Literature Review Highlights

January 2011

Toric ICL to Correct Ametropia in Keratoconic Eyes After CXL

By M.Shafik. Ophthalmology Times Europe. January/February 2011. Preliminary results

Safety and efficacy of Toric ICL implantation after CXL treatment in eyes with STABLE keratoconus are evaluated.
Inside this issue
TICL was implanted at least 9 months after CXL procedure and inclusion criteria included KC eyes with central clear
cornea at least 9 months after CXL and stable manifest refraction at least over the past 3 months.
TICL in KC eyes after 16 eyes of 10 patients were assessed over 1 year follow-up after TICL implantation
CXL: Preliminary Mean age was 25.6±4.1 years (21 to 33)
results 1 Mean preoperative SE was -7.61±4.10D (-2.25 to -15.75D)
Mean preoperative Cylinder was -4.34±1.62D (-2.0 to -7.5D)
Spontaneous TICL Mean postoperative Sphere decreased to plano
rotation 1 Mean postoperative Cylinder decreased to -0.05D
Mean postoperative UCVA improved to 0.88±0.18 and efficacy index was 1.4
100% of eyes gained one or more lines of UCVA
Bioptics after ICare: Mean vaulting was 509.75µ
Interface fluid
Excellent UCVA improvement in all eyes attributed to the merits of both modalities CXL improving corneal symmetry
complication 2 and TICL correcting residual sphere and cylinder as well was overcoming some aberrations induced by the corneal
irregularity
PB secondary to OVD Great discrepancy between manifest and objective refraction values. TICL calculation chosen based on manifest
remaning after AC- refraction which is the key parameter to successful correction of the refractive error.
pIOL 6H2 2 TICL as very promising tool to correct high refractive error in STABLE keratoconus after stabilizing the condition by
CXL.

Take-home message
• Combining TICL and CXL is an excellent refractive option in eyes with STABLE keratoconus. CXL mini-
mally invasive procedure to stabilize or slow the progression of keratoconus.
• Stability of manifest refraction as well as an accurate determination of the refractive error prior to TICL
calculation is key to ensure excellent visual performance.
• We advice taking manifest refraction as basis for TICL calculation.

Spontaneous Rotation of a Toric Implantable Collamer Lens

By Alejandro Navas et al. Case Rep Ophthalmol 2010;1:99-104 January 2011.

TICL spontaneous rotation 3 months after uneventful surgery in which successful repositioning lead to satisfac-
tory outcomes in the left eye of a 23-year-old-female. Her medical and ophthalmological histories were unre-
markable.

Preop Rx(D) -8.25 –5.25 x180°

ACD 3.42mm, WTW 11.7mm, CT 514µ, Ks 40.3@87°x45.5@177°
TICL impl -18.5 +6.0x93 TICM120V (Requiered rotation3°CW)
UCVA 1w post 20/30 (Rx –0.75 –0.75x178°)
Vault 1w post Around 700µ
UCVA 3m post 20/100 (Rx +2.5 –4.5x178°)
TICL rotation 35° CCW off-axis
UCVA after repositioning 20/25 stable during the rest of follow-up

Although the cause of this spontaneous rotation has been not stablished the author suggests as possible
causes trauma or bad foot-plates position. Since vault was optimal reposition was decided resolving the issue.
TICL rotation was 0.4% for this surgeon (250 TICL implanted and only one rotation case)
ICL repositioning is a safe, effective and easy procedure.

Take-home message
• 6 months after repositioning neither ASCO nor re-rotation was observed.
For further • General guidelines:
information, please
• If optimal vault repositioning
contact:
clinical@staarag.ch • If borderline or low vault consider exchange with longer lens vs repositioning.
 January 2011 Page 2

Interface Fluid Syndrome After Bioptics

By E.Bardet et al. J Refrac Surgery December 2010. Ahead of print

AC-pIOL (ICare) Explantation due to corneal decompensation associated to Interface Fluid Syndrome following
a deferred Bioptics (LASIK) in a 37-year–old man. Corneal flap using a mechanical microkeratome and ICare im-
plantation on his right eye were performed simultaneously.

Preop Rx(D) -9.50 -4.00 x10° (BCVA 20/200), CT 546µ and ECC 3449 c/mm2
1 day postop AC-pIOL dislocation and exchange with a larger diameter
2 months postop UCVA 20/200 and planned laser ablation aborted
30 months postop Severe VA loss and eye pain. Diffuse corneal edema and ECC decreased to 800c/mm2
3 years postop AC-pIOL explantation and fluid accumulation between flap and the stromal bed by UBM. Normal IOP.
4 years postop Penetrating keratoplasty

Corneal edema resulted in endothelial decompensation due to the AC-pIOL procedure.

The author surmised that aqueous humor diffused into the posterior corneal stroma and accumulated between the corneal flap and stroma.
Diffuse endothelial decompensation after LASIK in the absence of excimer laser ablation or flap lift may led secondary interface fluid syn-
drome.
Take-home message
• Endothelial Cell Loss is a serious AC-pIOL long-term complication that may lead corneal decompensation and subconse-
quently Penetrating Keratoplasty.

• “Interface fluid syndrome” due to severe endothelial decompensation may be secondary to Bioptics even in the absence of
excimer laser ablation or flap lift leading severe VA loss and finally Penetrating Keratoplasty.

Ultrasound Biomicroscopy in Pupillary Block Glaucoma Secondary to Ophthalmic

Viscosurgical Device Remnants in the Posterior Chamber After Anterior
Chamber Phakic Intraocular Lens Implantation
By Chuan-bin et al. J Cataract Refract Surg 2010 ;36:2204-2206

Acute pupillary block after 4 hours after AC-pIOL (6H2) implantation in a high myopic 25-year-old woman.
Surgical iridectomy was performed at 12 o’clock during an uneventful surgery.

4 hours postop Acute PB which was associated with IOP rise, shallow AC, eye pain and blurred vision.
UBM ruled out malignant glaucoma.
Management Unsuccessful both superior iridectomy enlarge and laser iridotomy at 6 o’clock and finally successful mid-
peripheral iridotomy at 9 o’clock. 2 hours later IOP normalized, ACD deepening and UCVA recovered to basline.

30 months follow-up Endothelial Cell Loss was 5.86%.

The author suggest that OVD material might have past to the PC through the pupil during the I/A procedure. Surgical iridec-
tomy did not work inducing pupillary block and accumulation of aqueous in the PC.
The author suggests to constrict the pupil before injecting OVD intraoperatively to avoid postoperative OVD retention in the
PC.

Take-home message
• Acute Pupillary Block due to OVD retention and/or non-functioning PIs can occur in the early postoperative.

• Phakic 6H2 is an PMMA angle-supported anterior chamber to treat myopia and hyperopia refractive errors.

• Complications related to Angle-supported anterior chamber pIOL are known such as nuclear cataract, severe endothe-
lial cell loss and pupil ovalization.

• Based on literature review main complication of Phakic 6 pIOL is severe endothelial cell loss due to its excessive
vault and relative large optic diameter (5.86% after 30 months in the current article).