EyeWorld Asia-Pacific June 2014 Issue

48 EWAP rEfrActivE June 2014 Long-term strategy for phakic IOLs by rich Daly EyeWorld Contributing Writer Surgeons develop plans to respond to the long- term complications of phakic iOLs that emerging research and clinical experience have identified C onsistent follow-up and patient education are more important than ever as early phakic IOL recipients enter the age range for common eye-related conditions, according to surgeons. Premature development of a cataract or damage to the corneal endothelium remain the leading long-term phakic IOL concerns for Uday Devgan, MD , in private practice, Los Angeles, Calif., U.S., and associate clinical professor of ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, Calif., U.S. Cataract development is particularly important in posterior chamber phakic IOLs (PC PIOLs) and when the PC PIOL is in close proximity (less than 0.5 mm) to the human crystalline lens, he said. “If it touches then there is a high degree of cataract development,” Dr. Devgan said. “We want to avoid inducing a cataract in a young, highly myopic patient—like the patients who receive PIOLs—due to the higher risk of retinal detachment and loss of accommodation with phacoemulsification.” Damage to the corneal endothelium is more common in anterior chamber phakic IOLs (AC PIOLs) since the AC PIOL is in closer proximity. Plan for tracking Jeffery D. Horn, MD , in private practice, Nashville, Tenn., U.S., routinely compares AC PIOL recipients’ corneal endothelial cell counts to preoperative measurements and checks patients for signs of cell morphology using spectral microscopy. The follow- up is limited to annual exams if the patient has good corneal endothelial cell counts (ECCs), no obviously concerning signs, and no unusual trend in cell loss. When annual ECCs reveal a significant and persistent drop in cell density, Dr. Devgan said, then removal of the PIOL may be indicated. Dr. Horn also checks the actual position of the lens. Although iris claw lenses tend not to change, angle-supported phakic IOLs could have differences due to the patients’ vault, which could leave a lens closer to the corneal endothelium and potentially lead to loss of endothelial cells. “In patients with greater percentages of cell loss from one visit to the next or who have lenses that under slit lamp examination or by OCT you can see the lens getting closer to the cornea, you may want to follow them more closely—every six months,” Dr. Horn said. Cases of shallow ICL vaults are the one instance in which Robert P. Rivera, MD , in private practice, Draper, Utah, follows patients more closely than routine annual refractive testing. “The typical ICL related cataract is anterior subcapsular in nature and is found in association with patients with shallow or flat vaults,” Dr. Rivera said. Although PIOL patients with cataracts are found to have flat vaults, the majority of his PIOL patients with flat vaults have yet to develop them, he said. Other conditions Dr. Horn has seen arise in PC PIOL patients include intraocular pressure spikes, LPIs that close, and poorly sized lenses that may require replacement. “They are commonly removed if there are issues with elevated pressure and pupil lock,” Dr. Horn said. Patients predisposed to glaucoma generally should not receive these lenses but if such patients do have a PIOL, they require annual gonioscopy Clinical images of cataract that has developed in a phakic IOL recipient. Cataract development is a particular concern in posterior chamber phakic IOL patients due to the close proximity of the implant to the human crystalline lens. If it touches then there is a high likelihood of cataract development. Source: Uday Devgan, MD