1. Indications
1.1. Myopia >-8 D
1.2. Myopic astigmatism
1.3. Stable Keratoconus
1.4. Keratoconus with corneal cross linking
1.5. Correction of residual refractive error in post keratoplasty cases
1.6. Correction of unilateral high refractive error in anisometropic amblyopia
1.7. Correction of postop refractive surprise
1.8. Multifocal diffractive phakic IOL to correct Presbyopia
2. Advantages
2.1. Preserves corneal architecture
2.2. Preserves accomodation as lens remains is unaltered
2.3. Reversible and exchangeable
2.4. High optical quality
2.5. Minimal spherical aberrations and coma than LASIK
2.6. Predictable and stable results
2.7. Loading and implantation requires a minimal learning curve
3. Disadvantages
3.1. May cause irreversible damage such as endothelial cell loss, glaucoma, cataract
3.2. Potential risks of intraocular procedures like endophthalmitis
3.3. Not suitable in shallow anterior chambers
3.4. Non foldable variants require larger incisions, causing post op astigmatism
4. Anterior chamber depth requirements for different phakic IOLs
4.1. Measured from Endothelium AcrySof phakic: >2.7 mm Artisan-Verisyse/Artiflex-Veriflex: 2.7 mm ICL: 2.8 mm for myopia, 3.0 mm for hyperopia PRL: 2.5 mm
5. PIOL sizing is determined by Anterior chamber depth (ACD) and horizontal white‑to‑white measurementsmeasurements
6. VAULT is the Vertical distance between the back surface of ICL and front surface of the crystalline lens.
6.1. Ideal vault size 250-750 μm
7. ONE SIZE FITS ALL- 8.5mm
8. Types
8.1. Anterior Chamber
8.1.1. Angle fixated
8.1.1.1. AcrySof Cachet
8.1.1.2. Kelmann duet
8.1.2. Iris fixated
8.1.2.1. Artisan/Verisyse
8.1.2.2. Artiflex/Veriflex
8.2. Posterior chamber
8.2.1. Implantable collamer lens
8.2.1.1. Made up of biocompatible material, Co-polymer of 60% poly-hydroxy ethyl methacrylate (HEMA), water (36%), and benzophenone (3.8%) and 0.2 % porcine collagen
8.2.1.1.1. Comes with four 360 micron holes- Two on optic, one each on trailing haptic and leading haptic
8.2.1.1.2. Toric IOL comes with extra two orientation marks on optic
8.2.2. Phakic refractive lens
9. Preoperative evaluation
9.1. Visual acuity assessment -Unaided and aided, Refractive status
9.2. Slit lamp examination- Undilated and Dilated states. Anterior and posterior segment evaluation, including peripheral fundus
9.3. IOP measurement
9.4. Gonioscopy
9.5. Keratometry
9.6. Axial length
9.7. Endothelial cell count
9.8. Horizontal W-W diameter assessment using Digital callipers/orbscan/IOL Master/ AS-OCT
9.9. Anterior chamber depth- using Orbscan/Pentacam/ IOL Master/ AS-OCT
9.10. Sulcus to Sulcus diameter
9.11. Angle to Angle diameter
9.12. Pupil diameter
9.13. IOL size and power calculation
10. Patient selection criteria
10.1. Preoperative refraction (Stable refraction ( <0.5 D )for 1 year)
10.2. Age >21 years
10.3. Endothelial cell count> 2300/mm2 (>2500 cells/ mm2 if >21 years old, >2000 if >40 years old)
10.4. WTW>11 mm
10.5. Anterior chamber depth> 2.8 mm
10.6. Irido-corneal angle > 30 degrees
10.7. Pupil diameter<6.5mm
11. Contraindications
11.1. Low endothelial cell count
11.2. Low AC depth
11.3. Advance Keratoconus
11.4. Active disease in the anterior segment
11.5. Recurrent or chronic uveitis
11.6. IOP >21 mm Hg or Glaucoma/Narrow angles/Iris/Angle anamolies
11.7. Clinically significant cataract, previous corneal or intraocular surgery (to be evaluated)
11.8. Zonular laxity/dehiscence
11.9. Pre-existing macular degeneration or macular pathology
11.10. Proliferative retinopathy
11.11. Systemic diseases (eg autoimmune disorder, connective tissue disease)
12. Complications
12.1. Posterior Chamber Phakic IOL related
12.1.1. INTRAOPERATIVE
12.1.1.1. Dropping of ICL while loading
12.1.1.2. Chipping of ICL
12.1.1.2.1. Causes- Inadequate viscoelastic in cartridge, Irregular/sharp edges of forceps or Improper hold of ICL with forceps
12.1.1.3. Reverse ICL
12.1.1.3.1. Causes- Faulty loading,incorrect orientation, Inadequate OVD in anterior chamber
12.1.1.4. Damage to anterior lens capsule
12.1.2. EARLY POST OPERATIVE
12.1.2.1. Raised IOP and Glaucoma
12.1.2.2. Pigment dispersion
12.1.2.3. Uveitis
12.1.2.4. Glare and halos
12.1.2.5. TASS
12.1.2.6. Endophthalmitis
12.1.3. LATE POST OPERATIVE
12.1.3.1. Cataract due to lens touch
12.1.3.2. Endothelial cell loss and corneal decompensation
12.1.3.3. Retinal detachment in high myopia cases
12.2. Angle supported Phakic IOL
12.2.1. Pupil ovalization
12.2.2. Endothelial cell loss
12.2.3. Angle fibrosis
12.2.4. Pigment dispersion
12.2.5. Direct damage to trabecular meshwork
12.2.6. Pupillary block glaucoma
12.2.7. Uveitis
12.3. Iris fixated Phakic IOL
12.3.1. Decentration/Disenclavation
12.3.2. Endothelial cell damage
12.3.3. Uveitis
12.3.4. Iris atrophy
12.3.5. Pigment dispersion
12.4. Problems with Vaulting
12.4.1. HIGH/Excessive vaulting (>750 microns )/Large ICL
12.4.1.1. Causes Angle-closure, Pupillary block glaucoma, Pigment dispersion glaucoma
12.4.2. LOW/Insufficient vaulting (< 250 microns ) Small ICL
12.4.2.1. Cataract due to contact