Reverse pupillary block with pigment dispersion and elevated intraocular pressure following bilateral phakic intraocular lens implantation.

The authors describe a case of reverse pupillary block with pigment dispersion following sequential phakic intraocular lens (pIOL) implantation for high myopia, in a young female patient. The intraocular pressure (IOP) elevation began 3 weeks postoperatively, for which Nd-YAG laser peripheral iridotomies (PIs) were attempted elsewhere. Despite maximum medical therapy, the IOP was uncontrolled. She was referred to our institute for further management. Examination showed anteriorly displaced iris-pIOL diaphragm, iris pigment dispersion and raised IOP. The PIs were incomplete. Based on clinical evaluation and investigations, we concluded that the excess area of contact of the posterior iris over the pIOL caused a reverse pupillary block and pigment dispersion. The IOPs were controlled by repeating laser iridotomies and with medical therapy. Subsequently, the patient developed a low lens vault leading to bilateral cataract. Sequential explantation of the pIOL along with cataract extraction was performed and her vision was restored.

Determination of progressive endothelial cell loss after posterior chamber phakic intraocular lens implantation.

Comments about endothelial cell loss after posterior chamber phakic intraocular lens are provided, with a particular emphasis on the importance of determining progressive postoperative cell density reduction, excluding that related to surgical trauma.

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.

A review of posterior chamber phakic intraocular lenses.

PURPOSE OF REVIEW: Posterior chamber phakic intraocular lenses (pIOLs) are increasing in popularity as a viable alternative to laser refractive surgery. The purpose of this review is to evaluate the recent updates to pIOLs and to assess the advancements and safety of the procedure. RECENT FINDINGS: Accurate lens sizing is the key determinant to suitable vault prediction, advancements to sizing formulae including the use of very high frequency (VHF) digital ultrasound and the application of artificial intelligence and machine learning has led to improved vault prediction and safety. The introduction of the central aquaport has been shown to reduce the formation of cataract and is now adopted in most myopic pIOLs. Recently published studies have demonstrated that pIOLs have an excellent safety profile with no increased risk of retinal detachment or endothelial cell loss. Advancements have led to the introduction of extended depth of focus pIOLs for the correction of presbyopia, further research is required to evaluate the efficacy of new lens designs. SUMMARY: pIOL surgery is experiencing traction with improved lens design and increased lenses choices such as larger optical zone and presbyopic options. Accuracy of implantable collamer lens sizing is paramount to the safety and clinical outcomes, greater predictability is likely to encourage more posterior chamber pIOL users due to fewer sizing related complications.

[Femtosecond laser assisted cataract surgery in a complicated cataract patient with reverse implantable collamer len: a case report].

The patient is a 33-year-old female who, 11 years ago, underwent bilateral posterior chamber phakic intraocular lens (pIOL) implantation due to myopia. She presented with a 2-year history of declining vision in her right eye and sought medical attention. She received femtosecond laser-assisted cataract surgery combined with pIOL extraction. Anterior segment optical coherence tomography and ultrasound biomicroscopy both showed an inverted pIOL in the right eye. Good visual results were achieved, and there were no complications during the six-month follow-up.

Presumed Unindicated Implantation of Posterior Chamber Phakic Intraocular Lens.

BACKGROUND Refractive surgery is one of the most frequently performed ocular surgeries worldwide. Implantation of the posterior chamber phakic intraocular lens has advantages over laser vision correction, especially in high refractive error cases. We present a case of a young adult women with poor vision who underwent bilateral posterior chamber phakic intraocular lens explantation due to high vault, shallow anterior chambers, and a picture of cone-rod dystrophy. CASE REPORT A 23-year-old woman was referred for poor vision following an implantation of bilateral toric implantable collamer lens (ICL) implantation when she was 18 years old for high myopic astigmatism and anisometropia. On presentation, the best corrected visual acuity was 4-6/200 and 2-3/200 in the right eye and left eye, respectively. Slit lamp examination indicated a clear cornea with pigment deposition on the endothelium, high ICL vault, shallow anterior chamber, and bowing of the iris bilaterally. The patient underwent bilateral removal of the ICLs on separate visits, yet the vision remained unchanged. Diagnostics revealed that the patient had bull's eye maculopathy with atrophy due to her cone-rod dystrophy, which caused the poor vision. CONCLUSIONS This report emphasizes the need for careful and appropriate patient and intraocular size selection for refractive surgery. It indicates the importance of thorough medical examination, including genetic testing, fundus examination, and optical coherence tomography when retinal dystrophy is suspected. Generally, close follow-up is crucial in the setting of high vaulting following ICL implantation to prevent secondary complications.

Comparison of higher-order aberrations between implantable collamer lens V4c implantation and simulated spectacle correction in patients with high myopia.

PURPOSE: To investigate the differences in higher-order aberrations between non-toric or toric implantable collamer lens (ICL or TICL) V4c implantation and simulated spectacle correction. METHODS: Patients with high myopia who underwent ICL/TICL V4c implantation were enrolled. The "total no defocus" pattern of iTrace aberrometry to simulate the condition of spectacle correction was measured before ICL/TICL implantation, and higher-order aberrations in this condition were compared to those 3 months after surgery. Related factors with changes in coma were comprehensively analyzed. RESULTS: A total of 89 right eyes of 89 patients were included. Compared to simulated spectacle correction, total-eye coma (P<0.0001 ICL, P<0.0001 TICL) and internal coma (P<0.0001 ICL, P<0.001 TICL) decreased in the ICL- and TICL-treated groups after surgery. Total-eye secondary astigmatism (P<0.0001 ICL, P=0.007 TICL) and internal secondary astigmatism (P<0.0001 ICL, P=0.009 TICL) were also decreased in both groups postoperatively. Spherical error showed positive correlations with variation in total-eye coma (r=0.37, P=0.004 ICL; r=0.56, P=0.001 TICL) and internal coma (r=0.30, P=0.02 ICL and r=0.45, P=0.01 TICL). Axial length revealed negative correlations with changes in total-eye coma (r=-0.45, P<0.001 ICL; r=-0.39, P=0.03 TICL) and internal coma (r=-0.28, P=0.03 ICL and r=-0.42, P=0.02 TICL). CONCLUSIONS: Both ICL- and TICL-treated groups demonstrated a decrease in coma and secondary astigmatism after 3 months, postoperatively. ICL/TICL may confer a compensatory effect on coma aberration and secondary astigmatism. Patients with a higher myopia achieved a greater improvement in coma and may benefit more from ICL/TICL implantation than from spectacle correction implantation than from spectacle correction.

Ten-year prevalence of rhegmatogenous retinal detachment in myopic eyes after posterior chamber phakic implantable collamer lens.

PURPOSE: To determine and compare the prevalence of rhegmatogenous retinal detachment (RRD) in myopic eyes operated of posterior chamber phakic implantable collamer lens (ICL) with a control group of nonoperated myopic eyes over 10 years of follow-up. SETTING: Clinica Baviera, Madrid, Spain. DESIGN: Retrospective cohort study. METHODS: There were 2 study cohorts: one with patients operated with ICL and a control group of nonoperated patients. The primary outcome of RRD was measured retrospectively, first through chart review of ICL-operated patients with at least 10 years of follow-up, then secondarily through telephone questionnaires and specialist verification for those with incomplete follow-up. Prevalence and incidence were calculated and compared, as well as their possible association with other risk factors. RESULTS: 58 operated patients completed follow-up in our clinic. A survey of 3849 more patients was conducted for a total of 252 operated with a mean spherical equivalent (SEQ) of -12.6 diopters (D) and 221 nonoperated with a mean SEQ of -10.5 D. 7 eyes developed an RRD in the operated vs 5 eyes among the nonoperated (prevalence 1.71% vs 1.25%, respectively, P = .773). The equivalence tests, the two one-sided test and the null hypothesis test between groups, were within the 0.02 limits, confirming the null hypothesis, and compared survival curves did not show significant differences ( P = .59). CONCLUSIONS: ICL implantation surgery for high myopia did not affect the prevalence of RRD in operated eyes compared with similar nonoperated eyes, in this long-term study.

A posterior chamber phakic refractive lens dislocated into the vitreous.

SIGNIFICANCE: We present a unique cause for zonular dehiscence, which provides a pathway for subsequent dislocation of an implanted phakic refractive lens (PRL) into the vitreous cavity. PURPOSE: To determine the cause of zonular dehiscence and to avoid similar complications after PRL implantation in the future. CASE REPORT: A 37-year-old highly myopic patient with refraction of -24.0 DS in both eyes received PRL implantation in both eyes. In the 14-month postoperative follow-up, it was found that the PRL dislocated into the vitreous cavity. The patient then underwent phacoemulsification and vitrectomy. The patient was treated successfully. No ocular complication was found. The visual acuity of the left eye was 20/40, two weeks after surgery. CONCLUSIONS: We report a unique cause for zonular dehiscence, and the clarification of its detailed characteristics may contribute to prevention of such a complication in the future.

Corneal endothelial ring following the implantation of toric implantable collamer lenses with a central hole: a case report.

BACKGROUND: To report a case of a corneal endothelial ring after toric implantable collamer lens (TICL, V4C) implantation in the right eye of a patient. CASE PRESENTATION: A 36-year-old woman with refractive errors of -8.00 DS/-2.00 DC * 8° in the right eye and - 6.50 DS/-1.75 DC * 177° in the left eye developed a corneal endothelial ring in the right eye on the first day after receiving TICLs implantation for treatment of high myopic astigmatism, which has not been previously reported as a complication of ICLs implantation. At 1 day postoperatively, the uncorrected distance visual acuity (UDVA) was 20/16, the intraocular pressure as measured by non-contact tonometry was 16.9 mmHg, and the vault as measured by anterior segment optical coherence tomography was 1238 µm. The eye was quiet and there was no unusual anterior chamber reaction. However, slit-lamp examination revealed an endothelial annular lesion of approximately 0.4 mm in diameter in the central part of the cornea, which was gray-white in color. The shape of the ring was the same as that of the central hole of the TICL. Specular microscopy showed that the mean endothelial cell density (ECD) of the ring significantly decreased to 1442 ± 263 cells/mm2, while the other part was still normal (2852 ± 103 cells/mm2). After 9 days of corticosteroid treatment and intense lubrication, the patient had a clear cornea, increased ECD (1532 ± 653 cells/mm2), and a good UDVA (20/16). CONCLUSION: This case suggests that a few hours after ICL V4C implantation, with a large vault, corneal displacement caused by an air puff would make the endothelium close to or even contact the ICL, producing a corneal endothelial ring. After ruling out various possible factors, we speculated that the endothelial ring was developed due to the non-contact tonometer air puff before slit-lamp evaluation, and this phenomenon was recorded by Corvis, which confirmed that the cornea could come in contact with the ICL due to gas shock. This "contact" may cause transient corneal endothelial damage.

DETERMINATION OF FACTORS ASSOCIATED WITH LONG-TERM ENDOTHELIAL LOSS AND REFRACTIVE RESULT IN PATIENTS WITH ARTISAN PHAKIC LENS.

PURPOSE: To determine the changes in endothelial cell density, refractive results, and risk factors associated with endothelial loss in patients with irisclaw phakic intraocular lenses for myopia/myopic astigmatism (Artisan). METHODOLOGY: Data collection was obtained from an existing database with information on patients with a phakic Artisan lens implant between 1998 and 2011 at the Virgilio Galvis Ophthalmology Centre, with at least 5 years of follow-up. As a second stage, an analysis was carried out to identify the change in endothelial cell density and its potential associated factors. RESULTS: A total of 80 eyes with myopic errors were included with a follow-up of 11.9 + 3.48 years. The percentage of total loss of endothelial cells was greater than 25% of the preoperative density in 43.8% of the eyes. A postoperative annual loss > 1.6% was found in 47.0% of the eyes with that information available. 41 eyes (51%) had final endothelial density < 2000 cells/mm2, and 7 (8.8%) eyes had endothelial cell density < 1000 cells/mm2. Among the variables studied, no associated factors for long-term endothelial loss were found. During the course of the study, 8 (10%) phakic intraocular lenses were explanted, including 3 with accelerated endothelial loss, and another 2 with cataract associated and a significantly low endothelial density. The last mean spherical equivalent was -0.81 (±1.01 D), and the final uncorrected distance visual acuity was 0.45 logMar (Snellen 20/56). CONCLUSION: Artisan-type phakic lenses are a good alternative for the correction of high myopic defects, with predictable refractive results in the long term. However, there is an increased loss of endothelial cells in the long term in a high percentage of patients. Strict postoperative follow-up, including endothelial evaluation, is required, and further studies are warranted.

Phakic intraocular lenses: an update and review for the treatment of myopia and myopic astigmatism in the United States.

PURPOSE OF REVIEW: To review all phakic intraocular lenses (pIOLs) available in the United States for the correction of myopia or myopic astigmatism and offer a clinical approach to their proper use, postoperative follow-up, and analysis of visual and adverse outcomes. RECENT FINDINGS: In March 2022, the FDA approved the EVO/EVO+ Visian ICL for widespread use, adding this lens to the two others available (Verisyse, Visian ICL). Cataract formation, endothelial cell loss (ECL) and surgical reintervention remain the most common adverse events. There are discrepancies between studies on ECL following implantation with pIOLs, although trends can be deduced with meta-analysis. Posterior Chamber-pIOLs (PC-pIOLs), especially the EVO/EVO+, have an overall lower mean adverse effect and subjective patient symptom profile when compared to Iris Fixated-pIOLS (IF-pIOLs). Advancements in PC-pIOL sizing have provided a noticeable difference in visual and safety outcomes. SUMMARY: All pIOLs available in the United States provide high-quality visual correction of moderate to high myopia and/or myopia with astigmatism. Proper follow-up for ECL and cataract formation is warranted.

Efficacy and Safety After Toric Posterior Chamber Implantable Collamer Lens and Toric Iris-Fixated Foldable Phakic Intraocular Lens for Myopic Astigmatism.

PURPOSE: To compare visual, refractive, and safety outcomes of toric posterior chamber Implantable Collamer Lens (T-ICL) (STAAR Surgical) and toric iris-fixated foldable phakic intraocular lens (IOL) (T-Artiflex; Ophtec BV) implantation for the correction of myopic astigmatism. METHODS: This retrospective cohort study included 312 eyes of 312 patients who had phakic IOL implantation for myopic astigmatism. Two groups were defined: 205 eyes that underwent T-ICL implantation and 107 eyes that underwent T-Artiflex implantation. Safety, efficacy, and predictability outcomes were evaluated preoperatively and at 12 months postoperatively. Refractive and corneal astigmatic vector analysis were performed using the Alpins method. RESULTS: One year postoperatively, uncorrected distance visual acuity was 0.05 ± 0.18 (T-ICL) and 0.10 ± 0.16 (T-Artiflex) logMAR, with efficacy indexes of 1.16 ± 0.27 and 1.05 ± 0.31, respectively (P < .001). Safety indexes were 1.28 ± 0.30 and 1.21 ± 0.31, respectively (P = .04). Spherical equivalent was within ±0.50 diopters (D) of emmetropia in 165 (80.5%) and 88 (82.2%) eyes, respectively. Refractive astigmatic analysis showed an index of success of 0.28 ± 0.33 (T-ICL) and 0.31 ± 0.26 (T-Artiflex) (P = .07). Surgically induced corneal astigmatism was 0.48 ± 0.74 and 0.81 ± 0.61 D, respectively (P < .001). Mean endothelial loss was 1.11% and 2.05%, respectively (P = .42). Six (2.9%) eyes in the T-ICL group and 1 (0.9%) eye in the T-Artiflex group had phakic IOL repositioning due to significant misalignment. No vision-threatening complications occurred. CONCLUSIONS: Both the T-ICL and T-Artiflex groups showed high visual and refractive efficacy with a good safety profile for the correction of myopic astigmatism. T-ICL implantation demonstrated significantly better efficacy and safety indexes after 12 months. Vector analysis showed similar refractive astigmatic correction in both groups, but T-Artiflex implantation revealed higher surgically induced corneal astigmatism. [J Refract Surg. 2022;38(6):339-347.].

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.

One-year analysis of the refractive stability, axial elongation and related factors in a high myopia population after Implantable Collamer Lens implantation.

PURPOSE: To investigate the refractive stability, axial length (AL) changes and their related factors in a high myopia population after Implantable Collamer Lens (ICL) implantation. METHODS: This prospective study included 116 eyes of 116 patients divided into several groups based on the spherical equivalent refractive error (SE)-SE > - 6 D, - 12 ≤ SE < - 6 D and SE < - 12 D groups-and AL-AL < 28 mm and AL ≥ 28 mm groups. The uncorrected and corrected distance visual acuity, refraction, AL and intraocular pressure were followed for 1 year. RESULTS: SE changed from - 11.53 ± 5.25 D preoperatively to - 0.33 ± 0.70 D at 1 week, and further changed to - 0.48 ± 0.77 D at 1 year after ICL implantation, with average progression being - 0.15 ± 0.37 D from 1 week to 1 year after surgery. AL changed from 27.95 ± 2.33 mm preoperatively to 27.98 ± 2.36 mm 1 year after surgery, with an average axial elongation of 0.03 ± 0.12 mm. The mean axial elongation rate was 0.05 mm/year in the SE < - 12 D group, being significantly faster than the other refractive groups (P < 0.05); it was 0.06 mm/year in the AL ≥ 28 mm group, being significantly faster than the AL < 28 mm group (P < 0.05). CONCLUSION: Patients with high myopia and long AL showed a continuous myopic progression and axial elongation at an adult age one year after ICL surgery, especially in those with myopia higher than - 12.00 D and AL longer than 28.00 mm.

[Correction of ametropia with posterior chamber phakic intraocular lens]. / Korrektsiya ametropii s pomoshch'yu zadnekamernykh fakichnykh intraokulyarnykh linz.

Posterior chamber phakic intraocular lens (PIOL) implantation is a widely accepted and performed refractive surgery for correction of moderate and high myopia used when corneal laser ablation procedures are not suitable. This paper analyzes literature data to reveal the advantages and limitations of the technology.

A critical evaluation of longitudinal changes of astigmatism following implantation of toric implantable collamer lens (TICL): a comparison between treated and untreated cases over 4 years.

PURPOSE: To evaluate residual astigmatism following correction with toric implantable collamer lens (TICL) (group I) over a period of 4 years and compare with the change of astigmatism in spectacle wearers (group II). METHODS: Groups I (86 cases implanted with TICL [EVO + Visian ICL, Staar Surgical, Nidau, Switzeland], preop refractive error [sphere and cylinder] - 22.25 DS to - 1.00 DS and - 5.50 DC to - 1.00 DC) and II (80 cases initial refractive error [sphere and cylinder] - 18.00 DS to 0.00 DS and - 7.00 DC to - 1.00 DC) were reviewed annually. Refractive and tomography data were subjected to vector analysis to determine surgically induced astigmatism (SIA), angle of error [Δθ° = angle of target-induced astigmatism (TIA) - angle of SIA], and ΔC [TIA-SIA powers] and total corneal astigmatism (TCA) in group I and induced change in astigmatism (ICA) in group II. RESULTS: In group I, on all occasions, SIA correlated with TIA (p < 0.05); differences between SIA and TIA means were insignificant and changes in TCA were not correlated with ΔC. Mean (± sd, 95% CI) residual astigmatic powers (RA) in attending group I cases (1-4 years) were - 0.40 DC (0.58, - 0.52 to - 0.28), - 0.40 DC (0.59, - 0.52 to - 0.27), - 0.41 DC (0.58, - 0.54 to - 0.28), and - 0.61 DC (0.74, - 0.82 to - 0.40). In group II, the corresponding ICA powers were - 0.47 DC (0.53, - 0.61 to - 0.32), - 0.49 DC (0.48, - 0.69 to - 0.29), - 0.60 DC (0.40, - 0.76 to - 0.44), and - 0.86 DC (0.71, - 1.19 to - 0.52). Differences between RA and ICA were not significant. Of the group I cases presenting at 1-4 years postop, 23, 18, 16, and 28 had RA powers ≤ - 0.75 DC. Of these 12, 10, 6, and 16 were associated with Δθ° > 5° (ΔC - 0.50 to 0 DC) and 5, 1, 4, and 4 were related to ΔC (Δθ° < 5°). CONCLUSION: The development of astigmatism after TICL implantation is on par with the natural change in astigmatism in untreated cases. In about 50% of TICL cases presenting with astigmatism ≤ - 0.75 DC, the residual astigmatism could be neutralized by realigning the TICL.