Eyeworld

63 EW REFRACTIVE January 2018 but did not receive approval. Part of the difficulty is that companies must invest a huge amount of money for the few people who are candidates. Getting a phakic IOL through FDA trials costs tens of millions of dollars at a minimum, and I think only a small percentage of candidates who want refractive surgery are better candidates for phakic IOLs than they are for LASIK." The future Dr. Parkhurst thinks that phakic IOLs will have an expanded role in the future. "We are anxiously awaiting the approval of a toric ICL," he said. "Right now, we only have myopic, spherical phakic IOLs. Once there's a toric, more patients will be eligible because many of our patients have at least some refractive cylinder. Additionally, making a very minor design modification by putting a central fenestration in the ICL has been shown to decrease risks of IOP elevation around the time of surgery and has even reduced the unlikely event of cataract forma- tion because there's better bathing of the anterior crystalline lens with aqueous through this central fenestration. I know many surgeons who have implemented this in other countries and have seen their ICL volumes go up significantly with the advent of that minor change." EW References 1. Refractive Errors & Refractive Surgery Preferred Practice Pattern. AAO. 2017. www. aao.org/Assets/96621d35-ff5f-4585-a504- bd87c550962d/636458318974830000/ refractive-ppp-in-press-10-24-17-pdf 2. Guber I, et al. Clinical outcomes and cataract formation rates in eyes 10 years after posterior phakic lens implantation for myopia. JAMA Ophthalmol. 2016;134:487–94. 3. Moya T, et al. Implantable collamer lens for myopia: Assessment 12 years after implanta- tion. J Refract Surg. 2015;31:548–56. Editors' note: Dr. Parkhurst has finan- cial interests with STAAR Surgical. Drs. Alió del Barrio and Devgan have no financial interests related to their comments. Contact information Alió del Barrio: Jorge_alio@hotmail.com Devgan: devgan@gmail.com Parkhurst: gparkhurst@parkhurstnuvision.com low end. On the upper end of age, the labeling for the ICL goes up to age 45. I think most people start leaning away from a phakic IOL ap- proach and toward other options at about age 50 for a couple of reasons. Today we do not have multifocal or extended depth of focus phakic IOLs. Once you get into full-fledged presbyopia, there are other options available that can address both myo- pia and presbyopia." Phakic IOL implantation requires careful surgical technique. "It is critical to monitor IOP in the early postoperative period because retained viscoelastic might induce acute glaucoma, which may cause residual Urrets-Zavalia or an anterior subcapsular cataract," Dr. Alió del Barrio said. "The surgeon should always monitor the patient in the clinic for 60 to 90 minutes after surgery, and the patient should not leave until the IOP is properly controlled." Deciding not to incorporate phakic IOLs into practice Some surgeons think that the disadvantages outweigh the advan- tages and have chosen not to offer them to patients. "I used to implant many of them because they filled an unmet need for my patients, however, I have stopped implanting them because it is an intraocular procedure and there can be endo- thelial cell loss and the development of cataracts," 2,3 said Uday Devgan, MD, Los Angeles. "Additionally, I think the rate of cataract formation is much more than we originally thought. My one golden rule of surgery is to give patients the same high level of care that I would want to receive. If my own child was a –12 or a –15, I would not implant a phakic IOL. I would tell him or her to wear contacts. It's just not good enough for me at this time, but it is an informed consent decision for the patient." Dr. Devgan noted that there were anterior chamber phakic IOLs in Europe that never came to the U.S. that were associated with problems. "Additionally, some other promising phakic IOLs that were in development are gone," he said. "Alcon [Fort Worth, Texas] had the Cachet anterior chamber phakic IOL that was made with the AcrySof material and underwent FDA trials

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