Eyeworld

46 For some, these lenses are a welcome surgical option, but more from them is needed in the U.S. F or the average myope, LASIK continues to be an excellent surgical option. But for the more extreme myope, LASIK just shouldn't cut it—the eye, that is. Phakic IOLs are becoming in- creasingly sophisticated, and while they aren't perfect, they do offer one of the best surgical options for pa- tients with significant amounts of myopia. What's available Two phakic lenses are currently ap- proved in the United States: the Verisyse (Abbott Medical Optics, Santa Ana, Calif.) and the Visian ICL (STAAR Surgical, Monrovia, Calif.). Another lens, the AcrySof Cachet Phakic Lens (Alcon, Fort Worth, Texas), is awaiting Food and Drug Administration approval. "From my perspective, phakic IOLs will be another tool in the tool kit of the eye surgeon … to correct patients not able to be corrected with LASIK," said Jeffrey D. Horn, M.D., Vision for Life, Nashville, Tenn., a panelist of a phakic IOL dis- cussion at the 2011 ASCRS•ASOA Symposium & Congress in San Diego. He also noted that each phakic IOL "tool" is very different. When asked about the Verisyse lens, Kerry Assil, M.D., Assil Eye In- stitute, Beverly Hills, Calif., said, "It's a great choice for the patient with an anterior chamber depth of 3.2 mm or larger as measured by the orb scan. The Verisyse lens is easily im- plantable without damage to the iris and crystalline lens and, if necessary, is also easily removable without damage to the lens." It is indicated for adults for reducing or eliminat- ing myopia ranging from –5.0 to –20.0 D, with less than or equal to 2.5 D of astigmatism at the spectacle plane. Dr. Horn disagreed. From his perspective, the Verisyse makes the procedure challenging in the hands of surgeons because it has to be clipped to the iris. The lens is not available yet in the U.S. in a soft, foldable form. "It requires a rela- tively large incision that needs to be sutured," Dr. Horn said. "For a pro- cedure where we are trying to con- trol refractive error, including astigmatism, that's not an effective choice." For Dr. Horn, the Visian lens is the superior choice. Dr. Horn said that one distinct advantage of the Visian ICL is the small incision size, which from his perspective can bet- ter control astigmatism. "It goes through a 3-mm or so incision," Dr. Horn said, and "It's not clipped to the iris." Dr. Assil responded, "The super majority of extreme myopes have with-the-rule astigmatism and the entry site for the [Verisyse] lens serves to diminish the astigmatism. The dissolvable 10-0 vicryl elimi- nates the need to address sutures post-operatively." Dr. Horn indicated that the risk of cataract formation with the Visian is higher, both in terms of surgically inducing it and post-op. "As the human lens gets thicker, the space between the human lens and the Visian lens decreases," po- tentially inducing cataract, he said. The Visian ICL is used for treat- ing adult patients with myopia be- tween –3.0 D and –20.0 D (with minor or no astigmatism), and a hy- peropic version is available interna- tionally, but not in the United States. Dr. Assil said, "Having im- planted both lenses [Visian and Verisyse], I agree that the Visian is a simple implantation; however, once properly implanted the Verisyse is more physiologically compatible for the longterm health of the eye. While it may weigh on the surgeon slightly more during surgery, the Verisyse lens will provide the sur- geon with a better night of sleep following surgery." The third phakic IOL option, the Acrysof Cachet lens, can be im- planted through a small incision and thus also controls astigmatism well, Dr. Horn said. "It's farther away from the human lens so it's less likely to cre- ate cataract," he said. "A potential downside is resulting endothelial cell loss. We're looking to see if problems with endothelial cell loss are related to that lens. My experi- ence is this is not the case, but the FDA needs to be sure before giving approval." According to Alcon, patients with prescriptions between –6.0 D and –16.5 D may be candidates for the Cachet lens. Limited uses to some, exciting to others Still, some surgeons have been dis- EW REFRACTIVE SURGERY 46 October 2011 by Matt Young EyeWorld Contributing Editor Phakic IOL update: Current technology, new uses, advantages, and drawbacks P hakic IOLs are a bit of an enigma. They are familiar tech- nology to the comprehensive ophthalmologist and refractive surgeon. They have an appeal to doctors and patients. The implantation steps are similar to other types of intraocu- lar lenses commonly used today. The re- fractive effects are compelling: Visual recovery is quick, in fact quicker than LASIK, PRK, or cataract surgery. The quality of vision is excellent. The refractive effects are predictable, stable, long lasting, and able to be titrated. These lenses can even be considered somewhat reversible in that they can be removed later on. As you can see, there are several advantages to phakic IOLs. Yet there has been a cloud of scrutiny over phakic IOL technologies. These lenses have been under investigation for many years. Only two lenses (one rigid, iris-fixated and one foldable posterior chamber lens) are currently available for use in the United States. Toric technology, presbyopia-cor- recting applications are possible and avail- able. Yet our regulatory systems have slowed down and provided obstacles hin- dering the advancement of this technology. The fact remains that this is exciting tech- nology with much promise for the future. I'm pleased to have a team of experts from around the world in this month's Refractive corner of the world on phakic IOLs. Drs. Assil, Devgan, Horn, Katsev, and Malyugin will discuss their experiences with phakic IOLs. I look forward to the day that this ex- citing technology finally reaches its potential. Kerry Solomon, M.D., refractive editor Refractive editor's corner of the world continued on page 48 The Verisyse IOL at 1 day post-op. It is one of two phakic lenses currently approved in the U.S. Source: Jack A. Singer, M.D. The Visian ICL is the other phakic lens currently approved in the country Source: STAAR Surgical 46-49 Refractive_EW October 2011-DL2_Layout 1 9/29/11 3:45 PM Page 46

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