Update on Treating High Myopia With Implantable Collamer Lenses

The optimization of the vault-predicting formula based on the anterior segment measurements from artemis insight 100

To optimize and evaluate the accuracy of the vault-predicting formula generated from a very high-frequency digital ultrasound robotic scanner (Artemis Insight 100). The relationship between the achieved lens vault (LVa) at one month after intraocular collamer lens (ICL) implantation surgery and the predicted vault (LVp) was analyzed by a retrospective study, and an optimized formula was built up. Then, the accuracy of the optimized vault-predicting formula was evaluated in a prospective study by comparing the LVa and the predicted vault from the optimized formula (LVop). The retrospective study included 77 patients (133 eyes) while the prospective study enrolled 90 patients (170 eyes). The difference between LVp and LVa at one month after surgery was statistically significant (P < 0.05), and the linear regression analysis of LVa against LVp yielded a good fit (R2 = 0.68). The optimized vault-predicting formula was LVop (μm) = 1.21 × LVp (μm) + 124.73. In the validation study, the difference between LVop and LVa was not statistically significant (P = 0.10), and a good agreement between LVop and LVa was shown by Bland-Altman analysis. The optimized vault-predicting formula could predict the actual LV after ICL implantation surgery, help to select an appropriate ICL size and reduce the need for re-operation.

Retinal complications post posterior chamber phakic intraocular lens implantation at a tertiary eye hospital in the Eastern Province of Saudi Arabia

PURPOSE

Phakic intraocular lenses treat higher degrees of myopia not possible previously with conventional refractive surgery. The aim of this study is to report the incidence and risk factors of retinal complications after posterior chamber PIOL implantation and assess the differences in biometric parameters between patients who developed such complications versus those who did not.

METHODS

This retrospective study recruited 514 patients who underwent ICL implantation to correct myopia at a tertiary eye hospital center in the Eastern province of Saudi Arabia. Follow up period was at least one year. Medical records of the patients were reviewed to obtain the required data. Associations between respondents' characteristics and retinal complications were evaluated using the Chi-squared test.

RESULTS

The mean (SD) age was 27.7 (± 6.5) years ranging from 18 to 47. Laser treatment was performed in 14 cases (2.7%). Retinal complications occurred in six cases (1.2%). The risk of retinal complication was significantly higher among patients with high axial length (OR = 1.3, 95% CI 1.2, 1.4) and patients with high pre-spherical equivalent before ICL (OR = 1.09, 95% CI 1.03, 1.4).

CONCLUSION

Patients with higher axial length and higher pre-spherical equivalent before ICL implantation are at high risk of retinal complications.

Managing Pigment Dispersion Glaucoma Postbilateral ICL Implantation in High Myopia: A Case Report on the Crucial Role of Gonioscopy in Correcting a Misdiagnosis

Secondary open-angle glaucoma (SOAG) is a rare yet consequential complication following implantable collamer lens (ICL), also known as a phakic intraocular lens insertion, particularly in high myopia patients. This case report emphasizes the importance of recognizing SOAG and details the diagnostic complexities, reevaluation procedures, and successful long-term management of a 24-year-old bilateral high myopia (-7.00 D) patient who initially received an erroneous diagnosis of secondary angle-closure glaucoma (SACG) after ICL insertion at an external medical facility. Persistent visual issues prompted the patient to seek a second opinion, leading to a comprehensive reevaluation that eventually unveiled pigment dispersion syndrome (PDS) as the underlying cause, subsequently resulting in SOAG. This case not only highlights the diagnostic challenges but also elucidates the re-evaluation process and effective 5-year management strategies employed to restore the patient's visual health and quality of life.

How to cite this article

Ramesh PV, Parthasarathi S, Azad A, et al. Managing Pigment Dispersion Glaucoma Postbilateral ICL Implantation in High Myopia: A Case Report on the Crucial Role of Gonioscopy in Correcting a Misdiagnosis. J Curr Glaucoma Pract 2024;18(1):31-36.

Changes of dysfunctional lens index before and after implantable collamer lens V4c implantation in patients with moderate-to-high myopia

BACKGROUND

Dysfunctional lens index (DLI) changing is rarely reported after implantable collamer lens (ICL) implantation. In the current research, we hope to investigate the changes of DLI by ray-tracing aberrometry before and after implantation of the posterior chamber phakic implantable collamer lens with a central artificial hole for patients with moderate-to-high myopia.

METHODS

This retrospective, observational case series included 206 eyes of 104 patients with moderate-to-high myopia who underwent ICL V4c implantation. Data were collected on ocular indicators preoperatively and at 1 day, 1, 3, and 6 months postoperatively. The i-Trace Visual Functional Analyzer was used to assess the DLI measurement.

RESULTS

The overall values of safety index and efficacy index were both more than 1. Preoperatively, the mean spherical equivalent (SE) of included 206 eyes was - 10.77 ± 3.46 diopter (D). Then at 1-day postoperation, the mean SE was - 0.22 ± 0.55 D, and barely changed from 1 day to 6 months postoperatively. Although the endothelial parameters had no significant differences between preoperation and postoperation, the mean loss of endothelial cells was 0.74 ± 0.98% at 6 months. Regarding the vault, there was a significant difference between each time of follow-up (P < 0.001). The mean of the vault decreased 109.6 ± 13.5 µm from 1-day post-op to 6 months post-op. The DLI values were 3.70, 9.26, 10.00, and 9.68 at baseline, 1, 3, and 6 months, respectively (P < 0.001), but no significant differences were found between 1, 3, and 6 months postoperatively (P > 0.05). The preoperative lnDLI showed a significant positive linear correlation (r = 0.621, P < 0.001) with the preoperative spherical equivalent (SE). The lnDLI was negatively correlated with the axial length (r = - 0.462, P < 0.001), corneal thickness (r = - 0.207, P = 0.003), preoperative LogMAR UDVA (r = - 0.189, P = 0.006), and preoperative LogMAR CDVA (r = - 0.306, P < 0.001).

CONCLUSIONS

The postoperative refractive parameters were confirmed excellent in efficacy, predictability, and stability in half a year. The DLI was significantly improved after the ICL V4c implantation in patients with moderate-to-high myopia and showed good stability during the follow-up periods. The DLI deserves a more comprehensive understanding and application in clinical services.

Predicting Vault and Size of Posterior Chamber Phakic Intraocular Lens Using Sulcus to Sulcus-Optimized Artificial Intelligence Technology

PURPOSE

To investigate the accuracy of posterior chamber phakic intraocular lens (PIOL) vault and size prediction models based on sulcus to sulcus (STS) optimized artificial intelligence and big data analysis technology.

DESIGN

Big data and artificial intelligence prediction model.

METHODS

We included 5873 eyes with posterior chamber PIOL implantation, and the postoperative vault was measured using an anterior segment analyzer (Pentacam AXL) 1 month postoperatively. A random forest regression model and classification model were used to predict the postoperative vault and PIOL size. The postoperative vault and PIOL size were set as output features; other vault-related eye parameters were set as input features. The influence of white to white (WTW), horizontal sulcus to sulcus (STS), and vertical STS on predicting postoperative vault and PIOL size was analyzed and compared.

RESULTS

The mean preoperative WTW diameter was 11.64 ± 0.37 mm, the mean horizontal STS diameter was 11.85 ± 0.47 mm, and the mean vertical STS diameter was 12.39 ± 0.52 mm. In the regression model for numerical prediction of the vault, the combination of WTW, horizontal STS, and vertical STS was the most optimal for vault prediction (R2 = 0.3091, root mean square error [RMSE] = 0.1705); solely relying on WTW was the least optimal (R2 = 0.2849, RMSE = 0.1735). Among the models for classification prediction of the vault, the combination of WTW, horizontal STS, and vertical STS was the most accurate (accuracy, 0.6302; mean area under the curve, 0.8008; and mean precision recall rate, 0.6940). Moreover, the combination of WTW, horizontal STS, and vertical STS exhibited the highest accuracy for classification prediction of PIOL size (accuracy, 0.8170; mean area under the curve, 0.9540; and mean precision recall rate, 0.8864). Whether in the regression prediction models of vault values or in the classification prediction models of vault and PIOL size, the accuracy of STS optimized model was significantly improved compared with the traditional WTW model (P < .001).

CONCLUSION

Artificial intelligence combined with STS optimization contributes to the accuracy of PIOL size and vault prediction models. The random forest machine-learning model optimized by STS is superior to the traditional WTW model.

Prospective clinical study of retinal microvascular alteration after ICL implantation

Purpose: To evaluate the retinal microvascular alteration after implantable collamer lens (ICL) implantation in moderate to high myopia patients using quantitative optical coherence tomography angiography (OCTA). Methods: This prospective cohort study included 50 eyes of 25 patients with preoperative spherical equivalent ≥ -3.00 D. Patients underwent bilateral ICL implantation at the Department of Ophthalmology, Peking University Third Hospital, from November 2018 to July 2019. OCTA was used to image the superficial and deep retinal capillary plexuses before ICL implantation surgery and at 3 months follow-up. Results: There was no significant difference in the microvascular density within each annular zone and all quadrantal zones of the superficial and deep layers found in myopia patients before and after ICL surgery. Conclusion: Levels of microvascular density in retinal capillary plexuses were stable, as detected by the OCTA, showing the high security of ICL implantation, which would not leave adverse effects on retinal microvasculature in myopia patients.

Immediate or Delayed Sequential Bilateral ICL Surgery: a Survey of Chinese Ophthalmologists

INTRODUCTION

In China, the demand for implantable collamer lens (ICL) surgery is booming. Immediate sequential bilateral ICL surgery (ISBICLS) benefits patients and clinics, but it remains controversial and lacks standardization. We aim to investigate the prevalence of, factors for, and surgeon attitudes toward ISBICLS.

METHODS

In this cross-sectional survey study, an electronic questionnaire about the practice and attitudes toward performing ISBICLS or delayed sequential bilateral ICL surgery (DSBICLS) was distributed to 792 qualified ICL surgeons in Mainland China, between 4 April and 22 April 2022.

RESULTS

A total of 531 surgeons (66.79%) from 30 provinces in Mainland China responded. Among them, 374 (67.23%) were currently performing ISBICLS. Fifty-two percent (277) of surgeons reported performing ISBICLS more than 50% of the time, while 85.05% of surgeons chose to perform the second eye surgery 1 day after the first eye surgery. Seventy percent (248) of surgeons performing ISBICLS chose to perform the second eye surgery less than 30 min after the first eye surgery. Surgeons who started ICL surgery earlier (before 2010, OR = 2.772, 95% CI = 1.290-5.957, P = 0.009; 2011-2013, OR = 2.479, 95% CI = 1.060-5.800, P = 0.036), completed one-eye ICL surgery faster (< 3 min, OR = 3.936, 95% CI = 1.505-10.293, P = 0.005) and modified the second eye ICL selection less frequently (1-25%, OR = 0.203, 95% CI = 0.054-0.771, P = 0.019; 26-50%, OR = 0.173, 95% CI = 0.041-0.726, P = 0.017; 51-75%, OR = 0.299, 95% CI = 0.041-0.726, P = 0.123; 76-100%, OR = 0.163, 95% CI = 0.039-0.688, P = 0.014) tended to perform ISBICLS. No significant association was found among clinical settings, preoperative measurement devices, and hospital policies with performing ISBICLS. Regarding their attitudes toward ISBICLS, 54.63% preferred ISBICLS and 45.37% preferred DSBICLS. The main supporting reasons were patient convenience (98.64%), faster vision rehabilitation (73.56%), and improved perioperative compliance (73.22%). The concerns regarding ISBICLS included the risk of endophthalmitis (62.22%), lack of recommendation in expert consensus (61.67%), and decreased vault predictability (60.93%). The most common desires for further adoption were expert consensus on surgical criteria and patient indicators for ISBICLS (82.3%).

CONCLUSIONS

ISBICLS has been gradually adopted in Mainland China, but has not been widely accepted as a routine procedure. Surgeons' experience and skills mainly influence whether ISBICLS is performed. Further research is needed to explore standardized protocols to prevent endophthalmitis, the appropriate time interval of two eye surgery, and requisitions for surgeon skills.

Application of mydriasis and eye steering in ultrawide field imaging for detecting peripheral retinal lesions in myopic patients

PURPOSE

To compare mydriatic and eye-steering ultrawide field imaging (UWFI) with standard non-mydriatic UWFI examination in detecting peripheral retinal lesions in myopic patients.

METHODS

Cross-sectional, observational study. 220 eyes of 110 myopic patients with known peripheral retinal lesions in at least one eye under Goldmann three mirror contact lens examination were recruited. Non-mydriatic standard and eye-steering UWFI images were taken centrally and with eye-steering technique in upper, lower, nasal and temporal gazes under Optomap UWFI (Daytona, Optos, UK). Mydriatic standard and eye-steering UWFI was captured in central gaze and four different peripheral gazes. Sensitivity of detecting peripheral retinal lesions under different UWFI settings was compared.

RESULTS

141 (64.09%) eyes were with peripheral retinal lesions. The sensitivity for detecting peripheral lesions from low to high was 41.84% (95% CI 33.62% to 50.54%) under non-mydriatic standard UWFI setting, 52.48% (95% CI 44.08% to 60.75%) under mydriatic standard setting, 75.18% (95% CI 67.21% to 82.06%) under non-mydriatic eye-steering setting and 86.52% (95% CI 79.76% to 91.69%) under mydriatic eye-steering setting. Both mydriasis and eye-steering technique increased sensitivity of detecting peripheral lesions with statistical significance (p<0.001). By applying eye-steering technique, sensitivity of detecting lesions located in superior and inferior quadrants witnessed a greater increase compared with other two quadrants (p<0.05). Neither spherical equivalence (p>0.05) nor axial length (p>0.05) was an independent influence factor for detecting peripheral lesions.

CONCLUSIONS

Eye-steering technique and mydriasis could both efficiently improve the sensitivity of detecting peripheral retinal lesions in myopic patients. Lesions of superior and inferior quadrants benefited more from eye-steering technique.

Correlation between intraoperative and postoperative vaulting of the EVO implantable Collamer lens: a retrospective study of real-time observations of vaulting using the RESCAN 700 system

Background

Implantable Collamer lens (ICL) vaulting is one of the most important parameters for the safety, aqueous humor circulation, and lens transparency after ICL implantation. This study aimed to investigate the factors associated with the actual vaulting after refractive EVO-ICL surgery.

Methods

This retrospective study included patients who underwent EVO-ICL surgery at a tertiary eye hospital between October and December 2019. A RESCAN 700 was used for the intraoperative and CIRRUS HD-OCT was used for postoperative observation of vaulting. Subjective and objective refractions, anterior ocular segment, corneal morphology, intraocular pressure (IOP), anterior chamber volume (ACV), crystalline lens rise (CLR), white-to-white distance (WTW), anterior chamber depth (ACD), axial length, corneal endothelial cell density (ECD), and fundoscopy were examined. A multivariable analysis was performed to determine the factors independently associated with 1-month postoperative vaulting.

Results

Fifty-one patients (102 eyes) were included. Compared with the eyes with normal vaulting, those with high vaulting had higher preoperative diopter values (P = 0.039), lower preoperative corrected visual acuity (P = 0.006), lower preoperative IOP (P = 0.029), higher preoperative ACD (P = 0.004), lower preoperative CLR (P = 0.046), higher ICL spherical equivalent (P = 0.030), higher intraoperative vaulting (P < 0.001), and lower IOP at 1 month (P = 0.045). The multivariable analysis showed that the only factor independently associated with high vaulting at 1 month after surgery was the intraoperative vaulting value (odds ratio = 1.005, 95% confidence interval: 1.002–1.007, P < 0.001). The intraoperative and 1-month postoperative vaulting values were positively correlated (R² = 0.562).

Conclusions

The RESCAN700 system can be used to perform intraoperative optical coherence tomography to predict the vaulting value of ICL at 1 month.

First Experiences with Implantation of Phakic Lenses in Correction of Myopia in R. N. Macedonia

Objective: Analysis of visual acuity parameters in patients with moderate to high myopia and myopic astigmatism 1 year after treatment with phakic intraocular lenses. Material and methods: This was a retrospective study on 35 patients (52 eyes) with moderate to high myopia who were implanted with the Visian V4c phakic implantable Collamer lens (Staar Surgical, Nidau, Switzerland). Examined parameters were: uncorrected distance visual acuity (UDVA) and best corrected visual acuity (CDVA), manifest and cycloplegic refraction, intraocular pressure, and endothelial cell count. The investigated parameters were measured preoperatively, 1, 3, 6 and 12 months postoperatively. Results: In 17 patients, phakic lenses were implanted binocularly and in 18 patients monocularly. Preoperatively 34.62% of patients had CDVA from 0.9 to 1.0. One year after the surgery 48.08% of patients had UDVA from 0.9 to 1.0. Preoperatively 80.77% of patients had diopter range from -6.00 Dsph to -10.00 Dsph. At 1 year postoperatively 78.85% of patients were within 0.00 Dsph to -1.00 Dsph. Preoperatively, in patients with astigmatism -4 Dcyl to -2 Dcyl dominated, as opposed to significant improvement postoperatively when 94.23% had astigmatism ranging from -1.0 Dcyl to 0 Dcyl. Conclusion: The implantation of phakic lenses demonstrated a successful postoperative outcome in the treatment of myopia and myopic astigmatism. Visual acuity and refraction show a gradual and significant improvement in visual function parameters within 1 year of lens implantation.

Vault changes and pupillary responses to light in myopic and toric implantable collamer lens

BACKGROUND

Achieving an appropriate vault is the main concern after the implantation of Implantable Collamer Lens (ICLs) for surgical correction of high myopia. The vault will vary with time and optical parameters, such as accommodation and pupil size. This research is to evaluate the vault change in Myopic and Toric ICLs under different lighting conditions; and to analyze the relationship between vault changes and pupillary responses to light.

METHODS

We enrolled and analyzed 68 eyes from 68 patients who were implanted with Myopic EVO ICLs; we also included 60 eyes from 60 patients who were implanted with Toric EVO ICLs. The anterior chamber depth, pupil size and the post-operative vault were evaluated, 1 week after the operation, using a Visante Optical Coherence Tomography (OCT) under different lighting conditions. For each eye that was assessed, we calculated the vault change, which is defined as the difference between vault under mesopic condition and photopic condition; and the rate of vault change, which is defined as the vault change divided by mesopic vault.

RESULTS

No significant difference was noted with the anterior chamber depth between mesopic and photopic conditions in either group. A significant decrease in vault and pupil size was detected under photopic condition in both groups. We found no difference in vault change between Myopic and Toric EVO ICLs under different lighting conditions. Moreover, the rate of vault change had a significant decrease with increased mesopic vault (baseline value).

CONCLUSIONS

Too low a mesopic vault has a big rate of vault change, which may cause the contact of ICL with crystalline lens in photopic state; Too high a mesopic vault would constrict the posterior movement of pupil. The findings of the study suggest that, for patients with high or low vault, we should be more careful and must perform checks in different lighting conditions.

Prevalence and causes of bilateral visual impairment in rural areas of Tianjin, China - The Tianjin Eye Study

PURPOSE

To estimate the prevalence, causes and risk factors of bilateral visual impairment in rural areas of Tianjin, China.

METHODS

A large population-based, cross-sectional study. A stratified random cluster sampling method was used to investigate 12 233 participants in all age groups living in rural Tianjin. Participants completed questionnaires and received professional ophthalmology examinations.

RESULTS

According to World Health Organization best-corrected visual acuity (BCVA) criteria, the crude prevalence of bilateral visual impairment (BCVA < 20/63), bilateral low vision (BCVA < 20/63 to ≥20/400) and bilateral blindness (BCVA < 20/400) was 2.53%, 2.40% and 0.14% (age- and gender-standardized prevalence was 1.86%, 1.76% and 0.11%). The prevalence increased with age and was higher in women than men. The most common causes of bilateral visual impairment in the total population were cataract (48.39%), refractive error/amblyopia (17.74%), age-related macular degeneration (AMD) (10.00%), diabetic retinopathy (5.81%) and glaucoma (3.87%). For participants younger than 50 years, refractive error/amblyopia was the leading cause of low vision and blindness, while cataract was the major cause in the participants over 50. Female gender, older age and self-reported diabetes were associated with increased risks of visual impairment.

CONCLUSION

The age- and gender-standardized prevalence of low vision, especially in the older group (50+), was higher in this study compared with previous studies in China. Refractive error/amblyopia was the leading cause of bilateral visual impairment in younger group, while cataract was the primary cause in the older group. These findings will provide useful information for planning comprehensive eye healthcare programmes in China.

Ex-PRESS shunt implantation for intractable glaucoma with posterior chamber phakic intraocular lens: a case report

Background

Implantation of the posterior chamber phakic intraocular lens has been widely performed to correct high and extreme myopia. Chronic intraocular pressure (IOP) elevation may occur in its late postoperative period. For medically uncontrolled cases, surgical treatment is necessary, and benefits should be weighed against risks when determining whether to remove the lens.

Case presentation

A 32-year-old man with extremely high myopia presented with progressive blurred vision and medically uncontrolled IOP in the right eye. His past ocular history was significant for bilateral implantable collamer lens (ICL) implantation ten years ago. On ophthalmic examination, the ICL was well placed with a vault height of 456 µm in the right eye. The anterior chamber angles were open but narrow, and mild to moderate trabecular pigmentation was noted. Ex-PRESS glaucoma filtration surgery without ICL removal was performed to control IOP. During surgery, an Ex-PRESS P50 shunt was inserted into the anterior chamber via the front edge of the blue-grey transition zone between the sclera and cornea. Transient hypotony and shallow anterior chamber occurred in the first week after surgery, along with an ICL tilt towards the cornea with reduced vault height. No other complications related to either the ICL or the Ex-PRESS shunt were noted. IOP remained stable at 12 ~ 14 mmHg at the first 3-month follow-up.

Conclusions

Ex-PRESS glaucoma filtration surgery might be a safe and effective alternative treatment for intractable glaucoma with high myopia and ICL implantation. Careful assessment of the ICL position and anterior chamber angle is necessary to plan the appropriate surgical procedure. A postoperative shallow anterior chamber may result in ICL dislocation.

A systematic review about the impact of phakic intraocular lenses on accommodation

Phakic intraocular lenses (pIOL) are the main treatment for patients who have either high ametropia or contraindications for laser refractive surgery. The main feature that makes this kind of lenses suitable for its implantation in young adults searching for independence of optical prescription is the conservation of accommodation, since lens extraction is not required. A systematic review has been performed to evaluate the scientific literature on the effect of pIOL implantation on accommodation. Critical assessment of the articles included in the review was achieved using the tool Critical Appraisal Skills Programme in its Spanish form (CASPe). After revising the complete text of 10 articles pre-selected, two quasi-experimental pre-post studies evaluating the outcomes of a specific model of posterior chamber pIOL were included in the systematic review. The CASPe scoring of both studies were 5/11. According to this outcome, the evidence describing the impact of the pIOL implantation on the accommodative function can be defined poor. Some trends are reported as the decrease in the amplitude of accommodation, a decrease positive relative accommodation and improvement of accommodation. However, these results should be confirmed in future controlled studies.

Prevalence of Signs and Symptoms of Dry Eye Disease 5 to 15 After Refractive Surgery

Purpose

To compare the prevalence of dry eye disease (DED) as determined by signs and symptoms in patients with a history of laser vision correction (LVC) or implantable collamer lens (ICL) implantation 5–15 years ago with a matched control group with no history of refractive surgery.

Patient and Methods

This was a cross-sectional case-control study. The subject population included patients who had LVC or ICL 5 to 15 years ago. The control group was age matched. A test eye was randomly chosen. Subjects were required to have good ocular health. DED was evaluated using categorical cut-off criteria for tear film osmolarity (measured in both eyes), the subjective Ocular Surface Disease Index (OSDI), the dynamic Objective Scatter Index (OSI), non-invasive keratography tear break-up time (NIKBUT), meibography, and the Schirmer 1 test.

Results

The study included 257 subjects (94 LVC, 80 ICL, 83 control). The frequency of hyperosmolarity was significantly higher in the LVC group vs the control (73% vs 50%, p = 0.002), In contrast, the frequency of subjective symptoms tended to be lower in the LVC group than in the control group (19% vs 31%; p = 0.06). These differences were not seen between the ICL and control group.

Conclusion

The results suggest that LVC may cause tear film instability as indicated by hyperosmolar tears up to 15 years after surgery, with few subjective symptoms of dry eye. This may have implications for IOL calculations for cataract or refractive lens exchange later in life.

Acute Angle-Closure Glaucoma Secondary to a Phakic Intraocular Lens, an Ophthalmic Emergency

Implantable collamer lenses (ICL) are phakic (natural lens remains in place) lenses that were first developed in the 1990s for correction of high myopia. The effectiveness and safety of ICLs are making them an increasingly popular option for vision correction in the myopic patient, competing with traditional options like glasses, contacts, and procedures such as laser-assisted in situ keratomileusis. Although generally safe, due to the position of the phakic ICL in the eye, pupillary block remains a rare but vision-threatening complication of ICL implantation. Pupillary block caused by phakic ICL is a serious complication that requires urgent recognition and intervention and is poorly described in emergency medicine literature. We describe a case of pupillary block five years after ICL implantation that was refractory to standard medical therapy, highlighting the importance of early diagnosis and referral for more definitive therapy.