REFRACTIVE EWAP MARCH 2024 19 a month.” For this reason, Dr. Lin said it’s important to explain to patients that these will likely be an issue. The overwhelming response is that patients are still very happy with their ICLs despite the glare and halos, she said. While Dr. Lin doesn’t have any specific contraindications for using the EVO ICL, she noted that she does see occasional cases of oversized ICLs, despite all the different ways she is measuring white to white (including UBM). This issue was something that she also noticed in the previous ICLs as well. “I’ve had some cases of the ICL being over vaulted,” she said. “I’ve been trying to use slightly smaller ICLs than the ones recommended by the nomogram.” Dr. Lin noted that she does not do bilateral, sameday ICLs because if there is an over vaulted ICL, she will use a smaller size for the second eye. Kimiya Shimizu, MD Sanno Hospital 8-10-1b Akasuka, Minato-ku, Tokyo, Japan kimiyas@iuhw.ac.jp First, I would like to note that more holes do not necessarily mean better. Some other posterior Chamber PIOLs have more holes than EVO ICL (KS-AquaPORT), but I don’t believe the circulation of aqueous humor will be improved in proportion to the number of holes. Under normal conditions, aqueous humor circulates from the posterior and to the anterior chamber through the pupil area, so I consider the location of the hole should be in the center and conducted the basic experiments that led to the development of EVO ICL (KS-AquaPORT). In this experiment, I implanted ICL lenses with different numbers, sizes, and positions of holes in porcine eyes and verified if lens opacities occurred. The results showed that when there were many holes around the optic, aqueous humor did not flow adequately in some areas and subcapsular opacities were observed. In contrast, when a single hole was made in the center of the optic, subcapsular opacities were well stained similarly to the controls. We believe that what is important is not the number of channels of aqueous humor but the convergence of aqueous humor toward the center. Second, although not specifically discussed in the paper, it is important to remember that the EVO ICL (KS-AquaPORT) is made of collamer, an excellent material that has been used for over 30 years. The introduction of a lens with a central hole has brought great benefits to patients and surgeons, but it is important to reiterate that this success is built on the long-term safety of collamer. Unlike cataract surgery, ICL is a procedure that is performed on relatively young patients, so the longterm safety of the material is very important to have been proven since it is placed in the eye for a long time. Since various PIOLs have appeared and disappeared in the past, a PIOL made of a material that has been in use for 30 years is valuable. Finally, I would like to mention the adaptation of the power range. Dr. Lin said in this article that EVO ICL (KS-AquaPORT) is a great option for high and moderate myopia. Although I stopped laser corneal refractive surgery, including SMILE, in 2015 has also has an impact, I have been actively performing ICL on patients with moderate to mild myopia. Indeed, the average preoperative refraction of patients in my clinic using EVO ICL (KS-AquaPORT) is less than –8.0 D, and I believe it will continue to be lower. Editors’ note: Dr. Shimizu is a consultant for STAAR AG, Kowa, and Hoya. ASIA-PACIFIC PERSPECTIVES Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. LESSONS LEARNED Arjan Hura, MD, MaloneyShamie Vision Institute, Los Angeles, California: • Multiple biometers and imaging modalities can help with ICL sizing, and utilizing different sizing nomograms can be beneficial in making a decision for cases that fall between two different sizes. • Just as with IOLs, it is important to be able to explant an ICL if implanting one. • Don’t rush at the end of a case, and take time to thoroughly remove as much OVD as possible. • Analyze your refractive outcomes and vaults to refine your sizing and power selection. Anterior segment OCT of OD measuring ICL vault on day 1 postop. Source: Alexandra Wiechmann, OD
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