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    Integrating phakic IOLs in a private practice

    Clinical experience with the Visian ICL and TICL

    Erik L. Mertens, MD, FEBO
    The implantation of IOLs in the eye has been part of cataract surgery practice for many years; however, it is only in more recent years that these implants have become available for refractive correction. To date, the resulting vision outcomes have been impressive. In fact, most refractive surgeons believe phakic IOLs will become the procedure of choice for certain forms of refractive correction. Because patients are wary of the perceived invasive nature of this procedure, however, phakic IOLs still have a long way to go in the race to gain patient popularity and trust.

    The pioneers of intraocular implants, Barraquer, Strampelli, Dannheim and Choyce, conducted the first ever trials using anterior chamber refractive lenses to correct high myopia in the 1950s. Unfortunately, because of imperfections in IOL design, complications ensued and the development of phakic implants was abandoned. It was not until the 1980s that development of these lenses was resurrected.

    Since then phakic IOLs have come a very long way and the concept of a phakic IOL is gaining popularity in the field of refractive surgery. The accuracy of refractive implants in restoring vision is now an acknowledged fact amongst surgeons and is regarded highly because the insertion procedure offers a method of correction that is removable, predictable, rapidly healing and does not permanently alter the shape or structures of the eye.

    Poor patient perception

    Status Update
    Erik Mertens, MD, FEBO, Medical Director of Antwerp Eye Centre, Antwerp, Belgium, agrees that the difficulties now lie in convincing the patient. He performed some research of his own by providing some of his patients with a phakic IOL information brochure and then following up with questions. The general consensus amongst his patients was that they are more attracted to laser surgery because they feel that IOL implantation would be far too invasive.

    Mertens is an advocate of the phakic lenses and believes that more needs to be done to change perception, "IOL implantation for refractive correction is a very elegant, five-minute procedure. A refractive practice should offer not only laser surgery, customized laser treatments, conductive keratoplasty, refractive lens exchange, but also phakic IOLs."

    Visian Toric ICL
    Mertens currently uses the Visian ICL and TICL (STAAR Surgical) in his refractive surgery practice and, during the two-year period from November 2003 to 2005, he had implanted a total of 307 ICLs (190 ICL; 117 TICL).

    Figure 1: ICL injection into anterior chamber.
    Made of STAAR's proprietary collagen copolymer, Collamer, which provides good biocompatibility and optical capability, the lens rests behind the iris in the ciliary sulcus. "The ICL and TICL offer the advantage of clear corneal small incisions of less than 3 mm, which require no stitches. Furthermore, re-treatment rate is 1% and recovery time is quick, with the majority of patients able to drive one day after surgery," enthuses Mertens.

    The technique

    • Topical antibiotics are administered before surgery. Eyelids and the eye are prepped with isobetadine solution.
    • A small 2.7 mm clear corneal incision is made temporally and one paracenthesis superior for the left eye and inferior for the right eye.
    • Methylcellulose (Occucoat; Bausch & Lomb) is injected into the anterior chamber.
    • ICL is loaded into a cartridge with the Aus der Au modified forceps (Janach, Italy).
    • ICL or TICL is introduced through a cartridge into the anterior chamber (Figure 1).
    • Once ICL is unfolded, toothed forceps (Duckworth & Kent) are used to place the haptics behind the iris.
    • When a TICL is used, the markings on the TICL are aligned with the corneal markings.
    • The methylcellulose is washed out with BSS mixed with vancomycin (3G/500 cc); a prophylactic measure for endophthalmitis.
    • After surgery acetazolamide 250 mg (Diamox) is administered orally. This is repeated six hours after surgery and the morning after surgery.
    • The patient's IOP is monitored for two hours postsurgery.

    The results so far

    Of Mertens' ICL/TICL patients, 76% of eyes have achieved 20/20 uncorrected visual acuity (UCVA) within 24 hours of surgery. In his experience, two eyes have required laser treatment subsequent to the procedure and one TICL required realignment as a result of incorrect placement at the time of surgery.

    Mertens has yet to observe lens opacities, possibly because of the use of methylcellulose behaving as a viscoelastic agent.

    "Good candidates for phakic IOL implantation are patients with thin corneas, dry eyes, forme fruste keratoconus and all myopes >-8 diopters. The refractive surgeon should consider the use of these implants more seriously for the correction of refractive error. So far, the benefits of this procedure speak for themselves and it is up to us to educate our patients and address their concerns," concludes Mertens.

    Erik L. Mertens, MD, FEBO is Director and Ophthalmic Surgeon at the Antwerp Eye Centre in Belgium. He is a consultant to STAAR Surgical. He can be reached by e-mail:

    Dr Erik L. Mertens

    Erik L. Mertens, MD, FEBO is Director and Ophthalmic Surgeon at the Antwerp Eye Centre in Belgium. He may be reached by E-mail: ...

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