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Visian icl

  1. 1. CHECK OUT OURInsert to DIGITAL edition January/February 2012 Highlights from the 2011 ICL/Toric ICL Experts Symposium Standard Procedure, Exceptional Results - BY ROBERTO ZALDIVAR, MD The Next-Generation Visian ICL - BY KIMIYA SHIMIZU, MD, PHD Clinical Pearls for Implantation of the V4c - BY ERIK L. MERTENS, MD, FEBOPHTH Evolution of Indications for the Visian ICL - BY ALAA EL-DANASOURY, MD, FRCS Nighttime Vision With Low-Diopter ICL - BY GREGORY D. PARKHURST, MD Revolutions in Refractive Surgery - BY GEORGES BAIKOFF, MD The Visian ICL: A Less-Invasive Refractive Surgery Procedure - BY JOSÉ F. ALFONSO, MD, PHD Toric ICL Implantation After CXL to Correct Ametropia in Keratoconic Eyes - BY MOHAMED SHAFIK, MD, PHD
  2. 2. VISIAN ICL Standard Procedure, Exceptional Results Reviewing 18 years of experience implanting phakic IOLs. By Roberto Zaldivar, MD I t has been more than 18 years since I first implanted a posterior chamber phakic IOL. My experience back then in the early 1990s has mirrored my current experience, as the majority of my patients across the decades have experienced excellent visual results after surgery. But many people are curious about those visual results—is this excellent visual quality really long term? In my experience, yes, visual results have been stable over the years, and this has been true across the numerous phakic IOL models I have implanted. The key is to conserve the space between the crystalline lens and the implant. In 1994, I implanted a posterior chamber phakic IOL in one of my friends. He was hyperopic, and the lens I implanted was a 10.00 D Visian ICL (STAAR Surgical). Eighteen years later, my friend’s vision is 20/20 in his right eye and 20/25 in his left. He is still happy with his visual results, and so am I. BACKGROUND The first generation of the Visian ICL was introduced in 1993- 1994. This collamer lens was supported by the zonules. At the time, however, many surgeons were apprehensive of implanting phakic IOLs because of the associated complications, which2 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  3. 3. VISIAN ICLincluded decentration, Aexcessive vault, pupillaryblock, and iris chafing. In myexperience with the originalmodel, decentration was themost frequent complication.This was quickly overcome Bwhen, based on my suggestions,STAAR Surgical redesignedthe ICL’s haptics. These newhaptics resembled feet andwere designed to avoid rotationof the lens. Angulation wasalso incorporated into the new Figure 1. (A) The biomicroscopicdesign, aiming to improve lens postoperative image demonstratespositioning within the sulcus. the visibility of the Visian ICL V4c’s Anterior subcapsular opacities KS-Aquaport, highlighted with thewere also common in the early red arrow. (B) The Sheimpflug imagedays of phakic IOLs, largely reveals adequate distancing betweenbecause of inadequate vaulting the V4c ICL and the crystalline lens,once the lens was implanted. which is called vault.After this point in time, the maincause of the induction of anterior subcapsular opacities was surgicaltrauma, which is still very rare, as well as high-viscosity ophthalmicviscosurgical device (OVD) trapped behind the lens or the absenceof vault. Another drawback frequently described was the pupillary January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 3
  4. 4. VISIAN ICL block caused by excessive space between the implant and the crystalline lens. Shortly after this was discovered, we suggested that peripheral iridectomies should always be performed before posterior chamber IOL implantation. Therefore, the Figure 2. These optical coherence use of iridectomies changed the tomography images show postopera- dynamics of phakic IOL surgery. tive ICL vaults of 0.63 mm in the right Once again, the dynamics eye and 0.88 mm in the left. are changing—this time by eliminating the need for iridectomies by adding a hole to the Visian ICL. This hole, the KS-Aquaport, allows a more natural aqueous flow without the need of an additional surgical procedure. The 0.36-mm aquaport, located centrally, defines the new design of the V4c ICL (Figure 1). This revolutionary posterior chamber phakic IOL is actually a revival of the old Centraflow design, which we developed in 1994. CASE STUDY I have implanted the V4c in 12 eyes. Thus far, my most interesting case is a patient who has the V4c in his left eye and an older Visian ICL model in the right. Before surgery, UCVA in both eyes was counting fingers and BCVA was 20/20 with a manifest refraction of -9.00 -0.50 X 150º and -9.00 -0.50 X 10º in the right and left eyes,4 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  5. 5. VISIAN ICLrespectively. I implanted a -10.00 D V4c in his left eye and a -12.00 DICM125VA in his right. After surgery, his UCVA improved to 20/20in both eyes, and the modulation transfer function (MTF) andoptical scatter index (OSI) were similar with both lens models (ODMTF: 36.6, OS MTF: 26.28; OD OSI: 1.1, OS OSI 1.0). The vault was0.63 mm in the right eye and 0.88 mm in the left (Figure 2). This patient is a prime example of the effectiveness of phakic IOLs,and this example especially highlights the usefulness of the VisianICL V4c with the KS-Aquaport. With this model, I no longer have toperform a iridectomy prior to surgery, saving the patient a trip tothe operating room and freeing up more time for my surgical staff.CONCLUSION Phakic IOL implantation is a standard surgery for me. I think thatphakic IOL implantation with the Visian ICL V4c will be the futuregold standard of refractive surgery. The most important concept thatour learning curve and experience have provided is the knowledgethat the quality of vision with this lens cannot be compared with thevisual outcomes of any other IOL. The Visian ICL provides the bestpoint spread function, the best MTF, and the best quality of vision. n Roberto Zaldivar, MD, is the Scientific Director of the Instituto Zaldivar, Mendoza, Argentina. Dr. Zaldivar states that he is a consultant to STAAR Surgical. He may be reached at tel: +54 261 441 9999; e-mail: zaldivar@ January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 5
  6. 6. VISIAN ICL The Next-Generation Visian ICL Optimizing fluid flow within the eye eliminates the need to perform peripheral iridotomy. By Kimiya Shimizu, MD, PhD M any studies have shown that visual performance after Visian ICL (STAAR Surgical) implantation is superior to visual performance after LASIK.1,2 This was enough to persuade me to move toward implanting phakic IOLs and away from laser vision correction in the majority of my refractive surgery patients. Other surgeons, however, are looking for more advantages before making the switch. For instance, some feel that the need to perform Nd:YAG peripheral iridotomy (PI) days before a phakic lens implantation is a drawback because of the additional surgical visit. Additionally, PIs can be painful for the patient; they can often lead to significant changes in the aqueous dynamics after surgery, and they may occasionally cause cataract, bullous keratopathy, and damage to the corneal endothelium. With the introduction of a new generation of the Visian ICL, the V4c, PIs before phakic IOL implantation are a thing of the past. This latest model may look strange with a hole in the middle, but this hole—the KS-Aquaport (KS-AP)—eliminates the need for a PI and creates a more comfortable and convenient experience for both the patient and the surgeon. By eliminating the need for PI, now phakic IOL implantation not only offers better visual performance than LASIK, but it also has equal efficiency.6IInsert to Cataract & Refractive Surgery Today Europe I January 2012
  7. 7. VISIAN ICLCOMPUTER SIMULATEDMODELS The V4c received theConformiteé Europeéne (CE) Figure 1. The in- and outflow locationsMark in April 2011; I helped for the V4c and the conventional the Centraflowproprietary technology used in this aquaport design. I have beenworking with STAAR Surgical since 2004 to investigate aqueousdynamics after phakic lens implantation in models with andwithout a hole located in the center of the lens. First, we simulatedaqueous dynamics after phakic IOL implantation in models withand without a hole using 3-D eye models. Both ICLs were -9.00 D,12.0 mm in length, and had a vaulting of 0.50 mm. With both lenses,the pore space between the posterior iris and the ICL was 0.05 mmand the angulus iridocornealis was 33º. Figure 1 shows the in- and outflow locations for aqueous humorin phakic IOL designs with and without a hole; outflow locationsinvolved 10% uveoscleral outflow and 90% trabecular outflow. Thesolid-state properties of the aqueous humor were equivalent to thoseof water, and the degree of viscosity was 7.1917X10-4 Pa·s at a 95º F.The quantity of aqueous humor produced by the ciliary body was setat 2.80 µL/min, and the initial pressure was set at 1 atmosphere. Aqueous humor flowed between the ICL and iris in theconventional ICL model, but flow was not observed between theconventional ICL and the crystalline lens. When the hole was present,however, the flow of aqueous humor was observed between the ICL January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 7
  8. 8. VISIAN ICL and the crystalline lens. The diameter of the hole in these simulations was at least 0.25 mm. ANIMAL MODELS We then conducted an animal study to confirm the movement of aqueous humor between the ICL and Figure 2. The movement of aqueous humor the crystalline lens. A was confirmed in the porcine eye that received phakic ICL with a 0.36- the ICL with a 0.36-mm hole. mm hole was inserted into one porcine eye and a conventional phakic ICL into the other. After surgery, the flow of aqueous humor was observed by injecting silicone powder behind the ICL in both eyes; movement was confirmed in the eye that received the ICL with a 0.36-mm hole. In this eye, the fluid moved from the lens equator toward the center, most likely resembling a normal aqueous flow pattern (Figure 2). In the eye with conventional ICL, we assumed that the aqueous fluid behind the ICL moved across the lens and toward the location of the PI. We also examined optical performance by measuring the modular transfer function (MTF) of both ICL designs. At a spatial frequency of 100 cycle/mm, the MTF for the conventional ICL and8 I Insert to CataraCt & refraCtIve surgery today europe I January 2012
  9. 9. VISIAN ICLthe ICL with a 0.36-mm hole A Bwas 0.33 and 0.32, respectively.PILOT, CLINICAL STUDIES Our next step was toperform a pilot study.Implantation of the VisianV4c was performed in one Figure 3. (A) Cataract formation waseye of eight patients, with the noted in one eye that received a con-contralateral eyes receiving ventional ICL; (B) no cataract formationa conventional ICL. Patients’ was noted in the eyes that received theaverage refractive correction V4c with the KS-AP.was -8.70 D, and the averagecylinder was 2.03 D. We demonstrated that, with the V4c, BCVAand UCVA were excellent, and there was no rise in intraocularpressure. Only one cataract was observed, and that was in an eyewith the conventional ICL (Figure 3). Follow-up was 3 years. We recently conducted a contralateral study in 42 eyes (21 patients) tocompare results with the Visian ICL V4c to results with the conventionalVisian ICL. PIs were first performed in those eyes that did not receivethe V4c. At 1 day postoperative, the anterior chamber was clear andthere were no signs of pigment dispersion or hemorrhage in eyes thatreceived the V4c. Additionally, there was less inflammation in theseeyes, and visual performance was similar to visual performance with theconventional ICL. There were no postoperative complications such asglare and halo, and all patients were satisfied with their results. January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 9
  10. 10. VISIAN ICL CONCLUSION The Visian V4c is an exciting development. It helps reduce the burden of phakic lens implantation by eliminating the need for PI. As we continue our observation of cataract formation after implantation of the Visian V4c, we are encouraged by the results from our preclinical and clinical studies and look forward to implanting more lenses in our patients. ■ Kimiya Shimizu, MD, PhD, is a Professor and Chair of the Department of Ophthalmology, School of Medicine, Kitasato University, Kanagawa, Japan. Dr. Shimizu states that he is a paid consultant to STAAR Surgical. He may be reached at tel: +81 42 778 8464; fax: +81 42 778 2357; e-mail: 1. Kamiya K, Shimizu K, Igarashi A, Komatsu M. Comparison of collamer toric implantable contact lens implantation and wavefront-guided laser in situ keratomileusis for high myopic astigmatism. J Cataract Refract Surg. 2008;34:1687-1693. Click here for article 2. Igarashi A, Kamiya K, Shimizu K, Komatsu M. Visual performance after implantable collamer lens implantation and wavefront-guided laser in situ keratomileusis for high myopia. Am J Ophthalmol. 2009;148:164-170. Click here for article10 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  11. 11. VISIAN ICLClinical Pearls forImplantation of the V4cInclusion of an aquaport in the center of the ICL boostspatient—and surgeon—satisfaction.By Erik L. Mertens, MD, FEBOphthI n June 2011, I implanted some of the first phakic IOLs with a 0.36- mm port located in the center of the optic. This aquaport, which is designed to restore more natural aqueous flow and eliminate theneed for iridotomy, sets the Visian ICL V4c (STAAR Surgical) apartfrom the earlier model, the V4b. Because I no longer have to performan iridotomy prior to lens implantation, the V4c has evolved the way Iperform phakic IOL implantation. In this article, I share some pearls forimplantation and highlight a recent case in which I implanted the V4c. I initially implanted the Visian ICL V4c in five eyes with myopia(range, -6.00 to -8.00 D) as part of larger series of 100 eyesimplanted with the V4c phakic IOL. These implantations wereprior to the full market launch in countries that accept ConformitéEuropéenne (CE) Mark approvals. I have now implanted 48 V4cimplants (38 spheric and 10 toric) in approximately 7 months, andmore than 1,300 V4c ICLs have been implanted across Europe.ADDITIONAL PORTS In addition to the proprietary KS-Aquaport in the center of the ICL, January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 11
  12. 12. VISIAN ICL the V4c also has two 0.36-mm ports located just outside the optic. Designed to simplify the removal of ophthalmic viscosurgical device (OVD) after surgery, these holes also allow aqueous to flow over a wider surface are of the crystalline lens. Inclusion of the aquaport as well as the two additional ports Figure 1. OCT image with vault outside the optic of the V4c measurement and KS-Aquaport give the surgeon a higher safety visualization. net and, as my patients have experienced, better surgical results. Specifically, the aquaport eliminates the need to perform Nd:YAG iridotomy or peripheral iridectomy before implantation of the ICL and therefore naturally the possible issues associated with these procedures. It also potentially reduces endothelial cell loss. EASY TO PERFORM The Nd:YAG iridotomy step has been completely eliminated with the V4c, making the overall procedure more in line with a LASIK procedure. It is faster, and it is more like a basic consultation surgery because implantation is done on the same day as the preoperative examination. During surgery, it is also easier to remove the OVD.12 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  13. 13. VISIAN ICL At the start of surgery, Iload the V4c into an injectorand fill the cartridge withan OVD. I then use a pair offorceps to pull the V4c intothe tip of the cartridge untilI can see all three holes. Thiswill ensure that the lens will Figure 2. Slit-lamp picture; thebe delivered into the anterior KS-Aquaport is visible.chamber safely and accurately.Once the lens is in place, I irrigate the OVD from the anteriorchamber, maneuvering the ICL to make some space and directingmy irrigation port toward the aquaport. The OVD easily migratesfrom the anterior chamber, where it can then be aspirated safely.POSTOPERATIVE FOLLOW-UP One day after surgery, the aquaport is still visible and can befound slightly temporal to the pupillary center (Figures 1 and 2).Typically the edges of the lens are not visible, and therefore glare isminimized. To date, there has been no induction of higher-orderaberrations after V4c implantation. We have not had to changeour nomogram for the ICL. In my experience, there have been no rises of intraocularpressure, no change in refractive outcomes, and no patientcomplaints or visual symptoms after surgery. January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 13
  14. 14. VISIAN ICL CASE STUDY In one of my most recent cases, a patient presented with thick corneas in both eyes. He had low myopia, -0.75 D of sphere in both eyes. The sulcus-to-sulcus was 12.20 mm, and the white-to-white was 11.40 mm; I chose a lens one size larger than the software suggested, implanting a 13.2 VTICM0 instead of a 12.6. Postoperatively, the vault was 760 µm in the right eye and 620 µm in the left eye. Just like all of my other patients implanted with the Visian ICL V4c, this patient was happy with his visual outcomes, and I was happy that the procedure took less time and was easier to perform than in the past. The combination of an aquaport in the center of the optic to alleviate the need for iridotomy and the additional ports outside the optic to ease removal of the OVD make the V4c my first choice for patients who are considering a phakic IOL (Click here to see video). n Erik L. Mertens, MD, FEBOphth, is Medical Director of Medipolis, Antwerp, Belgium. Dr. Mertens states that he is a paid consultant to STAAR Surgical. Dr. Mertens may be reached at tel: +32 3 828 29 49; email: I Insert to CataraCt & refraCtIve surgery today europe I January 2012
  15. 15. VISIAN ICLEvolution of Indicationsfor the Visian ICLImplantation of this lens is not just for patients with highmyopia anymore.By Alaa El-Danasoury, MD, FRCSO ver the past several years, the Visian ICL (STAAR Surgical) has become my exclusive phakic IOL of choice. Before this time, I implanted various phakic IOL designs, but,based on long-term results and patient satisfaction, I reached theconclusion that the Visian ICL provided my patients with the bestvisual outcomes after surgery. I began using the ICL in a selectpopulation of patients with LASIK contraindications—mainlyin those with high myopia, with thin or steep corneas, or withsuspicious topography. Today, however, there are a variety ofindications for phakic IOL implantation that continue to increaseyear after year.ADDITIONAL INDICATIONS Stable keratoconus. The first indication that I added wasfor patients with stable keratoconus. In these cases, I implanta toric ICL. The caveat is that the keratoconus (refraction andtopography) must be stable for at least 2 years. In the past 6 years of implanting the Visian ICL in this January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 15
  16. 16. VISIAN ICL population, which includes more than 180 eyes, I have not had to do a single corneal graft. In a subgroup of 29 eyes with keratoconus that received the toric ICL to correct compound myopic astigmatism, all patients are happy with their spectacle- corrected vision. With the exception of three outliers, all were within ±0.50 D of intended correction at 12 months. Additionally, 68.9% of eyes gained at least 1 line of visual acuity (1 line, 37.9%; 2 lines, 20.7%; and 4 lines, 10.3%); 31% of patients did not gain or lose lines, and no patient lost more than 1 line of visual acuity. I also found that predictability with a toric ICL is similar to predictability with a standard ICL. After implantation of an intrastromal corneal ring segment. I am now also comfortable implanting the Visian ICL in patients who need further correction after intracorneal ring segment implantation, as long as keratoconus is stable. These patients are usually good candidates for ICL implantation as long as they have acceptable BCVAs. Corneal collagen crosslinking for keratoconus. Patients whose keratoconus is stable but still need correction after corneal collagen crosslinking (CXL) are also very good candidates for the Visian ICL. CXL has helped thousands of patients with keratoconus in my practice; however, many of these patients still seek refractive correction after surgery. Some surgeons are starting to treat, at least partially, the refractive errors associated with keratoconus using surface ablation techniques. I do not perform excimer laser ablation before, after, or simultaneously with CXL, partly because16 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  17. 17. VISIAN ICLI am still waiting cautiouslyfor the long-term results andpredictability. This is alsobecause I believe that theVisian ICL is the better choiceto correct refractive error inthese patients, provided their Figure 1. The ICL was implanted in aBCVA is acceptable. patient who previously underwent I recently conducted a study corneal grafting. In this case, the vaultto determine the safety and was 0.24 mm.effectiveness of CXL after VisianICL implantation. What I foundis that even if keratoconusprogresses many years afterICL implantation, it is safe to Figure 2. The ICL can also be implantedperform CXL with the ICL in in a pseudophakic eye, with adequatethe eye without affecting the space between it and the of the lens. After corneal graft. Visian ICL implantation is my procedureof choice to correct emmetropia after corneal grafts, especiallylamellar grafts. During preoperative counseling, I explain to thepatient that approximately1 year after corneal grafting the sutures will be removed and thenin an additional 3 months, I will implant a Visian ICL (if the patienthas 1.00 D or less of cylinder) or a toric ICL (if the patient has morethan 1.00 D of cylinder) to correct residual emmetropia (Figure 1). January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 17
  18. 18. VISIAN ICL I choose to implant the Visian ICL instead of performing LASIK because the predictability is much higher due to variable changes to the cornea after LASIK. Pseudophakia. If a patient is pseudophakic and presents with a refractive surprise, I will now implant an ICL (Figure 2) because I feel that it provides the best possible results for these patients. This is the newest indication for me, with only four procedures to date. These patients are enjoying very good vision after secondary implantation of the Visian ICL. INCLUSION CRITERIA It is easy to see that the phakic IOL is not only for patients with LASIK indications, and in my practice we use the following protocol: • If the patient has very high myopia (more than 8.00 D), the Visian ICL is the best (only) choice; • If the patient has high myopia (6.00–8.00 D), the ICL is still my preferred choice, but I will give the patient the option of phakic IOL or femtosecond LASIK; and • If the patient is myopic and has less than 6.00 D, then I will perform femtosecond LASIK. However, every now and then, when a patient comes in who knows a family member or friend with a phakic IOL and wishes to receive the same treatment, I will happily implant the Visian ICL even in patients with very low amounts of myopia. With the Visian ICL’s new improvements, the indications for18 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  19. 19. VISIAN ICLphakic IOL implantation and the inclusion criteria will continueto expand. For instance, I am looking forward to treating patientswith lower refractive errors. I have a lot experience with the VisianICL over the past few years, and the bottom line is that sizing isexcellent; the white-to-white measurement is good, the sulcus-to-sulcus measurement is very good, and there is no iris chafing.CONCLUSION Phakic IOLs are an attractive option for refractive correction.Therefore, the Visian ICL, as well as the toric ICL, are an essentialcomponent of any accomplished refractive surgeon’s practice.Phakic lens implantation is not a complicated procedure; to me,this procedure keeps my refractive surgery patients very safe. I donot have to push the limits of LASIK, and new indications for thephakic IOL are continually developing, especially after release ofthe newest model, the V4c. ■ Alaa El-Danasoury, MD, FRCS, is Chief of Cornea and RefractiveSurgery Service at Magrabi Eye Hospitals and Centers, Saudi Arabia,Gulf Region & Egypt. Dr. El-Danasoury states that he is a paidconsultant to STAAR Surgical. He may be reached at e-mail: January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 19
  20. 20. VISIAN ICL Nighttime Vision With Low-Diopter ICL In one measure of visual quality, the ICL outperforms LASIK. By Gregory D. Parkhurst, MD T he armed forces are a unique population of individuals who are exposed to various environments, treacherous war zones, and frequent trauma. Due to the extreme nature of their surroundings and the intense demands placed on them, persons in the military must have excellent vision. The US Army has a conservative approach to adopting new technology; therefore, before any refractive surgery technique is approved for use, it must undergo studies to confirm stability and safety. Since 2003, more than 160,000 members of the US armed forces have reportedly undergone successful refractive surgery procedures.1 In 2007, the US Army began studying the use of phakic IOLs to correct refractive errors, specifically the Visian ICL (STAAR Surgical). The procedure was being studied on an investigational basis in soldiers at Army refractive surgery centers who were not candidates for laser vision correction. One of the centers that published results of this study was Fort Hood, Texas, which is home to approximately 42,000 soldiers and is the largest military installation in the world by land area. Approximately 4,000 refractive surgery procedures are performed each year at Fort Hood.20 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  21. 21. VISIAN ICLRETROSPECTIVE ANALYSIS Several studies have beenperformed to test the safetyand efficacy of the VisianICL. In the first retrospectiveanalysis performed at Fort Figure 1. Refractive predictabilityHood between June 2008 and plot for 13 eyes that underwent ICLJuly 2009, the preoperative implantation.characteristics and short-termpostoperative outcomes were analyzed for the first 206 cases of ICLimplantation. Preoperatively, the mean sphere, cylinder, and sphericalequivalent were -5.86 D (range, -2.50 to -11.00 D), -0.68 D (range, 0.00to -2.25 D), and -6.20 D (range, -2.63 to -11.50 D), respectively, and thestandard deviations were 1.92, 0.51, and 2.04, respectively. A total of 139eyes were available for 3-month follow-up. At 3 months, 96% of eyeshad achieved a UCVA of 20/20 or better, and 67% of eyes had achieveda UCVA of at least 20/15. Only six eyes did not achieve at least 20/20UCVA, all of which had 1.25 D or more of cylinder before surgery. At 3 months, the average targeted spherical equivalent was -0.22D; the average achieved spherical equivalent was -0.17 D. Of the 132available eyes having postoperative manifest refraction, 89% werewithin ±0.50 D of intended correction, and 100% were within ±1.00 Dof intended correction (Figure 1). The safety index for ICL implantation was 1.78, with 34% of patientsgaining at least 1 line of BCVA. Thirteen percent of patients gained 2lines, 21% gained 1 line, and 65% of patients neither lost nor gained January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 21
  22. 22. VISIAN ICL lines of BCVA. The efficacy index was 1.15, with 79% of patients achieving the same or better UCVA compared with the preoperative BCVA. Only 4.8% of patients reported occasional glare and halos, which was related to the iridotomy in two cases. In one eye, iritis developed 1 month after surgery. Three ICLs were explanted, one for excessive vault and two for human error in lens power selection. Lastly, one patient experienced new-onset nyctalopia. There was no incidence of postoperative endophthalmitis, retinal detachment, postoperative cystoid macular edema, pigment dispersion, iris chafing, corneal decompensation, or cataract. From this retrospective study, the authors concluded that early results showed the Visian ICL to be effective in this population when corneal topography or residual bed thickness was in question for LASIK. Between June 2008 and December 2010, we implanted the ICL in 792 of the 9,357 refractive surgery cases performed at Fort Hood. PROSPECTIVE NIGHT VISION ANALYSIS The second study we performed was a prospective comparative analysis of 95 eyes that underwent Visian ICL implantation or LASIK. All eyes were matched by degree of myopia (range, -3.00 to -11.50 D) and had no more than 2.25 D of astigmatism. Visual testing and aberrometry as well as interpretation of the results were performed by individuals who were blinded to the procedure. The study was nonrandomized, as the ICL is still used on an investigational basis in non-LASIK candidates (ie, patients with thin corneas, abnormal topography, corneal scars, etc.).22 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  23. 23. VISIAN ICL The LASIK cohort includedA B 24 patients (48 eyes) for whom a surgeon-specific nomogram adjustment (DataLink; Surgivision Consultants) was used to selectFigure 2. Refractive accuracy in the (A) the treatment profile for theLASIK and (B) ICL groups. laser ablation (400-Hz Allegretto Wave; Alcon Laboratories, Inc.).Flap creation was performed using a femtosecond laser (IntraLase;Abbott Medical Optics Inc.). In all 24 ICL patients (47 eyes), a laserperipheral iridotomy was performed before lens implantation, andduring surgery a primary incision was placed temporally or on thesteep axis of corneal cylinder. No astigmatic treatments (limbal relaxingincisions or bioptics) were performed. Outcome measures included refractive accuracy, photopic visualacuity and contrast sensitivity, aberrometry, and night vision acuity andcontrast sensitivity. Preoperatively, the mean spherical equivalent beforesurgery was -6.04 in the LASIK group and -6.1 in the ICL group (P=NS),and the mean preoperative astigmatism and pachymetry were 0.96 Dand 0.60 D and 571.3 µm and 547.3 µm, respectively, in each group. Three months after surgery, almost all (98%) eyes in the ICL group werewithin ±0.50 D of intended correction, and 92% in the LASIK group werewithin the same intended correction (Figure 2). In reference to distanceUCVA at 3 months, 96% of eyes were 20/20 or better, including caseswith up to 1.50 D of astigmatism and/or abnormal corneas, comparedwith 94% of patients in the LASIK group comprised of normal corneas January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 23
  24. 24. VISIAN ICL (Figure 3). Although there A B was no significant difference in photopic visual acuity between the groups, only eyes in the ICL group experienced a significant C improvement in photopic contrast sensitivity at 3 months. Additionally, low luminance visual acuity improved significantly in the ICL group, whereas there was no statistically significant improvement in the LASIK Figure 3. Distance UCVA in (A) LASIK group. Both groups experienced and (B) ICL patients at 3 months. (C) a significant improvement in low Change in BCVA at 3 months. luminance contrast sensitivity, and the improvement was statistically significantly greater in the ICL group (P=.040). This may be due to a greater induction of higher-order aberrations that was seen after LASIK as compared with ICL implantation. CONCLUSION To date, after more than 1,500 cases of ICL implantation at various Army refractive surgery centers, there have been zero reported cases of retinal detachment, endophthalmitis, postoperative cystoid macular edema, or traumatic lens dislocation. Although there is no way to quantify all types of potential eye trauma, the procedure has seemed to hold up well to trauma in a few known case reports (Figure 4). In studies performed24 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  25. 25. VISIAN ICLA B C Figure 4. (A) During long-jump training, this patient took a reflector belt to the eye 10 months after LASIK. (B) Epithelial ingrowth was seen 2 weeks after flap repositioning in this case, and the patient’s UCVA worsened to 20/50. (C) This patient was hit with an elbow in the eye 8 months after ICL implantation. The ICL was rotated vertically, and the patient’s UCVA remained 20/20; no cataract developed. thus far, the ICL has provided sharp vision and excellent low luminance contrast sensitivity, two important aspects for soldiers and other patients who function at night. For these reasons, I consider ICL implantation a viable option for refractive correction in troops. ■ Gregory D. Parkhurst, MD, is a cataract and refractive surgeon at McFarland Eye Centers, Little Rock, Arkansas. Dr. Parkhurst states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government. Opinions, interpretations, conclusions, and recommendations herein are those of the authors and are not necessarily endorsed by the US Army. January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 25
  26. 26. VISIAN ICL 1. Parkhurst GD, Psolka M, Kezirian GM. Phakic intraocular lens implantation in United States military warfighters: A retrospective analysis of early clinical outcomes of the Visian ICL. J Refract Surg. 2011. Click here for article26 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  27. 27. VISIAN ICLRevolutions in Refractive SurgeryA review of anterior chamber phakic IOLs.By Georges Baikoff, MDW hen I started implanting phakic IOLsmany years ago, there wasno available device to imagethe anterior segment. Atthe time, the small numberof us surgeons implantingthese lenses were pioneersof the technology. We didnot know exactly where the Figure 1. There must be adequatebest placement of the lens clearance between the edges of thewas, nor could we predict phakic IOL and the endothelium.our patients’ postoperativeresults. Over time, we learned that in order to have excellentpostoperative results, we needed to respect certain distances inthe anterior chamber, including clearance between the lens andthe endothelium (Figure 1). Today, we not only have the necessary tools to image the anteriorsegment, but we also have state-of-the art phakic lenses thatprovide patients with superior visual quality. One of these lenses January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 27
  28. 28. VISIAN ICL is the Visian ICL (STAAR Surgical). The V4b, and now the V4c, has an expanded treatment range that allows refractive surgeons to treat all patients—those who are both ineligible and eligible for LASIK. The newest design is the V4c, which includes Centraflow technology with the KS-Aquaport. This revolution in phakic IOL design has simplified the surgical procedure, eliminating the need for a peripheral iridotomy before implantation. EARLY PHAKIC IOL DESIGNS The culmination of the V4c lens design is a product of years of trial and error with other phakic IOLs. The first attempt at using an anterior chamber refractive lens to correct high myopia in the phakic eye occurred in the 1950s. Complications including glaucoma, corneal dystrophy, and hyphema were associated with imperfections in the lens design,1 and these efforts were abandoned. More than 30 years after the initial effort to design a phakic lens, I, along with Svyatoslav N. Fyodorov, MD, of Moscow, and Paul U. Fechner, MD, of Germany, tried to develop phakic IOLs. Dr. Fyodorov’s efforts ultimately led to the development of several phakic IOL concepts that are still in use today, including the design of the Visian ICL. The implant that I designed was an angle-supported implant, the ZB Baikoff Phakic IOL (Domilens GmbH). This one-piece phakic IOL had a PMMA haptic and optic. Because of its rigid design, it was inserted through a 5.5- mm incision. To prevent endothelial loss, at least 1.5 mm was left in between the edges of the optic and the endothelium. To date,28 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  29. 29. VISIAN ICLmany of these lenses have been explanted. The Artisan phakic IOL (Ophtec BV) is another model that had arocky beginning. It also has a one-piece lens design with a PMMAhaptic and optic that is implanted through a 5.5-mm incision. Oneof the major differences from the ZB Baikoff implant is that it is aniris-fixated design; this design can cause late considerable endothelialcell loss, and therefore safety in the earlier models was questionable.In our study, this lens had a 6% rate of pigment dispersion. Other phakic lens designs that enjoyed limited successes includethe Vivarte phakic IOL and the Newlife. The Vivarte showed goodsafety at 3 years, but after this point endothelial cell loss started tooccur and was higher than the typically acceptable rate of 2%. The main problem with anterior chamber phakic IOLs was thatthey seemed to cause pigment dispersion, which was mainly dueto the forward motion of the crystalline lens. Most of these lensstyles have since been removed from the eyes of our patients, aspigment dispersion synechiae on the surface of the capsule cancause cataract. Today, refractive results after phakic IOL implantation are stable,thanks to new posterior chamber lens designs, and there are feweroptical aberrations compared with LASIK.2,3 Phakic lenses surelyhave come a long way since the early 1980s, and thankfully we havea winning formula with the posterior chamber phakic IOL design.CONCLUSION To summarize, anterior chamber phakic IOLs cause various January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 29
  30. 30. VISIAN ICL complications that likely warrant removal of the lens. For this reason, I believe it is important to mainly use a posterior chamber phakic IOL. ■ Georges Baikoff, MD, is Director and Professor of Eye Surgery at the Ophthalmology Centre of the Monticelli Clinic, Marseilles, France. Dr. Baikoff states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +33 491 16 22 28; e-mail: 1. Baikoff G, Lutun E, Ferraz C, et al. Analysis of the eye’s anterior segment with an optical coherence tomography: static and dynamic study. J Cataract Refract Surg. 2004;30:1843-1850. Click here for article 2. Baikoff G, Lutun E, Ferraz C, et al. Refractive Phakic IOLs: contact of three different models with the crystalline lens, an AC OCT study case reports. J Cataract Refract Surg. 2004;30:2007-2012. Click here for article 3. Baikoff G, Bourgeon G, Jitsuo Jodai H, et al. Pigment dispersion and artisan implants. The crystalline lens rise as a safety criterion. J Cataract Refract Surg. 2005;31:674-680. Click here for article30 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  31. 31. VISIAN ICLThe Visian ICL: A Less-InvasiveRefractive Surgery ProcedureImplantation of a phakic IOL does not require a flap cut.By JosÉ F. Alfonso, MD, PhDT wo of the largest drawbacks for a young ophthalmologist just beginning his or her career in refractive surgery are the surgical complications associated with conventionalmicrokeratome cuts and the cost of owning a femtoseond laserto create a LASIK flap. Fortunately, microkertome cuts andfemtosecond-laser assisted flaps are no longer required to providepatients with the best refractive results, thanks to modern PRKtechniques and new phakic IOLs. These two strategies adequatelycorrect most ammetropies and provide us with the fundamentalcriteria of efficacy, safety, and predictability that our patients need.In this article, I demonstrate these arguments. I have more than 25 years of experience performing excimerlaser ablations including PRK as well as LASIK (with and withouta femtosecond laser), phakic IOL implantation, and refractivelensectomy. Most of our complications after PRK have beeneliminated by intraoperative use of mytomicin C and postoperativeapplication of sodium hyaluronate and contact lenses for the firstweek after surgery. In less than 72 hours after PRK, the wound heals,and within the first week the patient can resume normal activities. January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 31
  32. 32. VISIAN ICL The range of correction with PRK is between -5.00 and 2.50 D of sphere, with up to 5.00 D of astigmatism. PREFERRED STRATEGY FOR Figure 1. The spherical diopter range REFRACTIVE CORRECTION of the Visian ICL spans from -18.00 D My preferred refractive to 10.00 D. strategy, however, is implantation of a posterior chamber phakic IOL, such as the Visian ICL (STAAR Surgical). Beyond the good optical quality, phakic IOLs have a large dioptric range (Figure Figure 2. Safety profile of 123 eyes 1), allowing us to correct implanted with the Visian V4b. practically any refractive error. Additionally, because this lens has a large dioptric range (-18.00 to 10.00 D), we can marry lens implantation with PRK to avoid the need for LASIK. Numerous studies have demonstrated their good visual results.1-5 In our last study of 123 eyes (71 patients), we implanted the V4b ICL. The mean preoperative sphere was -8.20 ±3.34 D, which improved to -0.09 ±0.28 D after surgery. Mean cylinder improved from -0.90 ±0.68 D before surgery to -0.26 ±0.39 after surgery. Distance BCVA improved as well, from 0.90 ±0.10 before surgery to 1.0 ±0.1 after surgery.32 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  33. 33. VISIAN ICL We also showed the safety ofthe technique, as all eyes hadthe same or better vision afterlens implantation (Figure 2).The predictability is excellent,with more than 93% of eyesreaching the target refraction Figure 3. The mean postoperativeand, because of modern sizing vault in this population of eyes wasnomograms based on optical 464.8 ±228.1 µm.coherence tomography andultrasound biomicroscopy, weachieved a safe vault in morethan 90% of eyes (Figure 3). Figure 4. The new Visian V4c has aCataract formation was also hole in the center of the optic.easily avoided by optimizingthe calculation for selecting ICL size as well as exchanging the ICL ifcontact with the crystalline lens occurred. However, several studieshave confirmed that the incidence of cataract after ICL implantationis approximately 1.3%.2,6-8A NEW DESIGN, a new STRATEGY In addition to cataract formation, some surgeons are worriedabout inducing a pupillary block after phakic IOL implantation.Previously, surgeons had to perform an iridectomy before surgery;however, the newest Visian ICL, the V4c, has a perforating centralhole that allows aqueous humor flow without the need of an January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 33
  34. 34. VISIAN ICL iridectomy. We recently started implanting this lens (Visian V4c; Figure 4) and are impressed with the normal values of intraocular pressure measured immediately after surgery. The surgery is easier and faster than with previous models. Going back to those young ophtlamologists just starting their refractive surgery careers, even the novel surgeon can perfect this procedure, as there is only a short learning curve. In addition to using the new V4c in my patients, I have also started to combine ICL implantation with the use of intrastromal corneal ring segments (ICRSs). This is an effective technique for patients with keratoconus who also desire a large refractive correction. With this strategy, the main objective is to correct the corneal astigmatism with the ICRSs and the sphere with the ICL. Any residual astigmatism can then be treated with limbal relaxing incisions performed during the ICL surgery. CONCLUSION Phakic IOLs are an excellent choice to correct refractive errors for various reasons. In addition to the benefits of eliminating the need for flap creation, whether that is with a conventional microkeratome or femtosecond laser, phakic IOLs also provide patients with good optical quality. Specifically, the large dioptric range of the Visian ICL allows me to correct practically any refractive error, leaving my patients satisfied. I prefer ICL implantation over all other strategies and have started combining it with procedures such as PRK and ICRS implantation for even better results. ■34 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  35. 35. VISIAN ICL José F. Alfonso, MD, PhD, practices at the Fernández-Vega Ophthalmological Institute, Surgery Department, School of Medicine, University of Oviedo, Spain. Dr. Alfonso states thathe has no financial interest in the products or companies mentioned.He may be reached at tel: +34 985245533; fax: +34 985233288;e-mail: Alfonso JF, Fernández-Vega L, Lisa C, Fernandes P, Jorge J, Montés MicóR. Central vault after phakic intraocular lens implantation: Correlationwith anterior chamber depth, white-to-white distance, sphericalequivalent, and patient age. J Cataract Refract Surg. 2012;38:46-53. Clickhere for article2. Alfonso JF, Baamonde B, Fernández-Vega L, Fernandes P, González-Méijome JM, Montés-Micó R. Posterior chamber collagen copolymerphakic intraocular lenses to correct myopia: five-year follow-up. J CataractRefract Surg. 2011;37:873-880. Click here for article3. Alfonso JF, Baamonde B, Madrid-Costa D, Fernandes P, Jorge J, Montés-Micó R. Collagen copolymer toric posterior chamber phakic intraocularlenses to correct high myopic astigmatism. J Cataract Refract Surg.2010;36:1349-1357. Click here for article4. Alfonso JF, Fernández-Vega L, Fernandes P, González-Méijome JM,Montés-Micó R. Collagen copolymer toric posterior chamber phakicintraocular lens for myopic astigmatism: one-year follow-up. J CataractRefract Surg. 2010;36:568-576. Click here for article5. Alfonso JF, Lisa C, Abdelhamid A, Fernandes P, Jorge J, Montés-Micó R.Three-year follow-up of subjective vault following myopic implantable January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 35
  36. 36. VISIAN ICL collamer lens implantation. Graefes Arch Clin Exp Ophthalmol. 2010;248:1827-1835. 6. Sanders DR. Anterior subcapsular opacities and cataracts 5 years after surgery in the visian implantable collamer lens FDA trial. J Refract Surg. 2008;24:566-570. Click here for article 7. Alfonso JF, Lisa C, Palacios A, Fernandes P, González-Méijome JM, Montés- Micó R. Objective vs subjective vault measurement after myopic implantable collamer lens implantation. Am J Ophthalmol. 2009;147:978-983. 8. Fernandes P, González-Méijome JM, Madrid-Costa D, Ferrer-Blasco T, Jorge J, Montés-Micó R. Implantable collamer posterior chamber intraocular lenses: a review of potential complications. J Refract Surg. 2011;27:765-776. Click here for article36 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  37. 37. VISIAN ICLToric ICL Implantation AfterCXL to Correct Ametropia inKeratoconic EyesComparison of visual outcomes.By Mohamed Shafik, MD, PhDI n the early stages of keratoconus, corneal integrity can be restored using several different approaches, including corneal collagen crosslinking (CXL) to increase corneal rigidity,intrastromal corneal ring segments (ICRS) to flatten the corneaand change its refraction, and various forms of keratoplasty toreplace the damaged cornea with a healthy donor. Regardless ofthe strategy, the goal of keratoconus treatments is to correct thepatient’s distorted vision and, if caught early enough, spare thecornea from the need for transplantation. The newest of these keratoconus treatments is CXL. Thisminimally invasive procedure uses riboflavin and ultraviolet lightto increase the crosslinks in corneal collagen, thus flattening thekeratometric values, improving UCVA and BCVA, arresting theprogression of keratoconus, and possibly preventing furtherdeterioration of vision. The results after CXL are typicallysignificant in the first 6 months following the procedure and thenstabilize thereafter. January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 37
  38. 38. VISIAN ICL The ultimate goal of CXL is to produce a central shift of the cone, leading to a stable refraction; however, CXL does not treat the previous refractive error, and therefore the patient must continue relying on glasses or contact lenses for correction of sphere and cylinder. In our high-demand society, patients expect refractive procedures to offer a solution for all refractive errors. Therefore, I now offer patients a combination procedure: toric phakic IOL implantation after CXL. This strategy provides patients with a practical solution to correct ametropia in a stable, crosslinked keratoconus eye. I started using this combined procedure in July 2008, implanting the Visian Toric ICL (STAAR Surgical) approximately 9 months after CXL to correct the residual spherical and cylindrical refractive errors. STUDY My results with this combination strategy are promising. I now have 18-month follow-up for 16 eyes, all of which were keratoconic and had no history or physical signs of ocular disease (other than myopia); UCVA was 20/40 or worse, and intraocular pressure was below 20 mm Hg. All eyes had a normal anterior segment (anterior chamber depth of 3 mm or greater), a clear cornea 9 months after CXL, and a stable subjective refraction for at least 3 months before Toric ICL implantation. For each case, the the lens power was determined based on the patient’s subjective refraction of sphere, cylinder, and axis. The preoperative mean38 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  39. 39. VISIAN ICL BCVA was 0.63 ±0.14. After surgery, the mean UCVA was 0.88 ±0.18, with all eyes gaining 1 or more lines (Figure 1). I believe these outcomes were the result of Figure 1. BCVA (blue) and UCVA (red) combining CXL with Toric before CXL; before ICL implantation; 7 ICL implantation, as the CXL days and 1, 3, and 6 months after ICL flattened the cornea and implantation; and 1 and 2 years after improved corneal symmetry, ICL implantation. and the Toric ICL corrected residual sphere and cylinder to overcome the aberrations induced by the previous corneal irregularity. Results in these eyes were Figure 2. Mean keratometry in the ICL compared with the results (group 1) and ICRS (group 2) groups of 20 keratoconic eyes that before and at 3, 6, and 12 months after underwent ICRS implantation surgery. followed by CXL on the next day. The mean agein both groups was similar (25.6 ±4.1 years in the ICL group vs29.7 ±2.6 years in the ICRS group), and there were no intra- orpostoperative complications in either group. At 12 months, themean keratometry reading was 48.7 in the ICL group and 49.67 in January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 39
  40. 40. VISIAN ICL the ICRS group (Figure 2). At 1 week postoperative, the mean improvement in BCVA was 0.22 in both groups. By 12 months postoperative, BCVA gradually increased a total of Figure 3. BCVA in the ICL (group 1) and 0.29 in the ICL group and 0.42 ICRS (group 2) groups before and at 1 in the ICRS group (Figure 3). week and 1, 3, 6, and 12 months after Additionally, the spherical surgery. equivalent in the ICL group was -0.09, -0.06, -0.05, -0.02, and -0.02 at 1 week and 1, 3, 6, and 12 months, respectively in the ICL group compared with -7.10, -6.32, -7.00, -7.00, and -6.56 in the ICRS group (Figure 4). Figure 4. Spherical equivalent in the Analyzing these results ICL (group 1; red) and ICRS (group 2; revealed that ICRS yellow ) groups at 1 week and 1, 3, 6, implantation is a valuable and 12 months after surgery. solution for stabilizing keratoconus, especially in combination with CXL. However, ICRS implantation with or without CXL fails to correct the ametropia associated with keratoconus. We consider Toric ICL implantation after CXL to be a superior treatment, as it corrects refractive errors after CXL is used to40 I Insert to Cataract & Refractive Surgery Today Europe I January 2012
  41. 41. VISIAN ICLstabilize keratoconus. Visual acuity after Toric ICL implantation andCXL is also better than the BCVA after ICRS implantation and CXL.CONCLUSION As we know, keratoconus negatively affects not only our patient’squality of vision, inducing myopia and astigmatism, but theirquality of life as well. Among available treatment options, I believethat Toric ICL implantation after CXL is the most promisingmodality we have to stop the progression of keratoconus andcorrect refractive errors, including sphere and cylinder. CXL aloneonly has the power to stabilize the cornea and the refraction, butwithout a subjective refraction, it is almost impossible to produceperfect correction of refractive errors. That is why, together, CXLand Toric ICL implantation is my procedure of choice in patientswith keratoconus. ■ Mohamed Shafik, MD, PhD, is a Professor of Ophthalmology, University of Alexandria, and Director of Horus Vision Correction Center, Egypt. Dr. Shafik states thathe has no financial interest in the products or companies mentioned.He may be reached at e-mail: January 2012 I Insert to Cataract & Refractive Surgery Today Europe I 41
  42. 42. VISIAN ICL Additional Resources Visian ICL® brochure Increase your profitability with VisianICL®. Click here to view brochure Profitability: LASIK Versus Phakic IOLs PDF The refractive surgery profitability model shows that as phakic IOL volume increases, so does the profitability margin. Click here to view pdf The New Visian ICL® with CentraFLOW™ Technology Brochure Click here to view brochure42 I INSERT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I JANUARY 2012
  43. 43. VISIAN ICL Additional Resources Visian ICL® Consumer Video Click here to view videoVisian ICL® V4c Animation Video Click here to view video JANUARY 2012 I INSERT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I 43