INTRAOCULAR CONTACT LENS HKMA Structured CME Program John Chang, MD Director of Guy Hugh Chan Refractive Surgery Centre Hong Kong Sanatorium and Hospital 9 August 2007

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 !

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.

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

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

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

Video - ICL Injection

ICL Positioning Use the paracentisis

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

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

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

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

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

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

Stability of refraction

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%)

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.

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.

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)

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

Complications 2 eyes (2.7 %) developed ASC Mean pre-op MSE -9.28 D MSE at last visit -3.00 D 20/20 -1.25 20/20 UCVA 20/150 20/25 ACD 3.2 3.18 WTW 11.5 11 Lens type ICM125V4 ICM115V4 Comment onset at 20 month onset 13 days, visually significant at 18 months

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)

Early result: Toric ICL Mean ICL power: Sphere -18.44 ± 3.22 D Cylinder +3.68 ± 1.20 D Pre-op Post-op Mean sphere -13.85 ± 3.20 D -0.20 ± 0.51 D Mean cylinder +2.95 ± 1.07 D +0.64 ± 0.47 D Mean MSE -12.36 ± 3.06 D +0.03 ± 0.34 D

Early result: Toric ICL

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

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

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.

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)

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

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

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

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

Multi-Focal IOL *Diagrams from AMO

Refractive IOL - Array *Diagrams from AMO

*Diagrams from AMO

*Diagrams from AMO

*Diagrams from AMO

*Diagrams from AMO

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

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

*Diagrams from AMO

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

Patients No. of patients No. of eyes Mean age Range Array 59 95 54 + 11.9 35 to 85 ReSTOR 27 43 65 + 9.7 50 to 84 TecnisMF 130 179 59 + 13.3 7 to 87

Refraction Array ReSTOR TecnisMF Preop mean MRSE (D) -10.00 -0.60 -6.18 STD ±7.9 ±3.07 ±5.29 Range +7.75 to -31.25 +4.00 to -6.75 +5.63 to -18.00 Postop mean MRSE (D) -0.22 -0.26 0.04 ±1.01 ±0.68 ±0.57 +2.38 to -6.63 +1.00 to -2.00 +2.00 to -2.25

3 IOLs Comparison Cumulative Postop UCVA

3 IOLs Comparison Cumulative Postop BCVA

Safety Preop vs Postop BCVA: Gain / Loss

3 IOLs Comparison Cumulative Postop Near UCVA

Questionnaire Night glare* Halo* Satisfaction# Array 1.51 (32%) 1.68 (36%) 3.72 (92%) ReSTOR 1.03 (21%) 1.47 (30%) 3.77 (87%) TecnisMF 1.88 (44%) 1.99 (44%) 3.70 (93%) * 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

TecnisMF Questionnaire % of time spectacles are required 0% <50% >50% Reading 100% 0 0 (including newspaper, books, documents) Near tasks 100% 0 0 (including SMS, watch, etc) Distance 100% 0 0 1 patient requires spectacles for computer

Mix and Match- Early result Spectacles dependence Ave. Time Spent Yes No Distance ---- 0% 100% Reading 2.8 hr Computer 5.2 hr All patients are 100% of time SPECTACLES FREE

Thank You