REFRACTIVE 28 EWAP MARCH 2023 candidacy. Between 7–9 D of myopia is where the ICL might be favored over LASIK. Once a patient is significantly higher than that, the ICL holds a strong advantage, Dr. Walton said. Neda Shamie, MD, said that the classic ICL candidate is someone with high myopic correction who wouldn’t otherwise be a candidate for LASIK/PRK. “In our practice, even if a patient has good corneal thickness, if their correction is more than –8.5, we don’t think that the quality of vision that they can gain from corneal-based refractive surgery is good enough; when you change the contour of the cornea to correct –8.5 and more, the contrast and color perception are affected, quality of vision is affected, and glare and halos at night potentially become visually significant,” she said. Dr. Shamie has implanted the EVO ICL for lower corrections if the patient has dry eye that does not respond to conservative measures. She has also had a number of patients who are excellent candidates for LASIK, but they don’t like that LASIK involves tissue removal and don’t like that it’s not reversible, so they come in specifically asking for the EVO ICL. What’s different now? Blake Williamson, MD, has been thrilled with the launch of the EVO ICL and said his practice was involved in the early stages of the ICL when it came out almost 20 years ago. But it was always challenging because you have to do PIs, he said. PIs are no longer needed with the EVO ICL. Dr. Williamson said his practice switched to doing ICLs on the same day bilaterally. These patients, at the 4-hour pressure check, are routinely better than 20/20, he said. With LASIK, there might be flap edema and vision might not be totally crisp right away, Dr. Williamson said. With the ICL, there is no pain the first day, and quality of vision is spectacular, he said. “You’re not altering the shape of the cornea, it’s just enhancing the vision patients already have.” Because of that, Dr. Williamson will offer the EVO ICL in situations he otherwise reserved for LASIK. “It used to be my cutoff was –8.75 to –9 to say we can’t get it all with LASIK,” he said. “I’ve come down to –7, so if a patient is –7.5 and a good candidate for the EVO ICL and has the correct anterior chamber depth, I’m talking to them about the EVO ICL because that’s what I would want in my eye.” He recently did a –3 patient as well; the patient had corneas too thin even for PRK. As far as the EVO ICL eliminating the need for PIs, Dr. Schoenberg said there is a small hole in the center of the lens, which prevents the possibility of pupillary block. “That sounds like a small thing, but it’s a big deal,” Dr. Schoenberg said. It simplifies the procedure, eliminates one possible source of risk perioperatively, and eliminates long-term risk of the PI occluding, leading to pupillary block. Additionally, data out of Europe demonstrated that the addition of this flow port in the middle of the ICL reduced the rate of some isolated complications. Cataract formation dropped to almost zero. It’s also safer to do a lower vault, which reduces the risk of an angle closure, Dr. Schoenberg said. However, this does present a potential complication, as the small hole in the center of the lens could be a source of glare. “I treat it as a definitive source of glare for patients,” Dr. Schoenberg said. “I tell patients ‘You’re going to see a circular glow on day 1 and probably for a couple of weeks.’” In most patients, it fades and they stop noticing it, Dr. Schoenberg explained. There is the possibility that patient may not adapt to the glare and would have the visual disturbance long term, but if you were to remove the lens, the glare goes away. Roger Zaldivar, MD, said that this is a huge step forward for the ICL safety profile because it avoids the most common complications of anterior subcapsular cataract formation, pigment dispersion, and pupillary block. “Perhaps the most important fact to emphasize in the EVO ICL design is the zero cataract formation experienced during the last 10 years,” Dr. Zaldivar said. Patients’ surgical experience has improved remarkably, too, he said. He also noted that the hole in the lens might cause some Dr. Williamson implants the first EVO ICL in the state of Louisiana. Source: Blake Williamson, MD
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