1. SELECTION of PATIENTS PIOLs António Marinho, MD PhD Departamento de Cirurgia Refractiva Hospital Arrábida PORTO PORTUGAL

2. WHY PHAKIC IOLs? Phakic IOL’s are ideal for high ametropias because: F High predictability even in very high ametropias F Stability of refraction F Preserve accomodation F No loss (usually gains) of lines of BSCVA

3. WHEN PHAKIC IOLs? n Mínimal Age –18 years F exceptions –anisometropia –Stable refraction in the last 18 months n Above 50 years –low ametropia F LASIK –high ametropia F CLE n Myopia n - Subjective Refraction –under - 7D : LASIK –above -7D: Phakic IOL –Main Factor : Pachymetry n Hyperopia n - Cycloplegic Refraction –under + 3D : LASIK –above + 4D: Phakic IOL –Main factor: Keratometry

4. INCLUSION CRITERIA General n Stable refraction n No intraocular diseases (diabetes without retinopathy and well controlled glaucoma are relative contraindications,but any history of UVEITIS is absolute contraindication) n Ectatic disorders of the cornea are NOT contraindications

5. INCLUSION CRITERIA Specific n Anterior chamber anatomy (AC depth and AC size) n Endothelium profile n Iris shape Pupil Size n Perfect Surgery

6. Anterior chamber depth n AC depth (central) n > 2.80mm (endothelium to natural lens) n Higher IOL power may need deeper AC (see Ophtec tables) n Importance of critical distance

7. How to measure the AC depth ? n US biometer (not precise) n Orbscan n Scheimpflug (Pentacam) n OCT (Visante,SL-OCT)

8. How to evaluate the AC ? n US Biometer (not precise) n Orbscan n OCT (Visante,SL-OCT)

9. AC DEPTH (OCT)

10. Implantation simulation

11. Anterior chamber size n Angle to angle distance (AC phakic IOLs) n Sulcus to sulcus distance (ICL) n Not important for iris-fixated IOLs (“one size fits all)

12. How to measure AC Size ? n White to white (caliper,Orbscan,IOL master)---- not reliable n OCT (good to angle, but not to sulcus to sulcus)

13. AC SIZE (OCT)

14. Iris shape n Avoid convex iris n Most important in Hyperopia (clearance) n Possibility of posterior synechia

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

16. Posterior Synechia

17. Pupil Size n Mesopic pupil <6.0mm n Artisan 5mm Mesopic Pupil <7.0mm n Artisan 6mm Artiflex/Acrysof/ICL n Glare and halos

18. Endothelium Profile n Endothelial cell count: n 21 to 25 years 2800 cells/mm n 26 to 30 years 2650 cells/mm n 31 to 35 years 2400 cells/mm n 36 to 45 years 2200 cells/mm n > 45 years 2000 cells/mm n Endothelial cell shape (avoid high polymagatism)

19. Endothelium Profile

20. Endothelial Cell Count n Before Surgery (inclusion criteria) n 3 months after (shows surgical trauma) n Yearly afterwards (if important decrease EXPLANT)

21. Perfect Surgery n Atraumatic Surgery n Use cohesive viscoelastic n Center the IOL with the pupil (recheck at the end) – Artisan/Artiflex n Take all the visco out n Attention to post-op medication

22. WHICH PIOL? n Angle- supported ? n Posterior chamber ? n Iris- supported ?

23. PIOLs Which ? Acrysof,Artisan,Artiflex,ICL PRL