INTRAOCULARINTRAOCULARCONTACTCONTACT

LENSLENSHKMA Structured CME Program

John Chang, MDJohn Chang, MD

Director of Guy Hugh Chan Refractive Surgery CentreDirector of Guy Hugh Chan Refractive Surgery Centre

Hong Kong Sanatorium and HospitalHong Kong Sanatorium and Hospital9 August 2007

LASIK is not the best option for every patient

• Dioptre removal/optical zone & quality of vision trade-off• Large pupils• Dry eyes• Steep / flat corneas• « Funny corneas » / Keratoconus• Thin corneas

We all have those patients !

Phakic IOLs

Advantages

– Preserves Corneal topography.

– No induced aberrations

– => Better quality of vision

– High predictability.

– Stable refractive outcome.

– Safe in eyes with suspicious corneas.

– Removable

– Minimal capital expenses.

IntroductionIntroduction

• Posterior Chamber Sulcus Fixated Lens

• Version 4

• Myopia -3.00 D to > -20.00 D

• Hyperopia +3.00 D to +17.00 D

Lower left Leading right

Loading the ICL

• The ICL is marked to ensure proper orientation in the eye as it unfolds

Alignment Marks

Clear Corneal Incision

• Temporal, clear corneal incision orients best to iris plane

Video - ICL Injection

ICL Positioning

• Use the paracentisis

Video: ICL Positioning

• Rotate using the edge of the lens or on the haptic “body”

• OK to use footplates

73 Eyes73 Eyes

Since 6th May 2002

• Age : 23 to 47

• Mean age : 34.33 ± 6.37 yrs

• Male : 12

• Female : 36

Pre-Op MRSEPre-Op MRSE

• Range : -7.00 D to -24.75 D

• Mean : -14.38 ± 3.45 D

Follow upFollow up

• 1 day, 1 week, 1 month, 3 month, 6 month,

and 1 year and beyond

• Dilated slit lamp & fundus exam (DFE) for all eyes at 6 months

• Range: 2 weeks to 43.8 months

• Mean: 15.9 months

Predictability of RefractionPredictability of Refraction

Planned Refraction

• Within ± 0.50 D : 45 (61.6 %)

• Within ± 1.00 D : 59 (80.8 %)

Post-Op UCVAPost-Op UCVA

Those eyes with 20/20 or better Pre-Op BCVA

20/15 19 (48.7 %)

20/20 or better 31 (79.5 %)

20/25 or better 36 (92.3 %)

20/40 or better 39 (100.0 %)

Worse than 20/40 0 (0 %)

Total 39

Stability of refractionStability of refraction

Mean MSE at each follow up

-14.38

-0.39-0.14-0.3-0.19-0.1-0.1-0.23

-18

-14

-10

-6

-2

2

pre-op 1 wk 1 m 3 m 6 m 12 m 18 m 24 m

Follow up time

Dio

pte

r

mean MSE

SafetySafety

Pre- vs Post- BCVA

gained 2 or more lines 14 (19.2 %)

gained 1 line 39 (53.4 %)

no change 18 (24.7 %)

lost 1 line 2 (2.7 %)

Lost > 1 line 0 (0%)

Lost 1 lineLost 1 line

• Age: 39 M

• Pre-op MRSE: -10 D 20/20

• Post-op MRSE: +0.13 D 20/25

• Follow up: 1 month

Patient complaint of difficulty with reading and elected to

have ICL removed despite near VA J2 after 1 month.

Lost 1 lineLost 1 line

• Age: 39 F

• Pre-op MRSE: -13.88 D 20/15

• Post-op MRSE: -0.50 D 20/20

• Follow up: 14.9 months

Post-op BCVA varied between follow up visits from 20/15

to 20/20. No other complication was noted.

Complications Complications

Out of 73 eyes:

• 1 (1.4 %) ICL size too small – observe

• 1 (1.4 %) brow ache for 2 months

• 1 (1.4 %) ICL removed after 1 month ( pt didn’t like it)

39 year old male, c/o near vision problem

MRSE at 1 month: +0.13 D

• 1 (1.4 %) overcorrect by +1.5 D (VD not at 12mm)

ComplicationsComplications

• 1 eyes (1.4 %) complained of seeing extra light from P.I.

• 17 eyes (23.3 %) developed transient IOP rise within

2 month post op;

– range 23 to 30 mmHg;

– all controlled by timolol;

– all resolved by 1 month;

– only 3 eyes in 2006, all other before 2005

ComplicationsComplications

• 2 eyes (2.7 %) developed ASCMean pre-op MSE -9.28 D -11.25 D

MSE at last visit -3.00 D 20/20 -1.25 20/20

UCVA 20/150 20/25

ACD 3.2 3.18

WTW 11.5 11

Lens type ICM125V4 ICM115V4

Comment onset at 20 month onset 13 days, visually significant at 18 months

Early result: Toric ICLEarly result: Toric ICL

25 eyes (since June 2004)

• Age range: 23 to 44• Mean age: 32.0 ± 6.8 yrs • M : F 4 : 14• Mean follow up: 7.5 ± 4.4 months

(range 1.4 to 18.8 months)

Early result: Toric ICLEarly result: Toric ICL

Mean ICL power: Sphere -18.44 ± 3.22 DCylinder +3.68 ± 1.20 D

Pre-op Post-op

Mean sphere -13.85 ± 3.20 D -0.20 ± 0.51 D

Mean cylinder +2.95 ± 1.07 D +0.64 ± 0.47 D

Mean MSE -12.36 ± 3.06 D +0.03 ± 0.34 D

Early result: Toric ICLEarly result: Toric ICL

Post-op mean MSE at each follow up

-12.36

-0.060.030.180.210.36

-16

-12

-8

-4

0

4

pre-op 1 wk 1 m 3 m 6 m 12 m

Follow up

Dio

pte

r

mean MSE

Early result: Toric ICLEarly result: Toric ICL

Cumulative post-op BCVA and UCVA

20/20 or better pre-op BCVA

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

20/15 20/20 20/25 20/30 20/40

Post-op UCVA

Post-op BCVA

AdvantagesAdvantages

ICL vs LASIK

• No / Minimal night vision problems

• Stability /Faster recovery.

• Correct much higher ranges of myopia (-3.0 D to -20.0 D)

• Also correct hyperopia (+3.0 D to +17.0 D)

• Reversible

• No ectasia

AdvantagesAdvantages

ICL vs LASIK

• 2 patients had ICL in one eye (-19 D, -17 D) and LASIK in the

other eye(-14 D, -13 D)

• Higher myopia in the eyes with ICL

• Both patients report better quality vision with ICL despite the

higher myopia

• Stability – no initial overcorrection.

AdvantagesAdvantages

ICL vs ACIOL

• No endothelial cell loss, no AC reaction

• Small self-sealing incision

-No/less induced astigmatism

• No need to pre-cut flap in bioptics

• Can correct astigmatism at the same time

-(LRI or Toric ICL)

The Verisyse anterior-chamber Lens

Picture from www.gutsehen.de/gfx/iol_verisyse.jpg

DisadvantagesDisadvantages

• Clinically significant ASC 1.3%*

• Sizing can be difficult, Orbscan not always reliable

• Glaucoma? Pigment dispersion?

• Expensive

• 2 Procedures: Laser P.I. First (uncomfortable), then lens implantation

*5 year follow up US FDA MICL Clinical Trial – in press

ConclusionConclusion

• ICL and Toric ICL results very encouraging

• Transient IOP rise 2° to Occucoat?

• Accuracy as good / better than LASIK for high myopia

• Much better immediate and long term stability than Lasik.

• Technically not difficult (Avg surgery time 25 mins)

• No / Minimal night vision problems

• Short learning curve –easier than Phaco

What if one develops a cataract extraction leads to

immediate presbyopia?

Multi-Focal IOL

*Diagrams from AMO

Refractive IOL - Array

*Diagrams from AMO

*Diagrams from AMO

*Diagrams from AMO

*Diagrams from AMO

*Diagrams from AMO

Adjustment byhuman eyeto Multi-Focal IOL

*Diagrams from AMO

Basic Theory Basic Theory

• Diffractive MIOL - Tecnis MF

far focusnear focus

*Diagrams from AMO

*Diagrams from AMO

TecnisMF

Array

far focus

near focus

ReZoom

*Diagrams from AMO

PatientsPatients

No. of patients

No. of eyes

Mean age

Range

Array 59 95 54 + 11.9 35 to 85

ReSTOR 27 43 65 + 9.7 50 to 84

TecnisMF 130 179 59 + 13.3 7 to 87

RefractionRefractionArray ReSTOR TecnisMF

Preop mean MRSE (D)

-10.00 -0.60 -6.18

STD ±7.9 ±3.07 ±5.29

Range+7.75 to -

31.25+4.00 to -

6.75+5.63 to -

18.00

Postop mean MRSE (D)

-0.22 -0.26 0.04

STD ±1.01 ±0.68 ±0.57

Range +2.38 to -6.63+1.00 to -

2.00+2.00 to -2.25

3 IOLs 3 IOLs ComparisonComparison

Cumulative Postop UCVA

3 IOLs 3 IOLs ComparisonComparison

Cumulative Postop BCVA

SafetySafetyPreop vs Postop BCVA: Gain / Loss

3 IOLs 3 IOLs ComparisonComparison

Cumulative Postop Near UCVA

QuestionnaireQuestionnaire

Night glare*

Halo*Satisfaction#

Array 1.51 (32%) 1.68 (36%) 3.72 (92%)

ReSTOR 1.03 (21%) 1.47 (30%) 3.77 (87%)

TecnisMF 1.88 (44%) 1.99 (44%) 3.70 (93%)

* the higher the score, the more the severity (from 0-5)# the higher the score, the higher the satisfaction (from 0-5)(%) percentage of eyes had score ≥3

TecnisMF TecnisMF QuestionnaireQuestionnaire

% of time spectacles are required0% <50%

>50%Reading 100% 0 0(including newspaper, books, documents)Near tasks 100% 0 0(including SMS, watch, etc)Distance 100% 0 01 patient requires spectacles for computer

Mix and Match- Early Mix and Match- Early resultresult

Ave. Time Spent

Yes No

Distance ---- 0% 100%

Reading 2.8 hr 0% 100%

Computer

5.2 hr 0% 100%

Spectacles dependence

All patients are 100% of time SPECTACLES FREE

Thank You