Phakic IOL successful in patient with myopia and pseudophakia

Key Points

Tarpon Springs, FL-An implantable contact lens (ICL) offered a safe and reasonably accurate refractive solution for a patient with myopia and pseudophakia, according to J. Pitzer "Pit" Gills III, MD, St. Luke's Cataract and Laser Institute, Tarpon Springs, FL. He discussed the case of a male patient, aged 64 years, who was pseudophakic in both eyes.

The patient was a high myope, and his myopia increased when he experienced a retinal detachment in 1986 with scleral buckle in the right eye. After the detachment was repaired, "the patient subsequently developed a cataract in the right eye," Dr. Gills explained. "He had significant myopic degeneration that limited his potential vision. At the time of the cataract surgery, the surgeon intentionally targeted the right eye for –10 D to avoid anisometropia."

IOL exchange was performed on the left eye. The patient's potential acuity was limited due to myopic degeneration. The case was complicated by some wound leakage due to thin sclera, but the final outcome was good. The preoperative result following the exchange was plano sphere with 20/40 vision.

Options considered

"When it came time to address the right eye, we considered other options, thinking that we could do something that was a little less invasive than exchanging the lens," Dr. Gills said.

Although IOL exchange was one option, Dr. Gills noted that the patient already had undergone a complicated surgery and that vitrectomy would be required in a case in which a greater risk for retinal detachment already existed. Also, he said, the patient's long axial length predisposed him to wound leakage and hypotony.

LASIK was another option, but the patient didn't have enough corneal tissue and also had a history of dry eye syndrome, Dr. Gills said. "We also had a concern about creating optical aberrations when the patient's vision already was subnormal," he noted.

A third option was use of a "piggyback" IOL, but the only IOL available in the power required for this patient was a hard lens that would require a large incision.

"We weren't excited about making a large wound again in this particular patient," Dr. Gills said.

After discussing the options, Dr. Gills and the patient decided that a phakic lens (Visian Implantable Collamer Lens, STAAR Surgical Co.) would be implanted as a piggyback lens in the right eye. The ICL was available in the required power, and the small incision necessary meant the surgery could be performed with minimal risk.

"It's a very straightforward procedure when you implant an ICL in a pseudophakic patient," he said.

The phakic lens power was calculated as usual, based on refractive error. The patient was targeted for –0.63 D to allow for hyperopic shift from two 4-mm limbal relaxing incisions (LRIs).

"We targeted the patient for –0.63 D to give him the most functional vision," Dr. Gills said. "The patient elected to have LRIs to achieve his best uncorrected vision. However, I explained to the patient that an additional procedure such as LASIK or enhancement of his LRI may be required to correct any residual refractive error."

Peripheral iridectomy was performed 1 week before the procedure. Two LRIs were made at 3 o'clock and 9 o'clock at the time of the surgery.