Eyeworld

80 | EYEWORLD | APRIL 2019 ATARACT C by Stefanie Petrou Binder, MD EyeWorld Contributing Writer Contact information Findl: oliver@findl.at PRESENTATION SPOTLIGHT count at 10 years after surgery, demonstrating a significant linear chronic endothelial cell loss. Pa- tients with a smaller anterior chamber experienced a steeper decline in endothelial cell count. 3 "The indications for phakic intraocular lens explantations in patients implanted with foldable iris-fixated myopic and toric phakic IOLs include: cataract, endothelial cell loss, cataract after retinal surgery, endothelial cell loss after retinal surgery, high IOP, and excessive pigment on pIOL," Dr. Findl said. Iris-claw pIOL implantation does not always produce significant corneal endothelial cell loss, according to evidence that included patient data from more than a 10-year time span, comparing endothelial cell counts in iris-claw patients with unoperated eyes and individuals who had under- gone corneal refractive surgery. 4 Dr. Findl ex- plained that strict inclusion criteria might explain the study's good outcomes and suggested further monitoring was necessary. Implantable collamer lenses (ICL) are phakic IOLs that are implanted behind the iris in the posterior chamber and are used in the eyes of myopic patients. "Although anterior subcapsular cataracts were a problem at first with these lenses, the aquaport has largely alleviated this complication by allowing aqueous flow around the lens," Dr. Findl said. "Sizing is still critical, however. The sulcus to sulcus diameter determines vault. Little vault can cause cataract while large vault allows less iris to endothelium distance and possible endothelial cell loss or angle closure in hyperopic eyes. ICL symptoms of glare and halos do not seem to be worse postoperatively, and endothelial cell count seems to level out after 5 years from surgery as well," he said. RLE RLE can be a life-changing surgery, which puts the full weight of responsibility on the surgeon to be aware of potential problems. Surgeons performing RLE in long eyes should be aware of lens-iris diaphragm retropulsion syndrome, a relatively common complication of phacoemul- sification in vitrectomized eyes (42%), eyes with long axial length (12%), and larger incision size. 5 H ighly myopic, long eyes have a spe- cial set of challenges for refractive surgeons. Lending his expertise at a symposium at the 36th Congress of the European Society of Cataract and Refractive Surgeons, Oliver Findl, MD, shared today's best options for the correction of vision in the "long eye." Phakic IOLs Viable IOL options for individuals with long eyes include phakic IOLs and refractive lens exchange (RLE). Phakic IOLs consist of iris-fixated and posterior chamber devices. The outcomes from a wealth of studies allow the surgeon to not only choose the right device for the patient but also understand the risks and benefits involved with each type of IOL and anticipate complications. While the visual outcomes tend to be good with phakic IOLs, the potential complications can overshadow them. Many studies have investigated the Artisan phakic IOL (Ophtec). Lines of Snellen are typ- ically gained in long eyes with the Artisan IOL, although the refractive outcomes are not quite as good. Typically, more lines are gained in the more highly myopic eyes. Complications with the Ar- tisan lens include poor intraoperative centration (seen in almost 9%), intraoperative IOL corne- al touch, hemorrhage, late decentrations, and de-enclavations, which are all quite rare and some of which can happen years later with or without trauma. 1 "The greatest challenge, of course, is the endothelium and the endothelial cell loss," Dr. Findl said. "We should not forget that while the endothelial cell count can be reduced years after surgery, there is also natural loss of endothelial cells with age, without surgery." Chronic endothelial cell loss from 6 months to 5 years postoperatively was seen to be 10.5% in myopic and 10.2% in toric Artisan IOL eyes, with endothelial cell loss higher in foldable versus rigid versions of the Artisan lens. Explantations were carried out, owing to significant endothelial cell loss, in about 3% of all eyes studied. 2 A more recent publication from the same study group revealed a continued decline in the endothelial cell IOL preferences in long eyes and their complications About the doctor Oliver Findl, MD Vienna Institute for Research in Ocular Surgery Hanusch Hospital Vienna, Austria

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