selection of patients piols antónio marinho, md phd departamento de cirurgia refractiva hospital...
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SELECTION of PATIENTSPIOLs
António Marinho, MD PhDAntónio Marinho, MD PhD
Departamento de Cirurgia RefractivaDepartamento de Cirurgia Refractiva
Hospital ArrábidaHospital Arrábida
PORTO PORTUGALPORTO PORTUGAL
WHY PHAKIC IOLs?
Phakic IOL’s are ideal for high ametropias because:
High predictability even in very high ametropias
Stability of refraction Preserve accomodation No loss (usually gains) of lines of BSCVA
WHEN PHAKIC IOLs?
Mínimal Age– 18 years
exceptions– anisometropia
– Stable refraction in the last 18 months
Above 50 years– low ametropia
LASIK
– high ametropia CLE
Myopia - Subjective Refraction
– under - 7D : LASIK– above -7D: Phakic IOL– Main Factor : Pachymetry
Hyperopia - Cycloplegic Refraction
– under + 3D : LASIK– above + 4D: Phakic IOL– Main factor: Keratometry
INCLUSION CRITERIAGeneral
Stable refraction No intraocular diseases (diabetes
without retinopathy and well controlled glaucoma are relative contraindications,but any history of UVEITIS is absolute contraindication)
Ectatic disorders of the cornea are NOT contraindications
INCLUSION CRITERIASpecific
Anterior chamber anatomy (AC depth and AC size)
Endothelium profile
Iris shape Pupil Size
Perfect Surgery
Anterior chamber depth
AC depth (central) > 2.80mm (endothelium to natural lens)
Higher IOL power may need deeper AC (see Ophtec tables)
Importance of critical distance
How to measure the AC depth ?
US biometer (not precise)
Orbscan Scheimpflug (Pentacam)
OCT (Visante,SL-OCT)
Anterior chamber size
Angle to angle distance (AC phakic IOLs)
Sulcus to sulcus distance (ICL) Not important for iris-fixated IOLs (“one
size fits all)
How to measure AC Size ?
White to white (caliper,Orbscan,IOL master)---- not reliable
OCT (good to angle, but not to sulcus to sulcus)
Iris shape
Avoid convex iris
Most important in Hyperopia (clearance)
Possibility of posterior synechia
Pupil Size
Mesopic pupil <6.0mm
Artisan 5mm
Mesopic Pupil <7.0mm
Artisan 6mm Artiflex/Acrysof/ICL
Glare and halos
Endothelium Profile
Endothelial cell count: 21 to 25 years 2800 cells/mm 26 to 30 years 2650 cells/mm 31 to 35 years 2400 cells/mm 36 to 45 years 2200 cells/mm > 45 years 2000 cells/mm Endothelial cell shape (avoid high
polymagatism)
Endothelial Cell Count
Before Surgery (inclusion criteria)
3 months after (shows surgical trauma)
Yearly afterwards (if important decrease EXPLANT)
Perfect Surgery
Atraumatic Surgery Use cohesive viscoelastic Center the IOL with the pupil (recheck
at the end) – Artisan/Artiflex Take all the visco out Attention to post-op medication