EyeWorld Asia-Pacific September 2014 Issue

56 EWAP REFRACTIVE September 2014 Phakic IOLs: Not perfect, but viable options by Michelle Dalton EyeWorld Contributing Writer For some surgeons, these lenses offer hope to high myopes; for others, the potential complications outweigh the potential benefits T he correction of high myopia is limited, but phakic IOLs do provide a surgical option. “For many years we have been looking for a quality anterior chamber phakic IOL that could be easily performed in a clean room rather than an operating room,” said Eric D. Donnenfeld, MD , partner at Ophthalmic Consultants of Long Island, Rockville Centre, NY, U.S., and clinical professor of ophthalmology, New York University Medical School. With only two phakic lenses available in the U.S.—the Verisyse (Abbott Medical Optics, Santa Ana, Calif., U.S.) and the Visian (STAAR Surgical, Monrovia, Calif., U.S.)— options for U.S. physicians will remain limited. A third lens, the Cachet (Alcon, Fort Worth, Texas, U.S.), remains in clinical studies, as does a foldable version of the Verisyse (Veriflex, Abbott Medical Optics); the Visian ICL with CentraFlow (STAAR Surgical) is not available in the U.S. Neither the Verisyse nor the ICL is a perfect solution, said Kerry K. Assil, MD , medical director and chief executive officer, Assil Eye Institute, Beverly Hills and Santa Monica, Calif., U.S. “People have looked for a better mousetrap but haven’t been able to come up with one yet,” he said. Alternative attempts have focused on developing angle- fixated, anterior chamber IOLs, which have generally failed, as these lenses sit too close to the peripheral endothelium and also caused “unacceptable iris root inflammation. That chronic low grade trauma may eventually lead to the ovalization of the pupil,” among other issues, Dr. Assil said. Richard L. Lindstrom, MD , founder, Minnesota Eye Consultants, Minneapolis, Minn., U.S., said those kinds of complications are why he stopped implanting phakic lenses 2 years ago. “I was quite excited about the Alcon Cachet, but it is now showing select cases of late PAS, pupil ovaling, and unpredictable endothelial cell loss. I am also seeing late cases of cataract, pigment dispersion, secondary glaucoma, and unexpected endothelial cell loss with the Visian,” he said. His best long- term results have been with the Verisyse, “but I have seen erosion through the iris and subluxations here in select cases as well, and patients often are unaware of their problem.” As most surgeons can confirm, phakic IOL patients are also more likely to develop cataract/ dysfunctional lens syndrome in their 50s. Additionally, the majority “has significant astigmatism. And they’re young, so you shouldn’t perform relaxing incisions,” said Jeffrey D. Horn, MD , in private practice, Vision for Life, Nashville, Tenn., U.S. “Ideally, we’d like to go in with a lens that could correct the refraction and astigmatism in one fell swoop.” While the field has been stagnant for a while, the FDA recently approved the Visian toric, “which should be a significant addition to our armamentarium,” Dr. Donnenfeld said. Below, an update on current phakic IOLs. Cachet Dr. Horn, a principal investigator for the Cachet since its phase 2 studies, said that in his hands, complications have been few. He’s implanted the lens in 53 patients. “I did have to reposition the lens in a couple of patients, but that’s not unique,” he said. Some patients do experience a greater cell loss than anticipated, however. “It’s why I think the lens is on the An eye with a Verisyse phakic IOL and a nuclear cataract Source: Kevin Miller, MD The Visian ICL Source: STAAR Surgical continued on page 58