EyeWorld Asia-Pacific September 2014 Issue

58 EWAP rEfrActivE September 2014 back burner,” he said, although there is an active 10-year study. In the one patient with a “cell count that was lower and dropping faster than we would like,” Dr. Horn said he explanted the Cachet. “The lens was vaulting closer to the corneal endothelium than almost all of the other patients that I had.” Yet these patients remain some of his happiest, he said. The Cachet “has been shown to be better than previous generation anterior chamber phakic IOLs; it is demonstrating the same complications of previous generation lenses but with a reduced incidence,” Dr. Donnenfeld said. During the implantation phase of the studies, Dr. Horn noted that the lens did have some rotation that did not alter visual outcomes, but would make it an unlikely platform for a toric version, should the lens be submitted for U.S. regulatory approval. verisyse/Artisan In addition to serving high myopes, in the “right type of keratoconic patient,” the Verisyse lens “does extremely well over time,” Dr. Assil said. “These lenses have helped to avoid the alternative option of corneal transplantation on multiple occasions. Outside the U.S., this is the most popular lens in the world as a secondary IOL [in remedying aphakia].” There are two versions of the Verisyse, one of which is foldable, Dr. Assil said. The foldable version is not available in the U.S. “What I like about this lens is that it doesn’t cause cataracts because it sits in the anterior chamber and also relatively far from the endothelium,” he said. “In a very tiny subset, it can create endothelial cell loss over time, necessitating explantation (in less than 1% of implanted patients).” That subset includes those with shallow chambers or vigorous eye rubbers—people who should be excluded from receiving the lens in the first place, which comprises a small percentage of the potential patient population, he said. Because a foldable version is not available in the U.S., this lens “requires slightly greater surgeon skill to reliably implant,” Dr. Assil said. “However, having implanted the Verisyse for 18 years, I have encountered surprisingly few issues with either the initial astigmatism management or long-term drift. This has also been the experience of the industry with more than 40 years of use.” “The non-foldable version requires a 6 mm entry wound. Manipulation of that entry wound is more demanding than the remainder of the lens implantation.” Dr. Horn said the large incision size also makes it more difficult to control astigmatism. “It just strikes me as the wrong way to do a refractive surgical procedure when the goal should be to minimize the incision size and lessen the chance of induced astigmatism,” he said, adding potential complications such as high pressures and permanently fixed, dilated pupils have dissuaded him from using the lens. “No lens is perfect, but the idea you’re going to have to clip this lens onto the iris with a human lens behind it when you know you can put an ICL right behind the eye makes little sense to me,” he said. Dr. Donnenfeld said he used the Verisyse “for many years,” but in his hands required peribulbar anesthesia, a larger wound, and the need for sutures. However, late complications (dislocation and cataract formation) are rare, “and this lens has a 20-year track record.” visian icL This lens is “very easy” to insert, Dr. Horn said, but did acknowledge cataract formation is higher in patients with the ICL. The newer iterations have “reduced the propensity for cataract formation” as different sizes fit into the sulcus better, Dr. Assil said. “By introducing the pinhole opening in the center of the lens, some believe that it may also improve aqueous dynamics and diminish cataract formation over time, although that’s not so clear at this time.” The Visian ICL with CentraFlow lens is not available in the U.S. The ongoing challenge with this lens platform, Dr. Assil said, is that it sits behind the iris and “comes into intimate contact with the anterior lens capsule, and in some patients, by being adjacent to the iris pigment epithelium, it can cause mild pigment dispersion, prolonged inflammation, and pigmentary glaucoma.” Yet, if the CentraFlow was available, Dr. Assil “would love to use it on a subset of patients.” Dr. Horn has explanted about 10 ICLs because of cataract formation, although he did not implant the lenses; “cataract formation is higher than we initially thought and it’s higher than in the FDA studies,” he said. Given the choice, however, Dr. Horn would still prefer to implant the Cachet. in an ideal world Dr. Donnenfeld puts the Visian with CentraFlow on his wish list, as “it has no visual side effects and eliminates the need for two iridotomies that we now perform with all of our ICL cases. In addition I would like to see the Verisyse lens in the United States in a hyperopic version available as a secondary IOL for aphakia. This lens would offer significant advantages over current generation anterior chamber IOLs in many cases.” For the time being, Dr. Assil will continue to use both available lenses (while preferring the Verisyse), but holds out hope that the U.S. will approve other phakic lenses. Ideally, he would like to use the Veriflex, with the Visian with CentraFlow as his second choice. “While none of these lenses can be implanted without periodic surveillance, it is important to remember that these lenses are far safer than either LASIK or refractive lens exchange (RLE) in this patient population. To steer the field away altogether would irresponsibly promote overutilization of these alternative approaches along with their associated complications of corneal ectasia (LASIK) and retinal detachment (RLE),” Dr. Assil said. “As long as the Cachet is unapproved, I prefer the Visian to the Verisyse,” Dr. Horn said. “Ideally, I’d like to see the Cachet commercially available. It would definitely be my lens of choice.” EWAP Editors’ note: Dr. Assil has financial interests with Abbott Medical Optics. Dr. Horn is a principal investigator for the Cachet lens. Drs. Donnenfeld and Lindstrom have financial interests with Abbott Medical Optics and Alcon. contact information Assil: info@assileye.com Donnenfeld: ericdonnenfeld@gmail.com Horn: Jeff.Horn@bestvisionforlife.com Lindstrom: rllindstrom@mneye.com Phakic - from page 56