Visian ICL edges up on LASIK for high myopes

Better contrast sensitivity, quality of vision help make the

Visian phakic IOL some patients’ preferred choice

While LASIK is the popular choice for most patients seeking refractive correction—several million procedures are done each year— extremely nearsighted individuals opt for correction with the Visian ICL (Staar Surgical, Monrovia, Ca.), according to Stephen G. Turner, M.D., clinical assistant professor, University of California, San Francisco.
“There are some patients who have too much nearsightedness to correct with LASIK or whose corneas are too thin or whose corneas have an abnormal shape or who have a combination of all three things,” Dr. Turner said. “In such cases, LASIK would produce a bad result, and these patients are ideal for the ICL Visian.”

Visian ICL - LASIK Alternative

ICL vs. LASIK

Dr. Turner said that some patients for whom LASIK is possible can fare much better with the ICL. “For example, someone who is a -12 and who has a thick cornea can be [treated] with LASIK, but his visual result is not as good as it is with the ICL,” he said. “They have a greater drop in contrast sensitivity, [and] their quality of vision and their night vision is not as good as it is with the ICL.”
For these reasons, many of these patients do better with the phakic ICL than with LASIK, Dr. Turner said. The exact cutoff is still being debated and bandied. “Some people consider it to be -8 D, and some consider it to be -10 D,” Dr. Turner said.
There are also those patients who are in the gray zone—Dr. Turner cited a -9 D myope with 500-micron cornea. “You could maybe squeeze a LASIK out of it, but if you do so, you run the risk of ectasia, of significant night glare, and night-vision symptomatology, [whereas] you don’t have those risks with the phakic IOL,” he said.
In Dr. Turner’s experience, patients above the -12 D mark clearly benefit from the ICL over LASIK. “In our hands, the -12 and -14 D patients do better than the ones that have LASIK,” he said. “Their nighttime vision is better, they don’t have the halos, glare, star burst phenomenon to the extent that they do with LASIK, their contrast sensitivity is better, and their ability to discern shades of gray or more subtle shades instead of just black and white distinctions is better than it is with LASIK.”
Dr. Turner has had “astounding results” with the ICL in such high myopes.
“You take somebody who is a -14 D myope and you not only correct their vision, in many cases you can improve their vision,” he said. “For example, the best corrected pre-operative vision may be 20/40 or 20/50, and their best post-operative vision may be uncorrected at 20/25 or 20/30. We’ve seen that numerous times.”
Word about the ICL has not yet spread to many patients, and practitioners may need to tread carefully when approaching patients on the topic.
“Most people come to us wanting LASIK, and it’s a long explanation as to why they’re not good candidates for LASIK but are better candidates for the ICL,” Dr. Turner said. “That turns a lot of people off because they get frightened and they haven’t heard of this— it’s something newer.”
But ultimately, Dr. Turner said, most patients carefully listen to him explain what the lens has to offer them, and he is able to change their minds.
However, there are also some patients who are locked into the idea of having LASIK and will find a practitioner who will accommodate them. “A lot of times they’ll go elsewhere and they’ll have LASIK, even though that’s not the best thing to do, simply because that’s what the [other] doctor is more comfortable with,” he said. 

Considering complications

The procedure to implant the lens is fairly straightforward. “The Visian ICL goes through a small 3.2-mm stepped clear corneal incision that self-seals,” Dr. Turner said. The procedure takes about 10 minutes to 15 minutes and is quicker and easier for the patient, he said.
While most patients do very well with the lens, there are risks such as cataract formation, endophthalmitis, and corneal decompensation. So far, Dr. Turner, who has been using the lens since it was approved in December 2005, has seen only one complication.
“We had one case [in which] the patient developed a pressure rise in the eye, and an iritis and corneal infiltrates, and their vision dropped down,” he said. “Presumably they had a problem with preservatives in the eyedrops, and we thought that they had a viral keratitis.” The patient is currently faring much better.
To ensure the best results with the lens, Dr. Turner recommends careful antibiotic prophylaxis and urges practitioners to perform the surgery in a sterile operating room environment, not in a “garage type setup.”
He also cautions against bilateral surgery.
“I don’t think that bilateral cases should be done. I know people are doing it, but if you have a complication, it’s indefensible,” he said. “I’d wait a couple weeks and make sure that everything is fine and that the patient is comfortable with going ahead and doing the second eye.”
Overall, the ICL is another valuable piece in a refractive surgeon’s arsenal, Dr. Turner said. “I don’t see the ICL procedure as outdoing LASIK in terms of numbers, but this definitely has a place in the refractive armamentarium,” he said. “The very patients that want it and need it the most are those with extreme myopia, and for them the ICL is the answer.”


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