Last year I wrote a post lamenting the loss of the Alcon Cachet lens and giving my opinion on the Implantable Contact Lens (ICL).
I stated that this was not a good option as it led to potential complications of which cataract was one of them, and said that I would not implant these. Like many things in life I have come to change my stance on this. Why? Well, because I have come across many satisfied patients that had the ICL implanted and that would have been otherwise turned away and told that there were no options available to them. I have also attended a number of conferences in which many cases were presented of patients with ICL’s. The reality is, that if done well, ICL’s are a very good option for some patients. I personally know a surgeon who has implanted hundreds without a single complication. Lets therefore explore what an ICL is and who it is good for and who it is not good for.
What is an ICL
The Visian ICL is a lens which is implanted behind the iris and in front of the eye’s natural lens. It is not unlike a regular contact lens except that it is IN the eye rather than ON the eye. The term ICL actually stands for Implantable Collamer Lens so named because of the material of which it is made of.
Fig 1. An Implantable contact lens behind the iris
The lens is biocompatible and does not react with the eye
Implanting the ICL is a very straightforward procedure. It is usually done under a local anaesthetic but in some cases can be done under a full general anaesthetic. The pupil is initially dilated with dilating drops. The lens is introduced through a 2.4 mm clear corneal incision and manipulated under the iris through two side ports. This of course is done under viscoelastic which is removed at the end of the case. The pupil is then constricted at the end of the case with Miochol. That is it!
Who is this for?
The ideal candidate is a high myope but can also be a hyperope providing that they have an adequate anterior chamber depth.
Thus, any patient who has a refraction outside the range for Lasik ( >10 diopters for myopes or > 4 diopters for hyperopes). These patients, if under the age of 45 would normally be given no options as they are outside the laser range and too young for refractive lens exchange.
The key requirement, as stated above is that there is an anterior chamber depth of at least 3mm. This may not be the case in hyperopes in particular. If this requirement is not met then even the ICL is not an option
Who is this NOT for?
Young patients (>21 and < 45) who has a refraction within the scope of LASIK and who adequate corneal thickness are better of with LASIK or PRK.
Patients over the age of 45 (presbyopic) are better of with a refractive lens exchange (but may be OK for LASIK).
Anyone with an anterior chamber depth of less than 3mm is not suitable.
Keratocconus is contentious and I think may be best with NO treatment..
Eye rubbers are out! Why? Due to the risk of the ICL contacting the natural lens and causing trauma to it.
What are the risks of the ICL?
Firstly it is an intraocular procedure and therefore like all such procedures it can lead to problems. This however is a consideration for every cataract patient that I see and in 2014 the risk is acceptably small.
Secondly as the naysayers will point out, it can lead to cataract formation if the ICL comes in contact with the natural lens. Whilst this is true, the risk is low. I would argue that a 15 diopter myope who develops a cataract as a consequence of having an ICL implanted and has cataract operation, will still be significantly happier after their cataract operation than they were with their original glasses or contact lenses. Yes they will lose their accommodation but with monovision or multifocal intraocular lenses, this is no comparison to the problems with glasses or contacts.