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PHAKIC IOL’S ( pIOL’S ) IN CORRECTING HIGH MYOPIA

PHAKIC IOL’S ( pIOL’S ) IN CORRECTING HIGH MYOPIA. By: H.R. ZIAI MD. Esfand 1391 Isfahan. HISTORY. 1950s : First ideas formed 1988 : Angle supported PMMA, ZB5M & MA20, by Bikoff But :

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PHAKIC IOL’S ( pIOL’S ) IN CORRECTING HIGH MYOPIA

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  1. PHAKIC IOL’S( pIOL’S )INCORRECTING HIGH MYOPIA By: H.R. ZIAI MD. Esfand 1391 Isfahan

  2. HISTORY • 1950s : First ideas formed • 1988 : Angle supported PMMA, ZB5M & MA20, by Bikoff • But : • Discontinued because of complications ( corneal edema, iritis ,… )

  3. HISTORY • 1988 : First phakic iris – clawed IOL • introduced for myopia by Worst • 1998 : Artisan – Worst by OPHTEC • Then changed it’s name to Artisan – Verysise • and it’s flexible form to Artiflex

  4. HISTORY • 1987: First PC pIOL or sulcus support pIOLs introduced : • - Phakic Refractive Lens ( PRL ) by CIBA VISON . • And then : • - Implantable Contact Lens ( ICL ) • or Implantable Collamer Lens ( ICL ) • - Collamer is a copolymer of • hema ( 99% ) and porcine collagen ( 1% )

  5. CLASSIFICATION OF pIOLS • Ant.ChamberpIOLS ( AC pIOLS) • - Angle supported 1) PMMA • 2) Foldable - Iris – Clawed 1)PMMA • 1)Foldable • Post.ChamberpIOLS ( PC pIOLS ) • (or sulcus supported ) • \\\

  6. High Myopia - Myopia > -8.00 to -10.00 D - Stromal bed < 300µ after laser ablation - Keratometry < 34-36D after laser ablation INDICATIONS

  7. FDA Approval for Artisan/Artiflex - Myopia : -5.00 to -20.00 D - Ast. < 2.5 D - Age > 21 y - ACD > 3.2 mm

  8. FDA Approval for ICL : - Myopia : -3.00 to -20.00 D - Ast.< 2.50 D - Age 21 - 45 y - ACD > 3.00 mm

  9. High Hyperopia - Keratometry > 50 D after laser ablation - Available pIOLS : ICL : Up to +20.0 D Artisan : Up to +12.00

  10. - Laser ablation is the Tx of choice for Ast. up to 4.00 – 5.00 . - PIOLS are available too . • High Ast.

  11. - Any intraocular pathology ( Cat. , Glaucoma , NVI , Uveitis , … ) - ↓ ACD - ↓ Diameter CONTRAINDICATIONS

  12. - Rang of correction >> Laser - Easy technique ( Like Cat. Surgery ) - Less expensive instruments than Laser - Removable - No ↓ in contrast sensitivity even : ↑ Compared with spectacle -More predictable ADVANTAGS OF pIOLS

  13. - All intraocular risks - Large incision ( in PMMA types ) - Limitation in hyperopia due to small ant. segment - Irreversible complication DISADVANTAGES OF pIOLS

  14. - Power of IOL - Diameter of IOL for angle or sulcus supported IOLs - ACD - Specular microscopy - Optic size in correlation to scotoptic pupil size - All other rutin evaluation before cat. surgery PRE-OP EVALUATION

  15. But : Main challenge in angle or sulcus supported pIOLs is : “ Sizing IOL diameter” Through Angle-to-angle And ciliary sulcus diameter Cont.

  16. For angle supported pIOLS - 0.5 – 1.00 mm add to w-to-w measured manually or by orbscan, although not always correct . - Use of OCT/UBM Cont.

  17. Note: If diameter measured horizontally the lens must implanted horizontally; if implanted vertically, it causes Decenteration , Ovalization , Iritis , Glaucoma. Cont.

  18. For PC pIOLS ( sulcus supported ) - Add 0.50 – 1.00 mm to horizontal W-W - New ultrasound techniques like Artemis & UBM Cont.

  19. Surgical Technique (important points) -Incision , 2- 6.5mm (based on type ) - Sup. approach ( more common ) - Retrobulbar avoided ( glob perforation ) - IOL dialled to the best pupil-optic matching ANGLE SUPPORTED pIOLS

  20. - Surgical PI - OVD irrigated meticulously - Pilo 2 ( useful , but may decentered pupil Cont.

  21. - Haloes and Glare : more com complication ( 20 % ) more in 1th year, but : ↓ over time - Pupil ovalisation( 7-22% ) ( if oversized ) - Iris retraction and atrophy Complications

  22. Endothelial cell damage: -Surgical trauma - Presence of IOL - 5-7% in 1th year and less in next years Too small size : ↑ damage Cont.

  23. - ↑ IOP - Transient , 2’ to OVD - Topical CS - Pupilary block - Uveitis : 4.5% - Usually transient , 2’ to iris manipulation - In over sized IOL , may chronic, causing glaucoma cat. , PAS, Iris damage , … Cont.

  24. - Cataract - Less common than PC pIOL - Caused by trauma , uveitis - Age > 40 y at time of surgery - AL > 30 mm - RD : 3% If pIOL have additive risk for RD over the myopia?? Cont.

  25. Rare complications - Corneal decompensation - Urretis – Zavalia synd. - Malignant glaucoma - Endophthalmitis - Hyphema Cont.

  26. General information of Artisan - 0.5 mm vault ( 0.8 mm distance between IOL & crystalin lens) - Diameter : 8.5 mm - Optic : 6.5 & 6.0 mm - Center :0.2 mm thickness IRIS FIXATED pIOLs

  27. - Myopia - Hyperopia - RE After PK - Sever anisometropia in children - Aphakia - KCN - Progressive high myopia in psudophakic children Indications ( FDA ) :

  28. - Glare & haloes: 0-9% more in small optics ( 5mm ) and Large pupil ( > 5.5 mm ) - AC inflammation: 0.5% - Pigment dispersion : 2” to poor enclavation -Crystalin lens rise: like Hyeperopia ( Artiflex > Artisan ) because of step in optic-haptic junction Complications

  29. Endothelial cell loss - Intraoperative trauma ( main cause ) - more in first 6m post op. - ACD < 3.2 → ↑ risk Glaucoma - Usually transient - OVD , CS , pigment , inflammation Cont.

  30. Cataract : 3% - NS - Age > 40 at implantation time →↑risk - AL > 30 mm →↑ risk Other complications - Hyphema - Intermittent myopic shift - RD Cont.

  31. - PRL : Silicon , hydrophobe - ICL : Hydrophyl , biocompatible , permeable PC PIOLs ( SULCUS SUPPORTED )

  32. -Glare & halos 8.4 % , ↓ over time -Flare ; 27%, Up to 2y -Cataract - The major concern - 0.6 – 3 % - Traumatic contact , metabolic disturbance - Ant. sub capsular Complications

  33. Pigment dispersion & deposition - Iris rubbing - ↑ Size ( ↑ Vault ) →↑ dispersion Cont.

  34. Glaucoma - 2’ to pigment dispersion - Angle closure - Pupilary block ( if fibrin formed ) - ICL > PRL Decenteration : The most complication - Small size IOL, difficult problem - Even sometime dislocation into vitreous cavity

  35. Note : In PC pIOL, vault is of critical importance - ↑ Vault → ↑ Pigment dispersion - ↓ Vault → ↑ Cataract

  36. Implantation of pIOL followed by Laser ablation - In case of extremely myopia , high Ast. , lens power not available. - Safe and effective BIOPTICS

  37. - PIOLs have been used successfully for post PK Ast. - Artisan induces HOA less than APT because of reserving prolate shape of cornea. - ToricpIOL + CXL successfully have been used for correcting RE in mild to moderate KCN & PMD. FEW SELECTED POINTS

  38. - AC pIOLs have been used for TX of children with sever myopic anysometropia ( > -8.00 ) that resist or no cooperative for traditional amblyop therapy with encouraging results . Cont.

  39. Compared with corneal laser ablation, pIOLs are excellent in : - Predictability - Efficacy - Safety - Quality of vision CONCLUSION

  40. ضمن عرض پوزش بدلیل حجم بالای LECTUER ادامه اسلایدها امکان پذیر نمیباشد در صورت نیاز به ادامه لطفا به واحد سمعی و بصری مرکز آموزشی درمانی فیض مراجعه و یا با شماره تلفن 03114476010 داخلی 392تماس حاصل نمائید با تشکر

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