At a Day 3 ESCRS 2024 late afternoon symposium, the elite of the eye care world gathered with chairs Prof. Thomas Kohnen (Germany) and Dr. Liliana Werner (USA) to discuss some of the most pressing—and trending—topics in the anterior segment.
The phakic IOL face-Off: Navigating the best options for 45-50-year-olds
Phakic IOLs are in and on the rise, and the first section of the program dealt with various current issues in implanting phakic presbyopia-correcting IOLs in pre-cataract 45-50-year-olds.
Dr. Erik Mertens (Belgium) started off with a presentation on the advantages of presbyopia-correcting phakic IOLs (PIOLs) for patients of this age. Dr. Mertens highlighted the key benefits of phakic IOLs for this demographic, emphasizing their role in preserving the crystalline lens and the residual accommodation it provides.
For Dr. Mertens, nothing trumps maintaining the body’s natural structures. “Phakic IOLs allow us to maintain the natural lens, utilizing any remaining accommodation—a major win,” he stated.
Safety in these lenses was also a focal point of his talk, as he reassured the audience about the low risks associated with these lenses. “Retinal detachment rates don’t seem to increase after phakic IOL implantation. In a study of 2,000 eyes, the rate was only about 1.2%. And with endophthalmitis, we’re looking at an incredibly low incidence of 0.016% in a report of 18,000 eyes,” Dr. Mertens shared.
A unique selling point of these IOLs is their reversibility, which Dr. Mertens emphasized on behalf of all phakic fans. “Unlike in-the-bag IOLs, PIOLs are easier to remove if needed.
He also touched on their effectiveness for both myopia and hyperopia. “In hyperopic patients, there are more indications for lens exchange, but with phakic IOLs, the safety and efficacy remain strong,” he noted.
Next, Dr. Joaquín Fernández entered the fray for patients aged 45-50, offering insights into whether presbyopia-correcting phakic IOLs (PIOLs) or posterior chamber IOLs are the better option. His message? It’s all about balancing accommodation and quality of vision.
“For patients in this age group, we can perform refractive lens exchange or ICL,” Dr. Fernández explained. “Two key considerations are the amplitude of accommodation and the quality of vision.”
For these younger presbyopes, he emphasized the importance of contrast sensitivity testing, especially when visual acuity is 20/20 or better. “In this category, we expect high-quality vision and good accommodation,” he stated.
Dr. Fernández highlighted the performance of the EVO VIVA IOL in patients over age 50. “A one-line drop in CDVA was observed in this group, with defocus curve predictability at 60% ±0.5 D—compared to 78% for the EVO monofocal.” Regarding safety, “Thirty-two percent (32%) of patients experienced a loss of one or more lines of CDVA, compared to 14% with monofocal IOLs,” he noted.
In conclusion, Dr. Fernández pointed out, “Phakic IOLs are a promising solution for patients under 50 or those with a long axial length. But real-world studies and cost-effectiveness analyses are still needed for long-term safety and efficacy.”
In his presentation finishing up the topic, Dr. Michael Amon (Austria) explored the advantages of a supplementary IOL in the sulcus for this patient group.
Dr. Amon laid out the options: “In patients aged 45 to 50 with a clear lens and reduced accommodation, we can opt for a duet procedure using a monofocal bag IOL with an add-on IOL, clear lens extraction with a bag IOL, or a phakic IOL if there’s no posterior vitreous detachment.”
Dr. Amon’s talk focused on the “duet” procedure, which offers an adjustable option with primary add-on implantation. He explained, “The duet procedure allows fine-tuning of the results, delivering optical quality comparable to a single IOL while providing better and more stable centration.” But, as with any duet, there’s a risk of hitting a sour note: “Posterior vitreous detachment is a risk that should be monitored.”
Regarding the available options, Dr. Amon pointed out, “There are currently three additive IOLs on the market: the Cristalens Reverso, Rayner Sulcoflex and 1st Q. Made of hydrophilic acrylic, these lenses are designed for high biocompatibility due to contact with the uvea.” He emphasized, “Published data shows these lenses are safe and well-tolerated.”
Dislocated IOLs: To refix or replace?
The vexing question of managing dislocated intraocular lenses (IOLs) took over the spotlight next.
Dr. Shin Yamane (Japan), inventor of the Yamane technique, tackled a dilemma all eye surgeons know well: What’s the best approach for dealing with a dislocated intraocular lens (IOL)? Should you refix it or go for a full replacement?’
“The management of a dislocated IOL involves either the removal and fixation of a new IOL (IOL exchange) or refixing the old IOL,” Dr. Yamane said.
He pointed out the perks of an IOL exchange in this regard. “Less surgical time, better control of refraction, and, of course, the advantage of a shiny new IOL,” he quipped.
But it’s not all rainbows and sunshine. Refixation can get tricky, he noted, especially when dealing with issues like deformed haptics or the formation of Soemmering’s rings.
Dr. Yamane presented a series of cases demonstrating both refixation and exchange techniques, sharing his expertise on when each method might be the best choice. “For rigid IOLs, large incisions are needed,” he noted, highlighting one of the challenges of IOL exchange.
He also shared a video of the famous Yamane technique, emphasizing its precision: “The Yamane technique allows the achievement of constant outcomes.” He stressed the importance of the needle insertion angle to avoid tilting the IOL.
At the end, Dr. Yamane summed it all up simply by highlighting a special technique: “Refixation is useful in limited situations, but for removal. The Fukuoka technique, using Fukuoka forceps, is often the preferred option.”
Dr. Cathleen McCabe (United States) then shifted to the pros and cons of refixation versus explantation.
Dislocated IOLs, while rare, have causes as varied as pseudophakic exfoliation, prior eye surgeries, and good old-fashioned eye rubbing. Dr. McCabe noted, “The incidence of IOL dislocation is 0.08%, but males are five times more likely to develop it—perhaps they just rub their eyes more,” she joked. Trauma, capsular phimosis, and complicated cataract surgeries are also culprits, with the highest risk in patients under 40.
But when it happens, what’s the best course of action—refixate or explant? Dr. McCabe asked: “Why would you scleral-fixate the IOL and not just take it out?” She highlighted that studies comparing scleral-fixated and retro-pupillary iris-claw IOLs show similar outcomes and complications.
There are, however, situations where refixation is preferable. “If you want to retain a premium IOL, avoid conjunctival trauma, or skip an anterior vitrectomy, refixation is your friend,” Dr. McCabe advised.
She demonstrated two common scleral fixation techniques, the belt loop and polypropylene flanged methods. She noted, “The belt loop technique works well for most lenses and often spares patients from the risks of anterior vitrectomy.” Potential complications? “Endophthalmitis, decentration and flange erosion—but nothing’s perfect!”
In short, while there’s no one-size-fits-all answer, refixation often proves the more eye-saving option.
Next, it was time for Dr. Luis Izquierdo Jr. (Peru) to present, he shed light on the Artisan Aphakia IOL (Ophtec; Groningen, Netherlands) as a go-to solution for these cases.
Dr. Izquierdo explained, “Explantation and Artisan IOL implantation are key for lens and IOL subluxation, whether spontaneous or post-trauma.” He highlighted the Artisan model’s versatility: “The Artisan 205 Aphakia IOL is a one-size-fits-all solution, known for its predictable, stable and reliable outcomes.”
Dr. Izquierdo shared videos showcasing the Artisan IOL in action across different indications to support his claims. He concluded confidently, “In my experience, this aphakic retro pupillary lens is atraumatic, easy to implant with excellent centration and remarkably safe for the corneal endothelium.” He called for long-term studies to further validate these promising results.
Postoperative antibiotics: To drop or not to drop?
Dr. Andrzej Grzybowski (Poland) was the first to speak on the hotly debated question that led the proceedings to their conclusion: Do we still need antibiotic eye drops after cataract surgery? And he’s firmly in the pro-antibiotics camp.
“The incidence of postoperative endophthalmitis ranges from 0.08% to 0.68%,” Dr. Grzybowski pointed out. “That’s a risk many surgeons are unwilling to take.” With most surgeons sticking to post-op antibiotics, the fear of this rare but severe infection looms large.
But can we predict who’s at risk? Dr. Grzybowski highlighted a study of over 15,000 surgeries, noting, “A leaking wound on day one post-op was the single biggest relative risk for endophthalmitis.” Capsule breaks and vitreous in the anterior chamber also send alarm bells ringing.
As for prevention, Dr. Grzybowski didn’t hold back on practical tips: “Preoperative irrigation and no topical antibiotics, a solid surgical technique and good wound sealing are key. Don’t forget the intracameral antibiotics!”
And when it comes to those post-op drops? “Use them, but limit it to 3 to 5 days. High concentration, no tapering.”
In short, while the debate rages on, Dr. Grzybowski isn’t taking chances.
However, Dr. Anders Behndig (Sweden) took the other side.
“I strongly support the use of intracameral antibiotics, not post-operative eye drops,” he said before sharing some striking [unpublished] data from Sweden, where the introduction of intracameral antibiotics led to a more than five-fold decrease in endophthalmitis rates.
For those still clinging to their antibiotic drops, Dr. Behndig had more to say. “Few studies have shown a reduction in endophthalmitis with post-op antibiotics compared to placebo,” he pointed out.
But the real kicker came when he crunched the numbers. “Seven million cataract surgeries are performed annually in Europe, using 35,000 liters of levofloxacin eye drops, equivalent to 175 kg of the drug. And for what? We’re talking about preventing 1,400 cases of endophthalmitis—assuming we also use intracameral antibiotics.”
To wrap it up, Dr. Behndig delivered his final punchline: “We’re using 125 grams of levofloxacin to prevent one case of endophthalmitis possibly. And we don’t even know if it truly works!”
Editor’s Note: Reporting for this story took place at the 42nd Congress of the European Society of Cataract and Refractive Surgery (ESCRS 2024), held from 6-10 September in Barcelona, Spain.
