Phakic IOLs for Myopia and Presbyopia

For many myopic patients with presbyopia, phakic intraocular lenses (PIOL) may be a better surgical option than laser refractive procedures or crystalline lens replacement. PIOLs, including iris claw and posterior chamber lenses, are reversible and avoid several potential complications of irreversible alternatives, according to José Luis Güell MD, PhD.

In this group of myopic patients, “lens extraction clearly has retinal risk if you do it before [age] 55 or 60 years old, and laser corneal refractive surgery … will probably limit the options for the intraocular implant in the future,” Professor Güell said. PIOLs also preserve residual accommodation, improving near vision outcomes compared with pseudophakic IOLs using comparable presbyopia-correcting technology. He outlined three scenarios in which PIOLs can help presbyopic myopes maintain near vision uncorrected until cataracts set in.

Retaining existing PIOLs

The first scenario is myopic patients who already have PIOLs implanted and are now reaching presbyopia age. Most of these patients have had minor myopia progression over the years, Prof Güell noted.

In many cases, this progressing myopia, together with residual accommodation (which tends to be greater in myopes than in emmetropes and presbyopes), provides enough near vision to avoid near correction to at least age 50 to 55 years. With regular biometric, intraocular pressure (IOP), and corneal endothelial cell (EC) count parameters, these patients are often quite comfortable keeping PIOLs in place and using correction only in certain situations, such as night driving.

Targeting monovision

The second scenario is implanting monofocal spherical or toric PIOLs targeting monovision in patients without previous surgery. This has been Prof Güell’s go-to option for treating qualified presbyopic patients with myopia with or without astigmatism and can be done with either iris claw or posterior chamber PIOLs. It is a good alternative for younger patients, say around age 45 years, allowing delay of lens-replacement surgery until an age when retinal risk is lower, he said.

Presbyopia-correcting PIOLs

The third scenario is implanting presbyopia-correcting PIOLs in patients without previous PIOL surgery. Available options include the implantable collamer lens (ICL, STAAR Surgical) and Implantable Phakic Contact Lens (IPCL, Care Group) for posterior chamber placement. The Artiplus (Ophtec) iris claw lens for anterior chamber placement is awaiting CE approval in Europe, but will likely be available in early 2025, Prof Güell noted. So far, he said all three demonstrate significant gains in intermediate and near vision compared with monofocal versions of the same lenses, with the IPCL performing somewhat better than the ICL in published reports.

The Artiplus is notable because it uses the same multifocal refractive optic as the pseudophakic in-the-bag IOL made by the same manufacturer, Prof Güell added. An international study in which Prof Güell participated as clinical coordinator showed it provided uncorrected binocular vision exceeding 0.9 decimal at distance, intermediate, and near for most patients, exceeding the performance of competing PIOLs for near vision.

“Phakic IOLs (particularly the Artiplus model) play a very attractive role in 40- to 60-year-old myopic presbyopes,” Prof Güell concluded, emphasising additional long-term studies are needed to clarify the comparative efficacy and safety of the lenses, and surgeons should be trained in IOL exchange for both the anterior and posterior chambers.

Prof Güell made these comments at the 2024 ESCRS Congress in Barcelona.

José Luis Güell MD, PhD is a professor, founding partner, and cornea and refractive surgery specialist at the Ocular Microsurgery Institute, Barcelona, Spain. guell@imo.es