1. Phacoemulsification in eyes with previous anterior chamber phakic IOL surgery Walton Nosé, MD, PhD 1,2 Adriana dos Santos Forseto, MD 1 Mariana Ávila, MD 1,2 São Paulo, Brazil 1. Eye Clinic Day Hospital 2. Federal University of São Paulo - UNIFESP The authors have no financial interests in any of products mentioned in this presentation

2. Introduction Phakic anterior chamber intraocular lenses (AC IOLs) have been considered for the correction of refractive errors, especially for treating high myopia and hyperopia. Several reports have confirmed the efficacy and predictability of the phakic AC IOL in correcting high ametropia. However, concerns remain regarding long-term safety. Despite various reports on outcomes and complications related to these lenses, the reasons leading to their explantation and the outcome afterwards have been infrequently reported. Guell JL, Morral M, Gris O, Gaytan J, Sisquella M, Manero F. Five-year follow-up of 399 phakic Artisan-Verisyse implantation for myopia, hyperopia, and/or astigmatism. Ophthalmology 2008; 115:1002–1012. Colin J. Bilensectomy: the implications of removing phakic intraocular lenses at the time of cataract extraction. J Cataract Refract Surg 2000;26:2–3. 16. Alio JL, de la Hoz F, Ruiz-Moreno JM, Salem TF. Cataract surgery in highly myopic eyes corrected by phakic anterior chamber angle-supported lenses. J Cataract Refract Surg 2000;26:1303–11.

3. Purpose To report the indications, technique, results and complications of phacoemulsification (phaco) in highly myopic eyes with anterior chamber phakic intraocular lenses

4. Nine highly myopic eyes of 7 patients with previous implantation of a phakic AC IOL (11 to 19 years earlier): – Angle supported IOL (Nuvita): 8 eyes – Iris –Fixated IOL (Artisan): 1 eye Indications for phakic IOL explantation and phaco were: –Progressive endothelial cell loss (n=1) –Cataract (n=8) Surgical technique: –Topical anesthesia –A 5.5mm limbal incision was performed to allow the removal of the AC IOL –The wound was partially sutured in order to proceed with phaco through a 2.2mm incision –After irrigation and aspiration, a foldable IOL was inserted in the bag Methods

5. The central distance of the AC IOL to the cornea endothelium and the crystalline lens were analyzed with a Scheimpflug camera (EAS 1000, NIDEK) or optical coherence tomography (Visante OCT™, Carl Zeiss, Meditec, Inc.) prior to AC IOL explantation Complications, uncorrected visual acuity (UCVA), refraction, changes in best corrected visual acuity (BCVA) and endothelial cell density (ECD) were analyzed

6. Results The central distance of the AC IOL to the cornea endothelium ranged from 1.72 to 2.12mm and to the crystalline lens from 0.31 to 1.09mm The patient ages ranged from 45 to 67 years (mean 50.3  9.15 years) at the time of AC IOL explantation and phaco

7. Results LogMar Best Corrected Visual Acuity Pre and post AC IOL explantation and phaco BCVA improved in all eyes AC IOL explantation and phaco in Eye 2 was performed due endothelial cell loss

8. Results Mean follow-up was 1 year (range, 3 to 12 months) No intraoperative or postoperative complications were observed Uncorrected visual acuity (logMar) after AC IOL explantation and phaco ranged from 0.00 to 0.88 Postop spherical equivalent ranged from zero to – 2.00D* (mean -0.73D ± 0.97D) *myopia (-2.00) was programmed in 1 eye for near vision

9. Results No loss of BCVA was observed

10. Results BEFOREAFTER Average ECD2181,78 ± 637,471880,14 ± 623,25 p=0.057 T-test Endothelial cell density (ECD) before and after AC IOL explantation and phaco No significant endothelial cell loss was noted

11. Conclusions Phacoemulsification in eyes with AC phakic IOL was found to be safe and similar to that in no previously operated eyes except for the incision length and the possibility of astigmatic induction Nuclear cataract was the most frequent reason for AC IOL explantation