Phakic IOLs: The Future of Refractive Surgery

Robert M. Kershner, MD, FACS

Tucson, Arizona

If you have been considering adding refractive surgery to your facility but are struggling with the cost of buying or leasing a laser, a whole new world may soon open for you. In the next few years, phakic IOLs will burst upon the refractive surgery scene and change the way we treat ametropia forever. When they do, phakic IOL surgery will be a very attractive procedure to add to your suite of services, and a no-brainer addition if you already perform cataract surgery.

Phakic IOLs work exactly as normal IOLs do, but instead of replacing the natural crystalline lens, they enhance it. A number of companies have released phakic IOLs, but the one that holds the most promise, in my opinion, is the Implantable Contact Lens (ICL), made by Staar Surgical.

The Staar ICL is not a contact lens at all. It is a posterior chamber phakic IOL that rests in front of the lens, behind the iris without touching it. There are three versions of the lens being tested right now. The myopic lens should be available in the US in about 18 months (this lens is already available in Europe); soon after that, a toric lens to correct myopia and astigmatism should be released. A hyperopic lens won’t be far behind.

I started participating in the clinical trials for the ICL back in 1993. Back then, laser surgery was all the rage, but then, as now, lasers had their share of problems—high cost, technically demanding and irreversible. Plus, laser surgery was never a viable option for patients with high degrees of ametropia—the very patients who could most benefit from refractive surgery.

I’ve implanted several phakic IOLs so far, and I’m impressed by how easy the procedure can be. As with any refractive procedure, the patient needs an initial exam, refraction, including a corneal topography evaluation, an A-scan measurement, a chamber depth measurement, and a white-to-white corneal measurement, to assure proper lens placement in planning for the procedure. The surgery itself, which usually takes about 10 minutes, involves applying a drop of topical anesthesia, making a clear corneal incision, and injecting the lens. The surgeon has to be careful not to damage the crystalline lens during this procedure. Most surgeons will quickly get comfortable implanting these lenses with the same instrumentation and maneuvers with which they are already accustomed to with cataract surgery. Most patients can see immediately with superb visual quality (20/20 and even 20/15 in some cases), they retain accommodation, and there is no healing time (the incision heals naturally without a stitch). Another benefit is that the procedure is completely reversible; if the patient isn’t satisfied with his or her vision or needs a higher correction later on, we can remove the lens and insert another one. Risks of the procedure are on par with the risks of cataract surgery. There’s a chance that a surgeon may damage the intraocular structures during the procedure which could induce a cataract in the natural lens, and the rare occurrence of infection or inflammation, but these occurrences, I believe, will be rare.

Staar initially plans to market the IOLs for patients with high ametropia (the company is currently testing powers from –3 to –20 and +3 to +20), but they could correct any degree of refractive error. Staar estimates that the ICL lens kit, which would include the lens and an injector device, would cost about $750; together with other supplies (like an eye drape and BSS), OR time, and staff time, the total case costs would be well under $1,000. Well below the costs of LASIK and the laser, this procedure does not require a large investment in equipment and its potential for obsolescence.

I anticipate that facilities could charge about the same or a bit more for the procedure as LASIK—about $2,500 per eye. However, unlike LASIK, most of the revenue would go to the facility and the surgeon. For a facility that is already doing eye procedures and has an operating microscope and all the accoutrements needed for cataract surgery, the cost of adding phakic IOL surgery would be nothing at all.

Phakic IOLs are the future of refractive surgery. They allow for superior correction of refractive error without the often-prohibitive cost of buying or leasing a laser and microkeratome, the learning curve for doing the surgery is negligible, and the procedure could potentially benefit almost anyone with a refractive error. In the very near future, it’s quite feasible that we’ll enhance IOL surgery by creating IOLs that mimic the focusing ability of the natural lens, and even implanting IOLs with intraocular cameras and zoom lenses, allowing people to have better vision than they ever possible before. There’s no doubt in my mind that laser surgery on the cornea will have a limited lifetime—in the future surgeons will not be cutting, burning or removing tissue from the cornea—intraocular surgery will once again dominate the field of refractive surgery.

Robert M. Kershner, MD, FACS is director of the Eye Laser Centerin Tucson, Arizona and is Clinical Professor of Ophthalmology at the University of Utah School of Medicine, Moran Eye Center in Salt Lake City. Dr. Kershner has no proprietary or financial interest in the device or in STAAR Surgical.