PHAKIC IOL’S( pIOL’S )

INCORRECTING HIGH MYOPIA

By:H.R. ZIAI MD.

Esfand 1391Isfahan

HISTORY

• 1950s : First ideas formed• 1988 : Angle supported PMMA, ZB5M & MA20, by

Bikoff • But :• Discontinued because of complications

( corneal edema, iritis ,… )

HISTORY

• 1988 : First phakic iris – clawed IOL• introduced for myopia by Worst• 1998 : Artisan – Worst by OPHTEC• Then changed it’s name to Artisan – Verysise • and it’s flexible form to Artiflex

HISTORY

• 1987: First PC pIOL or sulcus support pIOLs introduced :•- Phakic Refractive Lens ( PRL ) by CIBA VISON .• And then :•- Implantable Contact Lens ( ICL )• or Implantable Collamer Lens ( ICL )•- Collamer is a copolymer of • hema ( 99% ) and porcine collagen ( 1% )

CLASSIFICATION OF pIOLS

• Ant.Chamber pIOLS ( AC pIOLS)• - Angle supported 1) PMMA• 2) Foldable -

Iris – Clawed 1)PMMA• 1)Foldable• Post.Chamber pIOLS ( PC pIOLS )• (or sulcus supported )• \\\

INDICATIONS

• High Myopia

• - Myopia > -8.00 to -10.00 D

• - Stromal bed < 300µ after laser ablation

• - Keratometry < 34-36D after laser ablation

•

• FDA Approval for Artisan/Artiflex

•- Myopia : -5.00 to -20.00 D

•- Ast. < 2.5 D

•- Age > 21 y

•- ACD > 3.2 mm

• FDA Approval for ICL :

•- Myopia : -3.00 to -20.00 D

•- Ast.< 2.50 D

•- Age 21 - 45 y

•- ACD > 3.00 mm

• High Hyperopia

• - Keratometry > 50 D after laser ablation

• - Available pIOLS :

• ICL : Up to +20.0 D

• Artisan : Up to +12.00

•

• - Laser ablation is the Tx of choice for Ast. up to 4.00 – 5.00 .

• - PIOLS are available too .

High Ast.

CONTRAINDICATIONS

• - Any intraocular pathology• ( Cat. , Glaucoma , NVI , Uveitis , … )•- ↓ ACD • - ↓ Diameter

ADVANTAGS OF pIOLS

• - Rang of correction >> Laser

• - Easy technique ( Like Cat. Surgery )

• - Less expensive instruments than Laser

• - Removable

• - No ↓ in contrast sensitivity

• even : ↑ Compared with spectacle

• -More predictable

DISADVANTAGES OF pIOLS

•- All intraocular risks

•- Large incision ( in PMMA types )

•- Limitation in hyperopia due to small ant. segment

•- Irreversible complication

PRE-OP EVALUATION

•- Power of IOL

•- Diameter of IOL for angle or sulcus supported IOLs

•- ACD

•- Specular microscopy

•- Optic size in correlation to scotoptic pupil size

•- All other rutin evaluation before cat. surgery

Cont.

• But :• Main challenge in angle or sulcus supported pIOLs

is :

• “ Sizing IOL diameter”• Through Angle-to-angle• And ciliary sulcus diameter

Cont.

• For angle supported pIOLS

•- 0.5 – 1.00 mm add to w-to-w measured manually

or by orbscan, although not always correct .

•- Use of OCT/UBM

Cont.

• Note:

•If diameter measured horizontally the lens must

implanted horizontally; if implanted vertically, it

causes Decenteration , Ovalization , Iritis , Glaucoma.

Cont.

• For PC pIOLS ( sulcus supported )

•- Add 0.50 – 1.00 mm to horizontal W-W

•- New ultrasound techniques like Artemis & UBM

ANGLE SUPPORTED pIOLS

• Surgical Technique (important points)

• -Incision , 2- 6.5mm (based on type )

•- Sup. approach ( more common )

•- Retrobulbar avoided ( glob perforation )

•- IOL dialled to the best pupil-optic matching

Cont.

•- Surgical PI

•- OVD irrigated meticulously

•- Pilo 2 ( useful , but may decentered pupil

Complications

•- Haloes and Glare : more com complication ( 20

% )

• more in 1th year, but : ↓ over time

•- Pupil ovalisation ( 7-22% ) ( if oversized )

•- Iris retraction and atrophy

Cont.

•Endothelial cell damage:

•-Surgical trauma -

Presence of IOL - 5-7%

in 1th year and less in next years

Too small size : ↑ damage

Cont.

•- ↑ IOP • - Transient , 2’ to OVD• - Topical CS• - Pupilary block•- Uveitis : 4.5%• - Usually transient , 2’ to iris manipulation• - In over sized IOL , may chronic, causing

glaucoma cat. , PAS, Iris damage , …

Cont.

•- Cataract

• - Less common than PC pIOL

• - Caused by trauma , uveitis

• - Age > 40 y at time of surgery

• - AL > 30 mm

•- RD : 3%

• If pIOL have additive risk for RD over the myopia??

Cont.

•Rare complications

• - Corneal decompensation

• - Urretis – Zavalia synd.

• - Malignant glaucoma

• - Endophthalmitis

• - Hyphema

IRIS FIXATED pIOLs

• General information of Artisan

• - 0.5 mm vault ( 0.8 mm distance between IOL &

crystalin lens)

• - Diameter : 8.5 mm

• - Optic : 6.5 & 6.0 mm

• - Center :0.2 mm thickness

Indications ( FDA ) :

•- Myopia

•- Hyperopia

•- RE After PK

•- Sever anisometropia in children

•- Aphakia

•- KCN

•- Progressive high myopia in psudophakic children

Complications •- Glare & haloes: 0-9% more in small optics ( 5mm ) and Large pupil ( > 5.5 mm )•- AC inflammation: 0.5%

•- Pigment dispersion : 2” to poor enclavation

• -Crystalin lens rise: like Hyeperopia

( Artiflex > Artisan ) because of step in

optic-haptic junction

Cont.

•Endothelial cell loss• - Intraoperative trauma ( main cause )• - more in first 6m post op.• - ACD < 3.2 → ↑ risk•Glaucoma• - Usually transient• - OVD , CS , pigment , inflammation

Cont.

•Cataract : 3% - NS•- Age > 40 at implantation time →↑risk•- AL > 30 mm →↑ risk

• Other complications• - Hyphema• - Intermittent myopic shift• - RD

PC PIOLs ( SULCUS SUPPORTED )

•- PRL : Silicon , hydrophobe

•- ICL : Hydrophyl , biocompatible , permeable

Complications

•-Glare & halos• 8.4 % , ↓ over time• -Flare ; 27%, Up to 2y•-Cataract• - The major concern• - 0.6 – 3 %• - Traumatic contact , metabolic disturbance• - Ant. sub capsular

Cont.

•Pigment dispersion & deposition

• - Iris rubbing

• - ↑ Size ( ↑ Vault ) →↑ dispersion

•Glaucoma • - 2’ to pigment dispersion• - Angle closure• - Pupilary block ( if fibrin formed )• - ICL > PRL•Decenteration : The most complication• - Small size IOL, difficult problem• - Even sometime dislocation into vitreous cavity

• Note :• In PC pIOL, vault is of critical importance•- ↑ Vault → ↑ Pigment dispersion•- ↓ Vault → ↑ Cataract

BIOPTICS

•Implantation of pIOL followed by Laser ablation

•- In case of extremely myopia , high Ast. , lens power

not available.

•- Safe and effective

FEW SELECTED POINTS

•- PIOLs have been used successfully for post PK Ast.

•- Artisan induces HOA less than APT because of

reserving prolate shape of cornea.

•- Toric pIOL + CXL successfully have been used for

correcting RE in mild to moderate KCN & PMD.

Cont.

• - AC pIOLs have been used for TX of children with

sever myopic anysometropia ( > -8.00 ) that resist or

no cooperative for traditional amblyop therapy with

encouraging results .

CONCLUSION

• Compared with corneal laser ablation, pIOLs are excellent in :

• - Predictability• - Efficacy• - Safety• - Quality of vision

پو1زش عرض ضمن

باالی حجم در LECTUERبدلیل نمیباشد پذیر امکان اسالیدها ادامهآموزشی مرکز بصری و سمعی واحد به لطفا ادامه به نیاز صورت

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