with central vault lower than 100 μm under photopically induced miosis. The mean vault value was 52 ± 19 µm under photopic light conditions and 113 ± 37 µm under scotopic conditions. The mean VR was 58 ± 24 μm. Anterior subcapsular lens opacities were found in only 1 eye (4.17%). The mean lens density was 7.94 ± 0.43, and no statistically significant differences were observed compared with the control group.

CONCLUSIONS

Long-term low vaulting in eyes implanted with a pIOL with a central port for correction of myopia was associated with a low risk for developing anterior crystalline lens opacities.

Intraoperative Versus Postoperative Vault Measurement After Implantable Collamer Lens Implantation in a Large Cohort of Patients

PURPOSE

To compare intraoperative and postoperative central vault measurement after implantable Collamer lens (ICL; STAAR Surgical) implantation using optical coherence tomography (OCT).

METHODS

A total of 574 eyes of 338 consecutive patients undergoing myopic ICL implantation were evaluated (mean age of 30.8 ± 5.7 years, 117 men and 221 women). Central ICL vault was measured both intraoperatively using the microscope-integrated iOCT (Optomedical Technologies GmbH) mounted on a standard surgical microscope (HS Hi-R NEO 900A; Haag-Streit Surgical GmbH), and postoperatively using the CASIA2 swept-source OCT (Tomey GmbH) at 4 and 24 hours.

RESULTS

Mean differences between intraoperative and postoperative vault values were 11.5 ± 29.0% of the mean value 4 hours postoperatively (P < .001) and 2.7 ± 33.5% of the mean value 24 hours postoperatively (P < .001). Correlation analysis shows significant agreement between vault values obtained intraoperatively and at the two postoperative times, 4 hours (Spearman Rho = 0.850, P < .001) and 24 hours (Spearman Rho = 0.745, P < .001). In 73% of cases, postoperative vault values 4 hours after the surgery could be predicted from intraoperative vault values, and so were 56% of vault values 1 day after surgery. Significant differences in vault were found at the different times, grouping cases by ICL size (Kruskal-Wallis, P = .028 for intraoperative vault, and P < .001 for both postoperative vault times), with smaller vault values for the smaller ICL size.

CONCLUSIONS

Intraoperative determination of ICL vault using iOCT is an effective method for predicting postoperative ICL vault and minimizing postoperative vault surprises that could require surgical retouching. [J Refract Surg. 2021;37(7):477-483.].

Posterior-chamber phakic implantable collamer lenses with a central port: a review

We aimed to summarize the outcomes reported following the implantation of the V4c implantable collamer lens with a central port (ICL, STAAR Surgical Inc) for myopia correction. A literature search in PubMed, Web of Science and Scopus was carried out to identify publications reporting clinical outcomes of patients who were implanted with the V4c ICL model and had a follow‐up period of at least 6 months. A total of 35 clinical studies published between 2012 and 2020 were included in the present review. A comprehensive analysis of the available data was performed, focusing on visual and refractive outcomes at different time‐points post‐surgery. In addition, adverse events and other parameters such as endothelial cell density, intraocular pressure and vault measurements—which were evaluated in some of the studies—were also compared. This review encompassed a total of 2904 eyes. The outcomes reported in this review lead us to conclude that ICL V4c implantation for myopia correction is a safe and efficient procedure, with stable visual and refractive outcomes and low adverse event rates. The patient’s anterior segment should be thoroughly characterized, and the ICL parameters should be carefully selected so as to achieve good outcomes and avoid complications.

[Intracorneal ring segments in keratoconus management]

Intracorneal ring segments (ICRS), used in the management of keratoconus since the 2000s, have enjoyed significant technological development. Various types of ICRS exist, whose arc length, thickness, and diameter can be chosen according to the desired effect on the spherical equivalent, keratometry and asphericity. Individualized implantation strategies, based on each patient's topographic and tomographic pattern, are constantly evolving. The surgical procedure is standardized, and complications remain very rare. Combined procedures (corneal collagen cross-linking and refractive photokeratectomy±topo-guided, phakic and pseudophakic intraocular lenses) are increasingly used and require a good knowledge of the effect of ICRS alone on the keratoconic cornea. The objective of this review is to summarize clinical practices used in the visual rehabilitation of keratoconic patients using the ICRS+- combined procedures.

SMILE Versus Implantable Collamer Lens Implantation for High Myopia: A Matched Comparative Study

PURPOSE

To compare the safety, efficacy, and patient-reported quality of vision of small incision lenticule extraction (SMILE) and implantable Collamer lens (ICL) implantation for the treatment of high myopia.

METHODS

A database of 1,634 SMILE (Carl Zeiss Meditec AG, Jena, Germany) and 225 ICL implantation (STAAR Surgical, Monrovia, CA) procedures was screened for patients with a binocular preoperative manifest refraction spherical equivalent between -6.00 and -10.00 diopters (D) and plano target refraction. One-to-one matching was performed by preoperative manifest refraction spherical equivalent, age, and pupil size. All identified patients were then prospectively examined at their next regular postoperative follow-up visit and presented with the standardized and clinically validated Quality of Vision questionnaire to gauge patient-reported postoperative visual quality.

RESULTS

A total of 80 eyes (40 patients) were eligible for 1:1 matching. Mean postoperative follow-up was 27.8 ± 14.3 months in the SMILE group and 26.6 ± 17.7 months in the ICL group (P = .44). Regarding the percentage of eyes within ±0.50 D of plano target, refractive predictability was better in eyes treated with ICL implantation (90%) than SMILE (72.5%) (P = .045). Mean UDVA was comparable (ICL: -0.09 ± 0.10 logMAR; SMILE: -0.06 ± 0.09 logMAR; P < .09), but the efficacy (1.28 vs 1.05; P < .001) and safety (1.31 ± 0.22 vs 1.10 ± 0.25; P < .001) indices were higher after ICL implantation. ICL implantation induced significantly fewer higher order aberrations (total higher order aberrations: SMILE 0.724 ± 0.174 µm vs ICL 0.436 ± 0.114 µm; P < .01). Regarding subjective quality of vision, patients who had ICL implantation were significantly less bothered by visual disturbances, which were mainly halos after ICL and starbursts and fluctuations of vision after SMILE (P < .05).

CONCLUSIONS

In this refraction-matched comparative study, ICL implantation for high myopia yielded better refractive accuracy, better uncorrected distance visual acuity, fewer higher order aberrations, and better subjective quality of vision than SMILE. [J Refract Surg. 2020;36(3):150-159.].

Comparison of anterior chamber angle changes following phakic intraocular lens with and without a central hole implantation for moderate to high myopic eyes

The aim of this study was to compare the anterior chamber angle changes after implantation of phakic intraocular lens with and without a central hole for moderate to high myopic eyes in Chinese people.This study enrolled 106 eyes of 54 people with intraocular lens V4 implantation and 105 eyes of 53 people with intraocular lens V4c implantation. Postoperative vault, intraocular pressure, and anterior chamber angle changes were assessed using noncontract tonometer and ultrasound biomicroscope, respectively, at 1, 3, 6, and 12months after the surgery.There were no significant differences (all P > .05) between the 2 groups in the depth of the central vault, intraocular pressure, or the width of anterior chamber angle at any time point post-surgery. The anterior chamber angle width in degree had a baseline of 54.40 ± 10.51 in V4c group, and decreased to 27.80 ± 5.62, 26.95 ± 5.56, 27.32 ± 5.66, 27.04 ± 5.47 at 1, 3, 6, and 12 months post-surgery, respectively. Mean preoperative value of 50.62 ± 11.77 decreased to 27.28 ± 6.53, 26.82 ± 6.03, 26.61 ± 5.80, 26.83 ± 5.76 at 1, 3, 6, 12 months, respectively, in V4 group. It had sufficient evidence (P < .001) that anterior chamber angle will narrow done after surgery, but there were no statistically significant differences within groups at any time point after surgery.The anterior chamber angle changes of the V4c group was essentially equivalent to that of conventional V4 group, although implantation of both models will lead to the decrease in anterior chamber angle width.

Explantation of phakic intraocular lenses: causes and outcomes

PURPOSE

To describe reasons for explantation of anterior and posterior chamber phakic intraocular lenses (pIOLs), as well as outcomes of the surgery.

METHODS

The medical files of patients who underwent pIOL explantation due to complications were reviewed. All patients were divided into three groups based on the type of explanted pIOL: anterior chamber angle-supported (AS pIOL), anterior chamber iris-fixated (IF pIOL), and posterior chamber (PC pIOL).

RESULTS

Sixty-two eyes of 41 patients were evaluated. There were 26 (41.9%), 16 (25.8%), and 20 (32.2%) eyes in the AS pIOL, IF pIOL, and PC pIOL groups, respectively. The mean interval between the implantation and removal of the pIOL (i.e., survival time) was 13.6 ± 8.1 years (range 0.01-21.22 years). The mean follow-up after the explantation was 22.5 ± 4.0 months (range 11.3-28.7 months). The main causes of explantation were cataract in the PC pIOL group (60%) and chronic endothelial cell loss in the AS pIOL group (53.8%) and IF pIOL group (56.2%). Overall, the procedure most often combined with pIOL explantation was phacoemulsification and implantation of a posterior chamber IOL (40.3%), followed by keratoplasty (9.6%). Intraoperative complications were significantly more common in the AS pIOL group than the other groups (p < 0.001).

CONCLUSIONS

Explantation of anterior chamber pIOLs due to severe endothelial cell loss and the proportion of keratoplasty was more common in patients with a relatively long survival time. Therefore, patients with pIOL implantation should be monitored regularly after surgery.

One-year visual outcomes and optical quality of femtosecond laser small incision lenticule extraction and Visian Implantable Collamer Lens (ICL V4c) implantation for high myopia

PURPOSE

To compare one-year visual outcomes and optical quality after femtosecond laser small incision lenticule extraction (SMILE) and Visian Implantable Collamer Lens with a central hole (ICL V4c) implantation for high myopia.

METHODS

This prospective non-randomized study included 37 eyes of 20 patients who underwent SMILE (G-S) and 39 eyes of 20 patients who underwent ICL V4c implantation (G-V). Spherical equivalent (SE), uncorrected distance visual acuity, corrected distance visual acuity, retinal image quality and intraocular scattering were evaluated at one year after surgery. Each model was adjusted for age, gender, eye and preoperative SE during treatment.

RESULTS

At the one-year follow-up, G-S and G-V showed similar safety index (1.13 ± 0.13 and 1.11 ± 0.15, respectively) and efficacy index (1.05 ± 0.14 and 1.06 ± 0.15, respectively). All 21 eyes with Toric ICL (TICL) had a postoperative astigmatism of ≤0.5 dioptres (D), while the astigmatism was ≤0.5 D in all G-S eyes. Thirty-six G-S eyes (97%) and 35 G-V eyes (90%) were within ± 0.5 D of the target SE. The changes in the modulation transfer function cut-off frequency (MTF_cut-off ) and the objective scatter index from before operation to one year following the operation were not significantly different between the groups (p = 0.523 and 0.826, respectively).

CONCLUSION

Both SMILE and ICL V4c implantation provide good safety, efficacy, predictability, and stability in correcting high myopia. Optical quality including intraocular scattering was great and relatively stable in both groups during the one-year observation period.

Relative position of the central hole after EVO-ICL implantation for moderate to high myopia

Background

This study aimed to evaluate the relative position of the central hole (C_H) of EVO Implantable Collamer Lens (EVO-ICL), the pupil center (C_P), and the corneal center (C_C) after implantation of EVO-ICLs for moderate to high myopia.

Methods

Eighty-nine eyes of forty-seven patients with moderate to high myopia were evaluated. The mean preoperative spherical equivalent (SE) was − 12.58 ± 4.13D. A routine postoperative follow-up was performed within 1 ~ 12 months. Positions of the C_H of EVO-ICLs, the C_P and the C_C were recorded using a slit lamp anterior segment photography system, and their relative distances were calculated with the Visio image analysis software.

Results

All surgeries were performed safely, and no complications were observed in follow-ups 4.3 ± 4.82 months after surgery. At the last follow-up, the safety index (postoperative CDVA/preoperative CDVA) was 1.23 ± 0.48, and the efficacy index (postoperative UDVA/preoperative CDVA) was 1.08 ± 0.31. The C_H in 85 eyes (95.51%) was superior to the C_C, with 47.19% (42/89) on the temporal side and 48.31% (43/89) on the nasal side. The C_H in 84 eyes (94.38%) was located on the temporal side of the C_P, with 56.18% (50/89) superior and 38.2% (34/89) inferior to the C_P. The C_P of 85 eyes (95.51%) was superior on the nasal side of the C_C. On the defined x-axis, the average distance from the C_H to C_C was significantly shorter than the average distance from the C_P to C_C (p < 0.001).

Conclusions

An imperfect match between the central hole of EVO-ICLs and the pupil center does not necessarily indicate ICL dislocation. Compared to the pupil center, the position of the central hole of EVO-ICL is closer to the corneal center.

Safety and visual outcomes following posterior chamber phakic intraocular lens bilensectomy

Background

To evaluate the safety, efficacy, refractive outcomes and causes for bilensectomy (phakic intraocular lens – pIOL – explantation with cataract surgery and pseudophakic intraocular lens implantation) in patients previously implanted with posterior chamber pIOLs.

Methods

This multi-center retrospective study included 87 eyes of 55 patients who underwent bilensectomy for posterior chamber pIOL with a follow up time of 12 months. The uncorrected and best corrected distance visual acuities (UDVA, CDVA), endothelial cell density before and after bilensectomy were assessed, as well as the cause of bilensectomy and intra or postoperative complications.

Results

There was a statistically significant improvement in uncorrected and best corrected visual acuities after bilensectomy (p = 0.00). The main reason for bilensectomy was cataract development (93.1% of the cases), followed by miscalculation of lens size, and corneal edema. The endothelial cell count remained stable without a statistically significant change after surgery (p = 0.67). The refractive efficacy index was 0.8, none of the patients lost lines of CDVA after surgery, 73% of the patients were within ±1 D (spherical equivalent) of the target refraction. Intraoperative complications were one posterior capsule rupture with the intraocular lens (IOL) implanted in the sulcus, and 3 eyes required the use of pupil expanders for adequate pupil dilation. Postoperatively, one eye developed retinal detachment. The three pIOLs models explanted were the Implantable Collamer Lens (ICL), Implantable Phakic Contact Lens (IPCL) and the Phakic Refractive Lens (PRL).

Conclusions

Good safety and visual outcomes were observed 1 year after bilensectomy for posterior chamber phakic intraocular lenses (PC pIOLs). There were few intra and postoperative complications and there was no significant endothelial cell loss after the bilensectomy procedure.

Pupillary capture of implantable collamer lens after oral antidepressants

We report the case of a 26-year-old man under treatment with the antidepressant drugs olanzapine and buspirone, which are associated with anticholinergic effects, in whom an implantable collamer lens (ICL) became spontaneously dislocated. ICL dislocation and pupil capture occurred 10 months postoperatively. The lens was successfully repositioned. The possible role of these drugs in the dislocation of the ICL is discussed.

Comparative study of anterior segment measurements using 3 different instruments in myopic patients after ICL implantation

Background

To compare and correlate anterior segment measurements of myopic eyes implanted with Implantable Collamer lens (ICL V4c) by using anterior segment optical coherence tomography (AS-OCT), Pentacam and ultrasound biomicroscopy (UBM).

Methods

Anterior chamber depth (ACD), distance between corneal endothelium and anterior surface of ICL(C-ICL) and central vault were measured in 82 phakic myopic eyes of 82 patients who underwent ICL surgery, by using AS-OCT, Pentacam and UBM consecutively at 3 months follow up. The correlation and agreement of instruments were accessed by using Intraclass correlation coefficient (ICC) and the Bland-Altman plot.

Results

AS-OCT showed higher ACD, C -ICL and central vault measurements than both of Pentacam and UBM (P < 0.001), while Pentacam showed lower measurements than UBM (P < 0.05). The Pearson correlation coefficient (r) was 0.91 to 0.96, and ICC was 0.95 to 0.98 for all measurements between difference devices (all P < 0.001). The 95% limits of agreement of ACD, C-ICL, vault measurements were 0.13 to 0.38 mm, − 0.07 to 0.27 mm, 0.08 to 0.34 mm between AS-OCT and Pentacam, − 0.03 to 0.33 mm, − 0.16 to 0.31 mm, − 0.10 to 0.26 mm between AS-OCT and UBM, and − 0.29 to 0.07 mm, − 0.25 to 0.20 mm, − 0.31 to 0.05 mm between Pentacam and UBM, respectively.

Conclusions

AS-OCT demonstrated significantly higher value, while Pentacam demonstrated significantly lower value than UBM for ACD, C-ICL and central vault measurements in myopic eyes after ICL surgery. Measurements with these instruments were highly correlated, but could not replace each other especially for vault. This study provided valuable information about how to judge the results of anterior segment parameters of eyes implanted with ICL V4c from different devices.

Trial registration

Registration number: ChiCTR-OOC-16008987. Retrospectively registered: 08 August 2016.

Predictability of the vault after posterior chamber phakic intraocular lens implantation using anterior segment optical coherence tomography

PURPOSE

To determine whether vault measurements after placement of a hole implantable collamer lens (hole ICL) (KS-AquaPORT) can be predicted by angle-to-angle (ATA) and white-to-white (WTW) measurements obtained with anterior segment optical coherence tomography (AS-OCT).

SETTING

Sanno Hospital, Tokyo, Japan.

DESIGN

Retrospective case series.

METHODS

Eyes were observed for 3 months after hole ICL implantation for myopia or myopic astigmatism. Central vault, ATA, and WTW measurements were obtained before and after surgery using the swept-source AS-OCT CASIA2 system.

RESULTS

The study included 44 eyes (23 patients). The mean patient age and preoperative spherical equivalent, ATA, and WTW values were 36.2 years ± 8.8 (SD), -6.23 ± 3.41 diopters (D), 12.03 ± 0.40 mm, and 11.72 ± 0.40 mm, respectively. The safety index and efficacy index 3 months postoperatively were 1.13 ± 0.21 and 0.91 ± 0.30, respectively. Regarding predictability, 93.2% of eyes were within ±0.50 D of the attempted correction and all eyes were within ±1.00 D. The reproducibility coefficients for the ATA distance and WTW distance were 0.998 and 0.960, respectively. The mean postoperative central vault was 491.6 ± 189.5 μm. There was a significant correlation between postoperative vault and the ICL size and ATA distance (Spearman rank correlation coefficient r = 0.59, P < .001) but not between the ICL size and WTW distance (r = 0.27, P = .08).

CONCLUSION

The ATA measurements had higher reproducibility than the WTW measurements on AS-OCT, making it is a more important predictor of postoperative vault.

Visual outcomes of Visian ICL implantation for high myopia in patients with shallow anterior chamber depth

Background

High myopia with shallow anterior chamber depth (ACD less than 2.8 mm) is not rare. This observational study aims to evaluate visual outcomes after implantation of the Visian Implantable Collamer Lens with a central hole (ICL V4c) in these patients.

Methods

A prospective cohort of consecutive 51 eyes of 31 patients (20 to 42 years old) was followed for at least 12 months (average 15.35 ± 4.90 months, rangers from 12 to 25 months). The preoperative ACD was 2.74 ± 0.04 mm (2.65 to 2.79 mm). Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), intraocular pressure (IOP), manifest refraction, vault, and endothelial cell density (ECD) were measured during the follow-ups after surgery.

Results

All surgeries were performed safely and no complication was observed during the follow-ups. At the last follow-up, the safety index (postoperative CDVA / preoperative CDVA) was 1.33 ± 0.60 and the efficacy index (postoperative UDVA / preoperative CDVA) was 1.14 ± 0.54. After the surgery, no eye had decreased CDVA and 59% (30 eyes) of the eyes gained at least one line. Forty-seven eyes (92%) were within ±1.0 D and 35 eyes (69%) were within ±0.5 D of the attempted refraction. The mean postoperative vault was 380.00 ± 152.84 μm (90 to 700 μm). The ECD was reduced by 8.38 ± 0.06% as compared to the preoperative value (p < 0.001). No significant change was observed in IOP (p = 0.061) at the last follow-up. Ultrasound Biomicroscopy (UBM) showed none of the eyes had trabecular-iris angle closed.

Conclusions

In this prospective observational study, ICL V4c implantation in patients with high myopia and shallow ACD achieved satisfying and stable visual outcomes. Its long-term safety and stability require further investigation.

Trial registration

This trial was retrospectively registered on 05/08/2018 under the number (ChiCTR1800017594).

Refractive surgery

Refractive surgery has evolved beyond laser refractive techniques over the past decade. Laser refractive surgery procedures (such as laser in-situ keratomileusis), surface ablation techniques (such as laser epithelial keratomileusis), and photorefractive keratectomy have now been established as fairly safe procedures that produce excellent visual outcomes for patients with low-to-moderate amounts of ametropia. Additionally, a broader selection of options are now available to treat a wider range of refractive errors. Small incision lenticule extraction uses a femtosecond laser to shape a refractive lenticule, which is removed through a small wound. The potential advantages of this procedure include greater tectonic strength and less dry eye. In the future, intracorneal implants could be used to treat hyperopia or presbyopia. Phakic intraocular implants and refractive lens exchange might be useful options in carefully selected patients for correcting high degrees of ametropia. Thus, physicians are now able to provide patients with the appropriate refractive corrective option based on the individual's risk-benefit profile.

The effect of mydriasis on moderate-to-high myopic eyes with implantable collamer lenses V4 and V4c

PURPOSE

To evaluate the vault change and anterior segment movement induced by mydriasis in moderate-to-high myopic eyes with implantable collamer lenses (ICL).

SETTING

Shanghai, China.

DESIGN

A prospective consecutive observational study.

METHODS

A total of 45 eyes of 24 patients with ICL V4 implantation and 128 eyes of 65 patients with ICL V4c implantation were included and analyzed. Anterior chamber depth, posterior corneal endothelium-to-ICL distance, and vault before and after mydriasis were measured by Pentacam (Oculus, Wetzlar, Germany) at 1, 3, and 6 months after surgery.

RESULTS

Significant vault increases and anterior chamber depth increases induced by mydriasis were noted in both ICL V4 and V4c groups at 1, 3, and 6 months postoperatively. The corneal endothelium-ICL distance increased significantly in eyes with implanted ICL V4c after mydriasis at 3 and 6 months. Moreover, mydriasis-induced vault increases were greater in the ICL V4 group than in the ICL V4c group at 3 and 6 months. In eyes with implanted ICL V4c, mydriasis-induced vault increases were significantly greater at 1 month than at 3 and 6 months.

CONCLUSION

Mydriasis results in a general vault increase in eyes with implanted ICLs. The adjustment of the pressure equilibrium via the central hole of the ICL V4c has an important role in vault change. The mydriasis-induced vault increases tend toward stability after 3 months postoperatively. Mydriasis is relatively safe in eyes with ICL implantation.

The Implantable Collamer Lens with a central port: review of the literature

The purpose of this review is to summarize preclinical and clinical data from publications appearing in the peer-reviewed scientific literature relevant to the safety and effectiveness of the EVO Implantable Collamer Lens (ICL) posterior chamber phakic refractive lens with a central port (V4c Visian ICL with KS Aquaport, STAAR Surgical, Inc.). A literature search was conducted using PubMed.gov to identify all articles relating to the EVO ICL. Articles were examined for their relevance, and the references cited in each article were also searched for additional relevant publications. On the basis of a total of 67 preclinical studies and clinical reports, including effectiveness data on 1,905 eyes with average weighted follow-up of 12.5 months and safety data on 4,196 eyes with weighted average follow up of 14.0 months, the EVO ICL is safe and effective for the correction of a broad range of refractive errors. High levels of postoperative uncorrected visual acuity, refractive predictability, and stability demonstrate the effectiveness of the EVO ICL. Safety data suggest reduced rates of anterior subcapsular cataract and pupillary block compared with earlier models. Improved safety and proven effectiveness make EVO an attractive option for surgeons and patients.

Analysis of pre-operative factors affecting range of optimal vaulting after implantation of 12.6-mm V4c implantable collamer lens in myopic eyes

Background

To evaluate clinical factors affecting postoperative vaulting in eyes that had achieved optimal vaulting within the range of 250–750 μm following implantation of 12.6-mm V4c implantable collamer lenses (ICL).

Methods

A total of 236 eyes of 236 patients that had achieved optimal vaulting following implantation of a 12.6-mm V4c ICL were retrospectively analyzed. Associations between postoperative vaulting and age, preoperative anterior chamber depth (ACD), preoperative axial length (AL), preoperative white-to-white diameter, preoperative pupil size, preoperative sulcus-to-sulcus diameter, and preoperative manifest refraction spherical equivalent were investigated using simple regression, stepwise multiple regression, and multinomial logistic regression analyses.

Results

Mean central vaulting at the 6-month follow-up was 519.0 ± 112.8 μm. Variables relevant to postoperative vaulting were, in order of influence, preoperative ACD (β = 0.305, p <  0.001), preoperative pupil size (β = 0.218, p <  0.001), and preoperative AL (β = 0.171, p = 0.006). Low preoperative pupil size was associated with low optimal vaulting (250 to 450 μm), relative to that observed in the mid optimal vaulting group (451 to 550 μm) (odds ratio = 0.532, P = 0.021). Increasing preoperative ACD was associated with high optimal vaulting (551 and 750 μm), relative to that observed the mid optimal vaulting group (odds ratio = 6.340, P = 0.034).

Conclusions

Myopic eyes with greater preoperative ACD, larger pupil size, and longer AL are predisposed to higher postoperative vaulting following 12.6-mm V4c ICL implantation. Therefore, the extremes of these parameters should be considered when choosing V4c ICL size.

Refractive outcomes and optical quality after implantation of posterior chamber phakic implantable collamer lens with a central hole (ICL V4c)

Background

To investigate refractive outcomes and optical quality after implantation of posterior chamber phakic implantable collamer lens with a central hole (ICL V4c) to correct high myopia.

Methods

Sixty seven eyes of 38 patients who underwent ICL V4c implantation were enrolled. The mean preoperative spherical equivalent (SE) was − 12.44 ± 3.15 D (range: − 6.63 to − 20.50 D). The refractive outcomes and optical quality of the eyes at postoperative 1 and 3 months were evaluated and compared.

Results

At 3 months postoperatively, the mean safety and efficacy indexes were 1.33 ± 0.22 and 1.14 ± 0.23, respectively. The mean SE was − 0.32 ± 0.52 D; no patient lost 1 or more lines of corrected distance visual acuity (CDVA), 13% remained unchanged, 45% gained 1 line and 42% gained 2 or more lines. The mean modulation transfer function cutoff frequency (MTF_cutoff), Strehl in two dimensions ratio, and objective scatter index (OSI) were 38.20 ± 9.96 cycles per degree, 0.21 ± 0.06, and 1.00 ± 0.73, respectively. No significant difference was found in any of the above parameters (P > 0.05) between 1 and 3 months. The postoperative intraocular pressure (IOP) did not change when compared with preoperative values (P > 0.05).

Conclusions

ICL V4c implantation is a safe, effective, and stable solution for high myopia. Patients will acquire high and stable postoperative optical quality. ICL V4c implantation has little influence on IOP.

Surgical Options for the Refractive Correction of Keratoconus: Myth or Reality

Keratoconus provides a decrease of quality of life to the patients who suffer from it. The treatment used as well as the method to correct the refractive error of these patients may influence on the impact of the disease on their quality of life. The purpose of this review is to describe the evidence about the conservative surgical treatment for keratoconus aiming to therapeutic and refractive effect. The visual rehabilitation for keratoconic corneas requires addressing three concerns: halting the ectatic process, improving corneal shape, and minimizing the residual refractive error. Cross-linking can halt the disease progression, intrastromal corneal ring segments can improve the corneal shape and hence the visual quality and reduce the refractive error, PRK can correct mild-moderate refractive error, and intraocular lenses can correct from low to high refractive error associated with keratoconus. Any of these surgical options can be performed alone or combined with the other techniques depending on what the case requires. Although it could be considered that the surgical option for the refracto-therapeutic treatment of the keratoconus is a reality, controlled, randomized studies with larger cohorts and longer follow-up periods are needed to determine which refractive procedure and/or sequence are most suitable for each case.

Impacts of Implantable Collamer Lens V4c Placement on Angle Measurements Made by Optical Coherence Tomography: Two-Year Follow-up

PURPOSE

To determine iridocorneal angle changes produced after 2 years of implantable collamer lens (ICL) V4c (STAAR Surgical AG, Nidau, Switzerland) placement by Fourier-domain optical coherence tomography (FD-OCT).

DESIGN

Prospective interventional case series.

METHODS

In 54 eyes of 27 myopic subjects FD-OCT iridocorneal angle measurements were made before and 1 month, 3 months, 1 year, and 2 years after ICL implant. Trabecular-iris angle (TIA), angle opening distance 500 μm from the scleral spur (AOD₅₀₀), and iridotrabecular contact length (TICL) were compared among these time points and the nasal, temporal, and inferior quadrants.

RESULTS

Preoperative TIAs were 49.5 ± 8.7, 48.3 ± 9.6, and 49.1 ±8.6 degrees for the nasal, temporal and inferior quadrants (P < .001). Corresponding values were 29.9 ± 10.4, 28.4 ± 10.8, and 28.8 ± 9.7 degrees at 1 month and 27.3 ± 8.8, 26.8 ± 8.1, and 28.9 ± 7 degrees at 2 years of follow-up, indicating angle narrowing of 39%-45% and no further narrowing beyond 1 month in the nasal (P = .133), temporal (P = .376), and inferior (P = 1.000) quadrants. Trabecular-iris contact (TIC) was observed in 8 eyes of 8 subjects, mostly only in the temporal quadrant. Mean TICL failed to vary during follow-up (307 ± 288 μm at 3 months and 225 ± 142 μm at 2 years, P = .159).

CONCLUSIONS

In response to ICL V4c implant, considerable angle narrowing was detected at 1 month but this narrowing remained stable at 2 years. In the 8 cases of TIC, no progression of contact was observed beyond 3 months postimplant.

Refractive outcomes and safety of the implantable collamer lens in young low-to-moderate myopes

Purpose

To evaluate visual and refractive outcomes and safety of implantable collamer lens (ICL) implantation in low-to-moderate myopia.

Setting

Private Practice – Dougherty Laser Vision, Westlake Village, CA, USA.

Methods

A chart review was performed in 56 (104 eyes) consecutive patients who underwent implantation of the Visian ICL V4 model. Inclusion criteria were age between 21 and 40 years, spherical equivalent between −3.00 D and −10.00 D, and cylinder up to −5 D. Data on visual acuity, refraction, and complications were collected.

Results

The mean time to the last postoperative visit was 13.1±14.0 months (range, 2 to 50 months). The mean preoperative spherical equivalent was −6.96±1.60 D and the mean preoperative cylinder was −1.03±0.88 D. The mean preoperative corrected distance visual acuity (CDVA) was 20/20 (range, 20/15 to 20/80) that remained unchanged at last postoperative visit. At the last postoperative visit, the spherical equivalent was −0.08±0.01 D and the cylinder was 0.29±0.71 D. Comparison of postoperative uncorrected distance visual acuity (UCDVA) to preoperative CDVA indicated that 27 eyes (26%) had better postoperative UCDVA and 61 eyes (59%) had UDVA equivalent to the preoperative CDVA. Postoperatively, 4 eyes lost 1 line of CDVA and no eyes lost >1 line of CDVA. There were 32 eyes that gained at least ≥1 of CDVA. There were no intraoperative complications. Postoperatively, 3 patients (6 eyes) had dry eye, and 1 patient complained of nighttime halos in 1 eye. At the last postoperative visit, there were no eyes with lens opacity or glaucoma.

Conclusion

ICL implantation for low and moderate myopia up to −10 D in patients up to 40 years of age was safe, accurate, and efficacious. ICL implantation may be a good alternative to laser in situ keratomileusis for young myopes less than −10.00 D.

Comparison Over Time of Vault in Chinese Eyes Receiving Implantable Contact Lenses With or Without a Central Hole

PURPOSE

To compare the longitudinal vault changes after implantation of a posterior chamber phakic intraocular lens (pIOL) (Visian implantable contact lens) with (ICL V4c) and without (ICL V4) a central artificial hole for moderate to high myopia in Chinese eyes.

DESIGN

Retrospective case series.

METHODS

This study comprised 78 eyes implanted with the ICL V4c model and 82 eyes implanted with the ICL V4 model at our department by the same surgeon. The time course of the postoperative pIOL vault changes was quantitatively assessed using ultrasound biomicroscopy over 6 months.

RESULTS

There was a trend toward a decrease in all measures of central vault, peripheral vault, and the endothelium-anterior pIOL distance for both central hole pIOL and conventional pIOL over time, although the variance was not statistically significant (all P > .05). There were no significant between-group differences in the amount of the pIOL central vault, peripheral vault, or the endothelium-anterior pIOL distance at any time point after surgery (all P > .05).

CONCLUSIONS

The time course of the central hole pIOL vault changes is essentially equivalent to that of the conventional pIOL vault, suggesting that the presence of the central hole did not significantly affect the pIOL position.

Effects of V4c-ICL Implantation on Myopic Patients' Vision-Related Daily Activities

The new type implantable Collamer lens with a central hole (V4c-ICL) is widely used to treat myopia. However, halos occur in some patients after surgery. The aim is to evaluate the effect of V4c-ICL implantation on vision-related daily activities. This retrospective study included 42 patients. Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), intraocular pressure (IOP), endothelial cell density (ECD), and vault were recorded and vision-related daily activities were evaluated at 3 months after operation. The average spherical equivalent was −0.12 ± 0.33 D at 3 months after operation. UCVA equal to or better than preoperative BCVA occurred in 98% of eyes. The average BCVA at 3 months after operation was −0.03 ± 0.07 LogMAR, which was significantly better than preoperative BCVA (0.08 ± 0.10 LogMAR) (P = 0.029). Apart from one patient (2.4%) who had difficulty reading computer screens, all patients had satisfactory or very satisfactory results. During the early postoperation, halos occurred in 23 patients (54.8%). However there were no significant differences in the scores of visual functions between patients with and without halos (P > 0.05). Patients were very satisfied with their vision-related daily activities at 3 months after operation. The central hole of V4c-ICL does not affect patients' vision-related daily activities.

Real-time assessment of intraoperative vaulting in implantable collamer lens and correlation with postoperative vaulting

PURPOSE

To assess the intraoperative vaulting in patients undergoing implantable collamer lens (ICL) implantation with microscope-integrated intraoperative optical coherence tomography (iOCT) and correlate it with the postoperative vaulting.

METHODS

Forty eyes of 22 consecutive patients undergoing ICL implantation were prospectively evaluated. Vaulting was measured intraoperatively using microscope-integrated iOCT. The ICL-lenticular relationship was dynamically assessed throughout the surgery. Postoperative vaulting was measured using anterior segment optical coherence tomography on the first postoperative day and after 1 month and compared with the intraoperative vaulting. Uncorrected and best-corrected Snellen visual acuity, intraocular pressure (IOP), and anterior and posterior segments were assessed in all cases.

RESULTS

The mean central vaulting noted intraoperatively was 558.4 ± 122.8 µm. Postoperative mean vaulting was 576.0 ± 131.2 µm on day 1 and 551.1 ± 122.5 µm on day 30. There was a significant correlation between the intraoperative and the postoperative day 1 vaulting (paired samples correlation: 0.969, p&lt;0.001) and day 30 vaulting (paired samples correlation: 0.945, p&lt;0.001). An ICL-lenticular touch was not noted at any time during the surgery. The postoperative course was uneventful and no patient developed raised IOP or lenticular changes by the last follow-up.

CONCLUSIONS

Intraoperative vaulting correlates well with postoperative vaulting and can aid in on-table detection of extremes of vaulting and decision-making. It enhances the safety of the surgical procedure by providing a real-time display of the intraoperative manipulations.

Meta-analysis and review: effectiveness, safety, and central port design of the intraocular collamer lens

The purpose of this review is to summarize relevant data from publications appearing in the peer-reviewed scientific literature over the past decade since US Food and Drug Administration approval of the implantable collamer lens (ICL), and, in particular, to review studies relating to sizing methodology, safety, and effectiveness, as well as more recent studies reporting clinical outcomes of the V4c Visian ICL with KS Aquaport, VICMO. A literature search was conducted using two databases, PubMed.gov and Science.gov, to identify all articles published after 2005 related to the Visian ICL (STAAR Surgical, Inc.). Articles were examined for their relevance to sizing methodology, clinical safety, and effectiveness, and the references cited in each article were also searched for additional relevant publications. The literature review revealed that all currently reported methods of determining the best-fit size of the ICL achieve similarly satisfactory results in terms of vault, the safe distance between the crystalline lens and the ICL. Specifically, meta-analysis demonstrated that sulcus-to-sulcus and white-to-white measurement-based sizing methods do not result in clinically meaningful nor statistically significant differences in vault (two-sample two-sided t-test using pooled mean and standard deviations; t (2,594)=1.33; P=0.18). The reported rates of complications related to vault are very low, except in two case series where additional risk factors such as higher levels of myopia and older age impacted the incidence of cataract. On the basis of preclinical studies and initial clinical reports, with up to 5 years of follow-up, the new VICMO central port design holds promise for further reduction of complications. Given its safety record and the significant improvement in vision and quality of life that the ICL makes possible, the benefits of ICL implantation outweigh the risks.