INTRAOCULAR CONTACT LENS

1. INTRAOCULARCONTACTLENS HKMA Structured CME Program John Chang, MD Director of Guy Hugh Chan Refractive Surgery Centre Hong Kong Sanatorium and Hospital

2. LASIK is not the best option for every patient • Dioptre removal/optical zone & quality of vision trade-off • Large pupils • Dry eyes • Steep / flat corneas • « Funny corneas » / Keratoconus • Thin corneas We all have those patients !

3. Phakic IOLs Advantages • Preserves Corneal topography. • No induced aberrations • => Better quality of vision • High predictability. • Stable refractive outcome. • Safe in eyes with suspicious corneas. • Removable • Minimal capital expenses.

4. Introduction • Posterior Chamber Sulcus Fixated Lens • Version 4 • Myopia -3.00 D to > -20.00 D • Hyperopia +3.00 D to +17.00 D

5. Loading the ICL • The ICL is marked to ensure proper orientation in the eye as it unfolds Lower left Leading right Alignment Marks

6. Clear Corneal Incision • Temporal, clear corneal incision orients best to iris plane

7. Video - ICL Injection

8. ICL Positioning • Use the paracentisis

9. Video: ICL Positioning • Rotate using the edge of the lens or on the haptic “body” • OK to use footplates

11. 73 Eyes Since 6th May 2002 • Age : 23 to 47 • Mean age : 34.33 ± 6.37 yrs • Male : 12 • Female : 36

12. Pre-Op MRSE • Range : -7.00 D to -24.75 D • Mean : -14.38 ± 3.45 D

13. Follow up • 1 day, 1 week, 1 month, 3 month, 6 month, and 1 year and beyond • Dilated slit lamp & fundus exam (DFE) for all eyes at 6 months • Range: 2 weeks to 43.8 months • Mean: 15.9 months

14. Predictability of Refraction Planned Refraction • Within ± 0.50 D : 45 (61.6 %) • Within ± 1.00 D : 59 (80.8 %)

15. Post-Op UCVA Those eyes with 20/20 or better Pre-Op BCVA 20/15 19 (48.7 %) 20/20 or better 31 (79.5 %) 20/25 or better 36 (92.3 %) 20/40 or better 39 (100.0 %) Worse than 20/40 0 (0 %) Total 39

16. Stability of refraction

17. Safety Pre- vs Post- BCVA gained 2 or more lines 14 (19.2 %) gained 1 line 39 (53.4 %) no change 18 (24.7 %) lost 1 line 2 (2.7 %) Lost > 1 line 0 (0%)

18. Lost 1 line • Age: 39 M • Pre-op MRSE: -10 D 20/20 • Post-op MRSE: +0.13 D 20/25 • Follow up: 1 month Patient complaint of difficulty with reading and elected to have ICL removed despite near VA J2 after 1 month.

19. Lost 1 line • Age: 39 F • Pre-op MRSE: -13.88 D 20/15 • Post-op MRSE: -0.50 D 20/20 • Follow up: 14.9 months Post-op BCVA varied between follow up visits from 20/15 to 20/20. No other complication was noted.

20. Complications Out of 73 eyes: • 1 (1.4 %) ICL size too small – observe • 1 (1.4 %) brow ache for 2 months • 1 (1.4 %) ICL removed after 1 month ( pt didn’t like it) 39 year old male, c/o near vision problem MRSE at 1 month: +0.13 D • 1 (1.4 %) overcorrect by +1.5 D (VD not at 12mm)

21. Complications • 1 eyes (1.4 %) complained of seeing extra light from P.I. • 17 eyes (23.3 %) developed transient IOP rise within 2 month post op; • range 23 to 30 mmHg; • all controlled by timolol; • all resolved by 1 month; • only 3 eyes in 2006, all other before 2005

22. Complications • 2 eyes (2.7 %) developed ASC

23. Early result: Toric ICL 25 eyes (since June 2004) • Age range: 23 to 44 • Mean age: 32.0 ± 6.8 yrs • M : F 4 : 14 • Mean follow up: 7.5 ± 4.4 months (range 1.4 to 18.8 months)

24. Early result: Toric ICL Mean ICL power: Sphere -18.44 ± 3.22 D Cylinder +3.68 ± 1.20 D

25. Early result: Toric ICL

26. Early result: Toric ICL Cumulative post-op BCVA and UCVA

27. Advantages ICL vs LASIK • No / Minimal night vision problems • Stability /Faster recovery. • Correct much higher ranges of myopia (-3.0 D to -20.0 D) • Also correct hyperopia (+3.0 D to +17.0 D) • Reversible • No ectasia

28. Advantages ICL vs LASIK • 2 patients had ICL in one eye (-19 D, -17 D) and LASIK in the other eye(-14 D, -13 D) • Higher myopia in the eyes with ICL • Both patients report better quality vision with ICL despite the higher myopia • Stability – no initial overcorrection.

29. Advantages ICL vs ACIOL • No endothelial cell loss, no AC reaction • Small self-sealing incision -No/less induced astigmatism • No need to pre-cut flap in bioptics • Can correct astigmatism at the same time -(LRI or Toric ICL)

30. The Verisyse anterior-chamber Lens Picture from www.gutsehen.de/gfx/iol_verisyse.jpg

31. Disadvantages • Clinically significant ASC 1.3%* • Sizing can be difficult, Orbscan not always reliable • Glaucoma? Pigment dispersion? • Expensive • 2 Procedures: Laser P.I. First (uncomfortable), then lens implantation *5 year follow up US FDA MICL Clinical Trial – in press

32. Conclusion • ICL and Toric ICL results very encouraging • Transient IOP rise 2° to Occucoat? • Accuracy as good / better than LASIK for high myopia • Much better immediate and long term stability than Lasik. • Technically not difficult (Avg surgery time 25 mins) • No / Minimal night vision problems • Short learning curve –easier than Phaco

33. What if one develops a cataract extraction leads to immediate presbyopia?

34. Multi-Focal IOL *Diagrams from AMO

35. Refractive IOL - Array *Diagrams from AMO

36. *Diagrams from AMO

37. *Diagrams from AMO

38. *Diagrams from AMO

39. *Diagrams from AMO

40. Adjustment by human eye to Multi-Focal IOL *Diagrams from AMO

41. Basic Theory • Diffractive MIOL - Tecnis MF near focus far focus *Diagrams from AMO

42. *Diagrams from AMO

43. near focus far focus TecnisMF Array ReZoom *Diagrams from AMO

44. Patients

45. Refraction

46. 3 IOLs Comparison Cumulative Postop UCVA

47. 3 IOLs Comparison Cumulative Postop BCVA

48. Safety Preop vs Postop BCVA: Gain / Loss

49. 3 IOLs Comparison Cumulative Postop Near UCVA

50. Questionnaire * the higher the score, the more the severity (from 0-5) # the higher the score, the higher the satisfaction (from 0-5) (%) percentage of eyes had score ≥3