Phakic IOLs State of the Art 1st Edition

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 Lucio Buratto, MD

Stephen Slade, MD, FACS

Nicola D. Hauranieh, MD
www.slackbooks.com

ISBN: 978-1-61711-061-0

Cover artwork by: Design Project Massimo Uberti - www.massimouberti.it

Copyright © 2012 by SLACK Incorporated

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Library of Congress Cataloging-in-Publication Data

Buratto, Lucio.
Phakic IOLs : state of the art / Lucio Buratto, Stephen Slade, Nicola Hauranieh.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-61711-061-0 (hardback)
I. Slade, Stephen - II. Hauranieh, Nicola. III. Title.
[DNLM: 1. Phakic Intraocular Lenses. 2. Lens Implantation, Intraocular. WW 358]
LC classification not assigned
617.7’524--dc23
2012001632

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 Dedication
To Marco Moncalvi, a dear friend.
Lucio Buratto, MD

To Rick Baker, OD, the best partner ever!

Stephen Slade, MD, FACS

To my big family. To Pietro Giardini, master of ophthalmology.

Nicola Hauranieh, MD
 Contents
Dedication ............................................................................................................................................................................... v
Acknowledgments .................................................................................................................................................................. ix
About the Authors ................................................................................................................................................................. xi
Contributing Authors ..........................................................................................................................................................xiii
Introduction .......................................................................................................................................................................... xv

Part I: History of Phakic IOLs ..........................................................................................................1

Chapter 1 Indications for Implantation ......................................................................................................................... 3
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 2 Contraindications ........................................................................................................................................... 5
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 3 Patient Selection.............................................................................................................................................. 7
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 4 Preoperative Diagnostics............................................................................................................................. 11
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 5 Instrumental Diagnostics ............................................................................................................................ 15
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 6 Optic Zone and the Pupil............................................................................................................................ 19
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 7 Calculation of the Power of the Phakic IOL ............................................................................................. 21
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 8 Choice of Anesthesia.................................................................................................................................... 25
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 9 Historical Models of IOLs ........................................................................................................................... 27
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 10 Current Models of IOLs............................................................................................................................... 31
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 11 Anterior Chamber IOL With Angle Support: AcrySof Cachet (Alcon) ............................................... 33
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 12 Anterior Chamber IOL With Iris Fixation: Verisyse (AMO)/Artisan (OPHTEC) .............................. 41
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 13 Foldable Anterior Chamber IOL for Iris Fixation: Veriflex (AMO)/Artiflex (OPHTEC) .................. 55
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 14 Phakic IOL for the Posterior Chamber: Implantable Contact Lens (STAAR) ..................................... 63
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 15 Phakic IOL for the Posterior Chamber: Phakic Refractive Lens (Carl Zeiss Meditec) ...................... 71
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 16 Therapy and Postoperative Control of Phakic IOLs ............................................................................... 73
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 17 Postoperative Complications ...................................................................................................................... 77
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
 viii Contents

Chapter 18 Astigmatism and Phakic IOLs ................................................................................................................... 91

Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 19 The Use of Bioptics for Residual Sphere or Astigmatism ...................................................................... 95
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 20 Comparison Between Phakic IOLs and LASIK ....................................................................................... 99
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 21 Long-Term Results ...................................................................................................................................... 103
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
Chapter 22 The Future of Phakic IOLs ........................................................................................................................ 107
Lucio Buratto, MD; Stephen Slade, MD, FACS; and Nicola Hauranieh, MD
References for Part I..........................................................................................................................................................111

Part II .................................................................................................................................................115
Chapter 23 Veriflex: Pearls for the Implantation and for the Right Position and Surgical Results ....................117
José L. Güell, MD; Merce Morral, PhD; Daniel Elies, MD; Oscar Gris, MD; and Felicidad Manero, MD
Chapter 24 The Implantable Collamer Lens Implantation Technique ................................................................... 123
Gregory D. Parkhurst, MD
Chapter 25 Posterior Chamber Phakic Toric Implantable Collamer Lens: Surgical Technique ......................... 129
Erik L. Mertens, MD, FEBOphth
Chapter 26 Our Implantable Collamer Lens Experience.......................................................................................... 135
Colonel Scott Barnes, MD
Chapter 27 The Implantable Collamer Lens: Long-Term Results and Complications ..........................................141
Gregory D. Parkhurst, MD
Chapter 28 Sizing the Implantable Collamer Lens With the Lovisolo Phakic IOL Sizer Software ................... 147
Carlo F. Lovisolo, MD
Chapter 29 The AcrySof Cachet Implantation Technique ........................................................................................ 153
W. Andrew Maxwell, MD, PhD
Chapter 30 Implantation of the AcrySof Cachet Angle-Supported Phakic IOL ................................................... 159
Michael C. Knorz, MD
Chapter 31 Comparison of the Artiflex With the AcrySof Cachet Phakic IOL .................................................... 163
Muriel Doors, MD and Rudy M. M. A. Nuijts, MD, PhD

Financial Disclosures .......................................................................................................................................................... 169

 Acknowledgments
I would like to thank all of the international contributors who, with their active collaboration and their sci-
entific support, have contributed to the high scientific content of this book.
I am especially grateful to Nicola Hauranieh for his invaluable and scrupulous commitment that was funda-
mental for the completion of this book; he also supervised the production and evolution of the book.
My sincere appreciation to Steve Slade for his invaluable contribution and his scientific skill.
I am deeply in debt to Guido Caramello, Vittorio Picardo, Giuseppe Perone, and Carlo Lovisolo for their wise
advice and most valuable suggestions.
My sincere thanks goes to Salvatore Ferrandes, who was responsible for the iconographic portions.
I also would like to thank the staff of Medicongress, in particular Monica Gingardi, for the organizational
and operational support provided.
And finally, Accademia Italiana di Scienze Oftalmologiche (AISO), for the scientific support and grant for
the publication of this book.
Lucio Buratto, MD
 About the Authors
Lucio Buratto, MD is considered a leading international expert in cataract and myopia surgery. He is a pioneer
in IOL implantation; in phacoemulsification; and in laser techniques for myopia, astigmatism, and hyperopia.
Since 1980, Dr. Buratto has organized and presided over 47 updating congresses on cataract and glaucoma
surgery and on laser therapy. He also organized 54 practical courses for teaching eye surgery and served as
spokesman and teacher in 386 courses and congresses.
In 1989, Dr. Buratto presented and was the world’s first surgeon to use the excimer laser for intrastromal ker-
atomileusis, and concurrently also started to treat low myopia using PRK techniques. In 1996, he was the world’s
first surgeon to use the new technique called “Down-Up LASIK,” which improved the LASIK procedure for the
correction of myopia. For teaching purposes, Dr. Buratto has performed surgical operations during live surgery
sessions for more than 200 international and Italian congresses, performed surgery during satellite broadcasts
to 54 countries in 4 different continents, and designed and produced 136 instruments for ocular surgery.
Dr. Buratto has written over 125 scientific publications and 53 monographs dedicated to ophthalmic surgery
and has received several awards, including Maestro of Italian Ophthalmology with Medal of Merit (1998);
Barraquer, during the International Congress of the American Academy (2000); Binkhorst Lecture during the
XXII Annual Meeting, Paris (2004); and Fyodorov Medal at the HSIOIRS meeting, Athens (2006).
Since 2007, Dr. Buratto has been Honorary President of the Italian Academy of Ophthalmological Sciences
(AISO) and past president of the Italian Association of Cataract and Refractive Surgery (AICCER). Presently, he
is the director of Centro Ambrosiano Oftalmico (Ophthalmic Microsurgery Center) and practices at his private
practice in Milan, Italy.

Stephen Slade, MD, FACS is a native Houstonian and is in private practice in Houston, TX. He graduated
Summa Cum Laude and Phi Beta Kappa from the University of Texas at Austin and the University of Texas
Medical School with a final elective year spent at Guy’s Hospital, London, UK. He completed a residency at
the LSU Eye Center in New Orleans, LA and fellowships in cataract and corneal surgery at Baylor College of
Medicine in Houston and in New York, NY on Project ORBIS.
Dr. Slade is a fellow of the American Academy of Ophthalmology and the American College of Surgeons.
He is an active teacher of surgical techniques and has taught and certified over 8000 surgeons in LASIK and
lamellar refractive surgery. Several hundred have chosen him for their own surgery. Dr. Slade is also an active
researcher and has served as medical monitor for several new technologies, including laser cataract surgery,
wavefront LASIK, Implantable Collamer Lenses, femtosecond lasers, keratophakia, and accommodating IOLs.
He has the nation’s longest experience in LASIK (along with Stephen Brint, MD), femtosecond laser LASIK,
accommodating IOLs, and femtosecond laser cataract surgery.
Dr. Slade has received numerous awards including 18 named lectures, Refractive Surgeon of the Year, two
China Service Medals, the Lans Award, the Casebeer Award, and the 2007 Barraquer Award. Dr. Slade was
selected by his peers for “Best Doctor,” “Texas Super Doctors,” and “Best Doctors in America” and has received
the Senior Honor Award of the American Academy of Ophthalmology. He is a regular presenter at medical
meetings and has received several “Best Speaker” awards and has twice won First Place at the American Society
of Cataract and Refractive Surgery Film Festival. He is on several editorial boards, including the Journal of
Refractive Surgery, and serves as Chief Medical Editor of Cataract and Refractive Surgery Today as well as President
of the American College of Ophthalmic Surgery.
Dr. Slade has produced many articles and book chapters, holds 5 patents or patents pending in the field, and
has authored or coauthored 8 textbooks on ophthalmic surgery. Dr. Slade has appeared on ABC, CBS, CNN,
NYT, WSJ and was the featured surgeon on the Emmy award-winning PBS documentary “20/10 by 2010?” nar-
rated by Walter Cronkite.

Nicola Hauranieh, MD is a Syrian native with Italian citizenship and lives in Brescia, Italy where he is in
private practice. He graduated at the University of Milan Medical School and completed a residency at the
University of Brescia School of Ophthalmology.
Dr. Hauranieh is a fellow of the Italian Academy of Ophthalmological Sciences (AISO), the Italian Society of
Ophthalmology (SOI), the European Society of Cataract and Refractive Surgery (ESCRS), the American Society
of Cataract and Refractive Surgery (ASCRS), and the American Academy of Ophthalmology (AAO). He has
participated in several research protocols, is a regular presenter at medical meetings in Europe and the United
States, and has received a “Best Speaker” award.
 xii About the Authors

Dr. Hauranieh has participated in producing articles and book chapters. His interest has always been cataract
and refractive surgery and the quality of vision. For 8 years, he has been working on the quality of vision and
new technologies; he and Dr. Giardini developed a system to evaluate the performance of near and intermediate
quality of vision with many papers presented about this argument.
 Contributing Authors
Colonel Scott Barnes, MD (Chapter 26) Carlo F. Lovisolo, MD (Chapter 28)
Chief, Ophthalmology and Refractive Eye Surgery Founder and Medical Director
Womack Army Medical Center QuattroElle Custom Eye Centers
Fort Bragg, North Carolina Milano & Nizza Monferrato (AT), Italy

Muriel Doors, MD (Chapter 31) Felicidad Manero, MD (Chapter 23)

Resident in Ophthalmology Cornea and Refractive Surgery Unit
Maastricht University Medical Center Instituto Microcirugia Ocular de Barcelona-IMO
Department of Ophthalmology Barcelona, Spain
Maastricht, The Netherlands
W. Andrew Maxwell, MD, PhD (Chapter 29)
Daniel Elies, MD (Chapter 23) California Eye Institute
Cornea and Refractive Surgery Unit Fresno, California
Instituto Microcirugia Ocular de Barcelona-IMO
Barcelona, Spain Erik L. Mertens, MD, FEBOphth (Chapter 25)
Medical Director and Eye Surgeon
Oscar Gris, MD (Chapter 23) Medipolis Eye Centre
Cornea and Refractive Surgery Unit Antwerp, Belgium
Instituto Microcirugia Ocular de Barcelona-IMO
Barcelona, Spain Merce Morral, PhD (Chapter 23)
Institut Clinic d’Oftalmologia
José L. Güell, MD (Chapter 23) Hospital Clinic I Provincial Barcelona
Associate Professor of Ophthalmology Barcelona, Spain
Autonoma University of Barcelona
Director, Cornea and Refractive Surgery Unit Rudy M. M. A. Nuijts, MD, PhD (Chapter 31)
Instituto Microcirugia Ocular de Barcelona-IMO Associate Professor of Ophthalmology
Barcelona, Spain Department of Ophthalmology
Medical University Center Maastricht
Michael C. Knorz, MD (Chapter 30) Maastricht, The Netherlands
FreeVis LASIK Center
Medical Faculty Gregory D. Parkhurst, MD (Chapters 24, 27)
Mannheim University of Heidelberg Cataract and Refractive Surgeon
Mannheim, Germany McFarland Eye Centers
Little Rock, Arkansas
 Introduction
Today, most patients with mild to moderate myopia may be treated with laser techniques that provide out-
standing visual acuity and excellent vision quality as well as meet their expectations. Yet, what alternatives are
available to our patients with severe myopia, suspect corneas, or other contraindications to laser vision correc-
tion?
Phakic IOLs are unquestionably one of the best solutions we can offer. Phakic IOLs offer high levels of effi-
cacy, stability, accuracy, and safety. These lenses provide excellent visual quality and a great deal of freedom
from glasses and contact lenses. The evolution of phakic IOL technology has provided wider and wider ranges
of options with greater choices of lenses.
The characteristics of the modern patient have changed. Patients now use smart phones and the Internet
extensively. They are technologically aware, and they search for and happily accept the concept of new ideas
and developments with little fear or suspicion. They will often ask their doctor, “Have there been any new
developments in technology since my previous visit? Are you in a position to treat my eyes now?” It is the duty
of the physician, after a thorough examination and assessment of the individual patient’s needs, to provide all of
the available and latest choices to the patient. There is usually a simple answer among the several options—the
excimer laser with its range of technology, the selection of phakic IOL implants, and lastly, clear lens extraction
with the implantation of one of the many multifocal IOLs. For the doctor, it is a satisfying experience to be able
to list the alternatives available and equally delightful to observe the patient’s expression as he or she listens.
In Phakic IOLs: State of the Art, we have attempted to examine the state of the art of phakic IOLs. We have
divided the science into several primary chapters: the history of phakic IOLs and the difficult periods of its
development, indications and contraindications, evaluations necessary for the correct selection of the IOL,
lenses that are currently available, implantation techniques, intraoperative and postoperative complications,
explantation techniques, and reasons why the lens should be explanted. In the last chapter of Part I, we compare
phakic IOLs with LASIK and bioptics, concluding with the future of phakic IOLs. We have tried to provide our
readers all of the available scientific information and results of the various studies published over the years,
demonstrating and confirming the ongoing evolution in this field. We sincerely hope that the book may prove
useful for doctors in their routine professional activities, to improve and perfect their surgical options for the
benefit of their patients.

“I hope that one day my invention, the lens for iris fixation, will give hope and new life to patients around
the world…”
J. G. F. Worst (Haren, The Netherlands), May 2003

We hope you enjoy reading our book as much as we enjoyed writing it.

Lucio Buratto, MD; Stephen Slade, MD, FACS; Nicola Hauranieh, MD