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)

How to evaluate the AC ?

US Biometer (not precise)

Orbscan

OCT (Visante,SL-OCT)

AC DEPTH (OCT)AC DEPTH (OCT)

Implantation simulationImplantation simulation

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)

AC SIZE (OCT)AC SIZE (OCT)

Iris shape

Avoid convex iris

Most important in Hyperopia (clearance)

Possibility of posterior synechia

Preop ACD too small <2,8mm Iris = convex

Preop ACD too small <2,8mm Iris = convex

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)

Endothelium Profile

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

WHICH PIOL?

Angle- supported ?

Posterior chamber ?

Iris- supported ?

PIOLs Which ?Acrysof,Artisan,Artiflex,ICL

PRL