Refractive Surgery for Myopia

Implantation of the posterior chamber phakic implantable collamer lens (ICL) offers a very accurate and safe option for improving visual acuity in eyes with all levels of myopia, according to Roger Zaldivar MD.

“By 2050, 50% of the world’s population will be myopic, including about 1 billion people with more than 6.00 D of myopia. Piggybacking on these data, consider that about 6 million people drop out of contact lens wear each year,” he said.

“I encourage surgeons who have not implanted the ICL to think about using it. In my opinion, it will be the refractive procedure that will have the most growth in the next couple of years.”

List of attributes

Made of a collagen co-polymer with its biocompatibility established through a 30-year track record, he noted the current version of the ICL with its central port allows for both greater safety and faster surgery compared to previous iterations.

“The central port was a game changer,” Dr Zaldivar said. “It eliminated the need to perform a peripheral iridectomy and revolutionised the procedure’s safety profile. Today, the whole surgical procedure takes less than five minutes.”

Compared with all other surgical treatments, the ICL also has the highest safety and efficacy index. Dr Zaldivar cited an analysis of a large cohort of eyes stratified into three groups according to baseline refraction that showed mean CDVA improved from baseline in all groups—but the magnitude of improvement increased as the degree of baseline myopia increased.¹

“We found some eyes treated for >10.00 D of myopia gained four or more lines of CDVA,” Dr Zaldivar said.

Consistent with its efficacy and safety profile, the ICL has garnered high levels of patient satisfaction.

“Even among low myopes, who are perhaps the most difficult patients to make happy, we found 92% rated their satisfaction as ‘10’ (the highest level), and the other 8% graded satisfaction as ‘9’,” Dr Zaldivar said.

Patient selection and procedure tips

The ICL is available in powers ranging from -1.00 D to -18.00 D. Based on its clinical performance, Dr Zaldivar said he is now comfortable offering it to patients aged up to 52 years, whereas his previous cut-off was 45 years.

Appropriate patients would have demonstrated stable refraction and an anterior chamber depth ≥3.00 mm. Shown through the use of a very high-frequency digital ultrasound robotic scanner that the ICL rests on the ciliary body in ~80% of eyes, Dr Zaldivar said he has developed a new formula based on ultrasound measurement that accurately predicts ICL vault, building his confidence in achieving a safe outcome.²

Offering surgical tips, Dr Zaldivar said creating a generous main incision and using the Zaldivar ICL Manipulator for implantation help avoid flipping the IOL. He also recommended using a specific 2% methylcellulose product (OcuCoat) for filling the anterior chamber and being careful when aspirating viscoelastic at the end of the procedure.

“Aspirate gently in a circular pattern over the lens, and do not over-aspirate in the centre because the turbulence created could induce cataract by pushing fluid through the central hole.”

Dr Zaldivar spoke during the 2023 ESCRS Congress in Vienna.

Roger Zaldivar MD, MBA is CEO of the Instituto Zaldiv ar in Mendoza, Argentina. zaldivarroger@gmail.com

1. Zaldivar R, Zaldivar R, Gordillo CH, Adamek P. “Visual Acuity Improvement in Low, Moderate and High Myopia After Posterior-Chamber Phakic Implantable Collamer Lens Surgery in a Large Patient Cohort,” Clin Ophthalmol. 2023; 17: 1179–1185. 

2. Zaldivar R, Zaldivar R, Adamek P, Quintero G, Cerviño A. “Descriptive Analysis of Footplate Position After Myopic Implantable Collamer Lens Implantation Using a Very High-Frequency Ultrasound Robotic Scanner,” Clin Ophthalmol. 2022; 16: 3993–4001.