Daisuke Aizawa,MD Kazutaka Kamiya,MD Tetsuya Ikeda,MD Kimiya Shimizu,MD

Assessment of a triple procedure in patients with ICL-induced cataracts　　 ~ICLTM removal, phacoemulsification and　　　　 intraocular lens implantation

Daisuke Aizawa,MD

Kazutaka Kamiya,MD

Tetsuya Ikeda,MD

Kimiya Shimizu,MD

Kitasato Univ. School of Medicine,JAPAN

ASCRS 2008, Chicago

Department of Ophthalmology2008

Kitasato University School of Medicine

ICLTM implantation has advantages over LASIK

in high myopic correction. （ Aizawa et.al. APSCRS 2007 ）

Introduction

On the other hand, cataracts are among the complications of this procedure.

We assessed the triple procedure of ICL removal, PEA and IOL implantation.



Age (at ICL implantation time) 46.9 ± 2.8 (37 ～ 57) y.o.

Pre-op refraction -15.1 ± 5.8 (-10.4 ～ -24.0) D

Axial length 29.3 ± 1.9 (26.1 ～ 32.0) mm

ICL type Ver. II: 9 eyes, Ver. IV: 1 eye

Period (implant to extraction) 4.0 ± 2.1 (1.6 ～ 8.1) years

Age (when ICL extraction) 51.1 ± 4.2 (45 ～ 62) y.o.

10 eyes of 8 patients (6 eyes of male, 4 eyes of female)

Objects & Methods

IOL MasterTM was used for axial length measurement. （ SRK-T ）

Operation ・ Topical anesthesia

・ ICL extraction via 3 mm temporal corneal incision

・ PEA+IOL through the same incision



0.0

0.1

1.0

10.0

ICL術前 ICL術後白内障術前白内障術後

矯正視力裸眼視力

Vis

ual a

cuity

0.310.68

0.73 1.10

*

*

*

1.050.81

0.73

0.02

Before ICL After ICL Cataract After ICL removal implantation implantation formation and IOL implantation

　 P ＜ 0.001 （ Wilcoxon signed rank test ）

BSCVA UCVA

Safety index = 1.51 Efficacy index = 0.93

Results 1 Visual acuity


0.0

1.0

2.0

3.0

4.0

5.0

6.0

0.0 1.0 2.0 3.0 4.0 5.0 6.0

undercorrection

overcorrection


< ±0.5D ： 80%< ±1.0D ： 90%

Attempted (D)

Ach

ieve

d (D

)

Results 2,3 Predictability, Manifest refraction (SE)

-25.0

0.0

ICL術前 ICL術後白内障術前白内障術後

-2.9 -2.0

-15.1

-1.6

Man

ifest

ref

ract

ion

(D)

Before ICL After ICL Cataract After ICL removal implantation implantation formation and IOL implantation

-25

0

Ach

ieve

d (D

)

Attempted (D)0 1 2 3 4 5 6

0

1

2

3

4

5

6

Manifest refraction (SE)Predictability



0.0

20.0

ICL術前白内障術前白内障術後

13.212.9

N.S.

13.5

IOP

(m

mH

g)

（ Wilcoxon signed rank test ）

Results 4,5 IOP, Endothelial cell density

Before ICL Cataract After ICL removal implantation formation and IOL implantation

0

3000

ICL術前白内障術前白内障術後

25262296

*

*Cell loss 9.1%

2555

Co

rnea

l en

dot

hel

ial c

ell

den

sity

(ce

lls/㎜

2）

　 P ＜ 0.01　　（ Wilcoxon signed rank test ）

Before ICL Cataract After ICL removal implantation formation and IOL implantation

0

20

0

3000IOP Endothelial cell density



Ages atimplant’n/extraction

Pre-op refraction（ D ）

ICLtenure of use

(years)

ICLversion

Vaulting （ μm ）

Cataract type

53 / 55 -10.4 2.4 Ⅱ 148.8 nuclear

37 / 44 -10.8 7.4 Ⅱ 171.7 nuclear

44 / 46 -13.0 2.1 Ⅱ 0 ant’r, subcapsular



48 / 51 -16.4 3.4 Ⅱ 0 nuclear

46 / 48 -14.4 1.6 Ⅱ 262.7 nuclear

53 / 56 -24.0 2.7 Ⅱ 102.6 nuclear

44 / 52 -16.0 8.1 Ⅱ 181.0 nuclear

57 / 62 -18.5 5.4 Ⅳ 0 nuclear

Mean 46.9 / 51.1 -15.1 4.0 - 86.7 -

Results 6 Vaulting (ICL to lens)


Nuclear cataract (7 eyes) → common in high myopia

　　　　　・ Age at ICL removal (present study): 51.1 ± 4.2 y.o.

　　・ Age at cat. operation in high myopia: 56.8 ± 10.0 y.o.

　　・ Average age at cat. operation: 63.4 ± 8.9 y.o.

high myopia occur cat. earlier Anterior subcapsular cat. (3 eyes) → suspected ICL-induced

　　・ after crystalline lens exposure to ICL

　　・ as a nutritional disturbance as changes in the dynamic

state of aqueous humor


（ Trinidade F et al. J Cataract Refract Surg. 1998 ）

（ K.Fujisawa et al ; Graefes Arch Clin Exp Ophthalmol. 2006 ）

（ Shimizu JSCRS 2007 ）

Assessment 1 Cataract type


・ version II: anterior-subcapsular (3 eyes / 9 patients)

nuclear (6 eyes / 9 patients)

・ version IV: nuclear (1 eye / 1 patient)

　　　　 Version IV lenses have higher vaulting.

　　　　　　　 We consider that is the reason why ASC is unlikely.


Ver.Ⅱ Ver.Ⅲ Ver.Ⅳ

Optical zone larger Vaulting: +0.17mm

Assessment 2 Lens Version & Cataract Type


0

10

20

30

40

50

60

70

80

90

100


*** IOL master, (SRK-T) (Shimizu et.al. JSCRS 2007)

** IOL master, (SRK-T, Double-K method) (Iida et. al. JSCRS 2006)

Predictability of IOL power calculation in ICL implanted eyes is almost equal to that in unoperated high myopic eyes without any specific calculation method.

ICLImplantedeye

LASIKeye

highmyopiceye

* IOL master, (SRK-T)90% 90.5%

60-80%

****

(%)

Assessment 3 Predictability (error < ±1.0D)

Predictability of cataract surgery

**



2.27 1.51

8.11

5.55

3.67

2.15

0

2

4

6

8

10

12

20代 30代 40代 50代

（ Shimizu, JSCRS 2007 ）

ICL implanted eyes

high myopic eyes

regular eyes

Cataract occurs earlier in high myopia. Pseudo-accommodation is greater in IOL eyes in high

myopia. In high myopic eyes in patients in their 50s, breadth of

accommodation and pseudo-accommodation after cataract surgery and implantation with ICLs are approximately the same. 　　　　　　

Acc

om

mo

da

tion

an

d

Pse

ud

o-a

cco

mm

od

atio

n

(D)

Accommodation and Pseudo-accommodation

20’s 30’s 40’s 50’s

Assessment 4 Changes in accommodation



Cataracts occurred frequently in elderly persons and in cases of old type ICL implantations.

Even if cataracts are formed,

Conclusions

the ICL can be removed easily,IOL power can be calculated enough predictably,no decrease in area of distinct vision,and good visual performance is maintained.

Daisuke Aizawa,MD Kazutaka Kamiya,MD Tetsuya Ikeda,MD Kimiya Shimizu,MD

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