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Kudsieh, M. Sánchez-Dehesa Sáez, I. Flores Moreno, J.M. Ruiz Moreno" "autores" => array:4 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Kudsieh" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Sánchez-Dehesa Sáez" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Flores Moreno" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Ruiz Moreno" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669120300381" "doi" => "10.1016/j.oftal.2020.01.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669120300381?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579420300402?idApp=UINPBA00004N" "url" => "/21735794/0000009500000004/v1_202004240656/S2173579420300402/v1_202004240656/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173579420300359" "issn" => "21735794" "doi" => "10.1016/j.oftale.2019.12.007" "estado" => "S300" "fechaPublicacion" => "2020-04-01" "aid" => "1616" "copyright" => "Sociedad Española de Oftalmología" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Soc Esp Oftalmol. 2020;95:171-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Agreement in retinal nerve fiber layer values and comparison in children using two optical coherence tomography devices" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "171" "paginaFinal" => "177" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Grado de concordancia y diferencias entre los valores de capa de fibras nerviosas de la retina peripapilar en niños mediante dos tipos de tomografía de coherencia óptica espectral" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1784 "Ancho" => 2170 "Tamanyo" => 208539 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bland–Altman graph for establishing match between RNFLm of OCT Spectralis against OCT Cirrus. Values shown in micrometers (μm). Typical deviation: 5.01 μm.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. Ruiz Caro Larrea, L. Cabrejas Martínez, I. Mahíllo Fernández, M.A. Alonso Peralta, I. Jiménez-Alfaro Morote" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Ruiz Caro Larrea" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Cabrejas Martínez" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Mahíllo Fernández" ] 3 => array:2 [ "nombre" => "M.A." "apellidos" => "Alonso Peralta" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Jiménez-Alfaro Morote" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669120300083" "doi" => "10.1016/j.oftal.2019.12.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669120300083?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579420300359?idApp=UINPBA00004N" "url" => "/21735794/0000009500000004/v1_202004240656/S2173579420300359/v1_202004240656/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Phakic intraocular lenses: Recent advances and innovations" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "178" "paginaFinal" => "187" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "E. Martínez-Plaza, A. López-Miguel, A. Holgueras, R.I. Barraquer, J.L. Alió, M.J. Maldonado" "autores" => array:6 [ 0 => array:3 [ "nombre" => "E." "apellidos" => "Martínez-Plaza" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "López-Miguel" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Holgueras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "R.I." "apellidos" => "Barraquer" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "J.L." "apellidos" => "Alió" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:4 [ "nombre" => "M.J." "apellidos" => "Maldonado" "email" => array:1 [ 0 => "maldonado@ioba.med.uva.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Instituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institut Universitari Barraquer, Universitat Autònoma de Barcelona, Universitat Internacional de Catalunya, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Vissum Instituto Oftalmológico de Alicante, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Red Temática de Investigación Colaborativa en Oftalmología (OftaRed), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lentes intraoculares fáquicas: recientes avances e innovaciones" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Phakic intraocular lenses (pIOL) are implanted mainly with the purpose of correcting medium and high ametropia. They are also indicated for patients with contraindications for keratorefractive techniques. Successful results with pIOL has been recently reported for the correction of low ametropia.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This procedure can be regarded as an addition because, in contrast with laser ablation techniques, its does not involve the extraction of ocular tissue. Based on location and fixation technique, pIOLs can be anterior chamber—either angle support or anchored in the iris—or posterior chamber.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Surgery for implanting pIOLs features numerous advantages such as quick visual recovery, excellent safety and efficacy levels, predictability and stability, significant visual acuity improvement (compared to best corrected visual acuity with spectacles [BCVAWS]), preservation of accommodation and procedure reversibility.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> The possible complications of this surgery largely depend on location and lens support and include raised intraocular pressure (either acute due to pupil blockage or chronic), early cataracts, dyscoria (pupil ovalization) and corneal edema (endothelial damage), among others.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of the present review is to provide updated evidence on pIOLs available at present in Europe. Specifications regarding type, brand name and model, materials, diopter power ranges, overall and optic zone diameters are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Angle support anterior chamber phakic lenses</span><p id="par0020" class="elsevierStylePara elsevierViewall">A considerable number of angle support anterior chamber pIOLs have appeared in recent decades. Many of these, such as, the Kelman Duet, Acrysof Cachet, Vivarte/GBR, I-Care, ThinPhAc, Vision Membrane Lens, ZB by Baikoff, Nuvita, ZSAL, Safety Flex Phakic 6H<span class="elsevierStyleSup">125</span>, lenses, among others, were progressively withdrawn from the market for various reasons including high postop complication rates compared to other pIOL types, which led to diminished demand.far As|as, the authors have been able to confirm, the only angle support pIOL available at present in Europe is ZSAL-4-Plus (Morcher GmbH, Stuttgart, Germany). The standard version of this lens comprises myopia correction between −3.0, Germany), −20.0<span class="elsevierStyleHsp" style=""></span>D, with a total optic zone diameter of 5.8<span class="elsevierStyleHsp" style=""></span>mm. the power of the lens is assessed with spreadsheets provided by the manufacturer, based on the Van der Heijde formula.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Iris support anterior chamber phakic lenses</span><p id="par0025" class="elsevierStylePara elsevierViewall">At present, there are 2 types of iris support anterior chamber pIOLs in the market, i.e., Artisan/Verisyse and Artiflex/Veriflex (Ophtec BV, Groningen, The Netherlands/AMO, Santa Ana, CA, USA), with several models each. The former are rigid and made with polymethylmethacrylate (PMMA) with ultraviolet filter and correction rages for myopia (−1.0 to −23.5<span class="elsevierStyleHsp" style=""></span>D) and hyperopia (+1.0 to +12.0<span class="elsevierStyleHsp" style=""></span>D), to which toricity can be added (−1.0 to −7.5<span class="elsevierStyleHsp" style=""></span>D cylinder). The latter are made with flexible material (polysiloxane optics with PMMA haptics) and myopic range (−2.0 to −14.5<span class="elsevierStyleHsp" style=""></span>D) as well as toricity (−1.0 to −5.0<span class="elsevierStyleHsp" style=""></span>D cylinder), although these are not yet available for hyperopia correction. As stated by the manufacturers,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> toricity is achieved in both types adding a negative cylinder at 0° or at 90°. According to each model, the optic diameter zone can be 5.0 or 6.0<span class="elsevierStyleHsp" style=""></span>mm, whereas the overall diameter is 8.5<span class="elsevierStyleHsp" style=""></span>mm in all models (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Both types are affixed by gripping the haptics to the middle-peripheral portion of the iris stroma, which is virtually void of any movement, allowing normal pupil dynamics. In order to facilitate the anchoring to the iris, instruments are available for pneumatic interlocking (VacuFix).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> When connected to the vacuum pump of the lens surgery system, the iris stroma can be locked and raised between the lens haptics so that the tissue is locked when the pneumatic interlock is released. As the maneuver is easier than with other instruments, the lens can be centered with greater precision. The vast power of these lenses is assessed with a specific calculator (ArtiCalc) or the spreadsheets provided by the manufacturer of for this purpose.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Posterior lens phakic lenses</span><p id="par0035" class="elsevierStylePara elsevierViewall">At present 3 types of posterior chamber pIOLs are available in the European market. The first was developed in the 90s and is made with collagen copolymer and hydrophilic acrylic known as <span class="elsevierStyleItalic">collamer</span>. It was initially marketed as an <span class="elsevierStyleItalic">Implantable Contact Lens</span> (ICL) and subsequently the <span class="elsevierStyleItalic">Visian</span> brand was added. More recently other pIOLs have entered the market, including the <span class="elsevierStyleItalic">Implantable Phakic Contact Lens</span> (IPCL) and the <span class="elsevierStyleItalic">Eyecryl Phakic</span>, both made of hydrophilic acrylic material without collagen.</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Visian implantable contact lens</span><p id="par0040" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Visian ICL</span> family of lenses (STAAR Surgical, Nidau, Switzerland) comprises 3 different models, all of which have 2 ports in the haptic zone which are located in diametrically opposite locations, i.e., the orifice in the <span class="elsevierStyleItalic">distal</span> haptic must be located to the <span class="elsevierStyleItalic">right</span>, and the orifice in the proximal haptic must be located to the <span class="elsevierStyleItalic">left.</span> Two additional lenses that are external to the optic zone are used to facilitate the lens orientation maneuvers and extracting viscoelastic during surgery. The classic model, V4b (or simply <span class="elsevierStyleItalic">Visian ICL</span>) is not provided with a central port and therefore requires iridotomy to avoid the risk of pupil blockage. It is utilized at present only for hyperopia corrections, with a range between +0.5 and +10.0<span class="elsevierStyleHsp" style=""></span>D, in 0.5<span class="elsevierStyleHsp" style=""></span>D steps (and 0.25 steps between +0.5 and +2.75<span class="elsevierStyleHsp" style=""></span>D).</p><p id="par0045" class="elsevierStylePara elsevierViewall">In turn, the V4c model <span class="elsevierStyleItalic">(EVO Visian ICL)</span> features a 360<span class="elsevierStyleHsp" style=""></span>μm central port <span class="elsevierStyleItalic">(KS-Aquaport)</span> to improve aqueous humor circulation and preempt the need for iridotomy. This model comprises a range of myopic powers between −0.5 and −18.0<span class="elsevierStyleHsp" style=""></span>D, with steps of 0.5<span class="elsevierStyleHsp" style=""></span>D (and 0.25 between −0.5 and −3.0<span class="elsevierStyleHsp" style=""></span>D). The more advanced V5 module <span class="elsevierStyleItalic">(EVO+ Visian ICL)</span> includes, in addition to the central port, a larger diameter optics zone although in a limited myopic range (up to −14.0<span class="elsevierStyleHsp" style=""></span>D).</p><p id="par0050" class="elsevierStylePara elsevierViewall">All three models include versions with toricity, including a cylinder from +0.5 to +6.0<span class="elsevierStyleHsp" style=""></span>D, in 0.5<span class="elsevierStyleHsp" style=""></span>D steps. The 0.25<span class="elsevierStyleHsp" style=""></span>D sphere steps are excluded and a neutral 0.0<span class="elsevierStyleHsp" style=""></span>D is included. Calculations for power and other parameters is done with the online OCOS application (https://evo-ocos.staarag.ch/Live) provided by the manufacturer for registered users.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Implantable phakic contact lens</span><p id="par0055" class="elsevierStylePara elsevierViewall">IPCL lenses (CareGroup, Baroda, India) were the first alternative posterior chamber pIOL that appeared in recent years. Its design includes characteristics that are shared with the ICL such as the general dome-shaped disc and differences such as the presence of 2 ports in the upper periphery of the optic in addition to the central port (the latter only in version <span class="elsevierStyleSmallCaps">V</span>.2.0 and in the negative power lenses) and a further 4 in the paracentral haptic zone as well as spaces in 4 of the 6 haptic ends in order to improve elasticity and adaptability to the available space in the posterior chamber.</p><p id="par0060" class="elsevierStylePara elsevierViewall">IPCL provide broader correction ranges than ICL, both myopic (−0.5 to −30.0<span class="elsevierStyleHsp" style=""></span>D) and hyperopic (+0.5 to +15.0<span class="elsevierStyleHsp" style=""></span>D), with the possibility in the IPCLT model of including cylinders of up to +12.0<span class="elsevierStyleHsp" style=""></span>D in 0.5<span class="elsevierStyleHsp" style=""></span>D steps. Optics zone diameters are slightly larger than ICL diameters for the corresponding powers. The best IPCL powers are assessed using the spreadsheets provided by the manufacturer, and it should be noted that the extreme power lenses are defined by the manufacturer as «customized» and manufactured only by order.</p><p id="par0065" class="elsevierStylePara elsevierViewall">On the other hand, IPCLs were the first to include multifocal lenses (trifocal refractive-diffractive) for correcting presbytia (<span class="elsevierStyleItalic">Presbyopic IPCLD</span> and <span class="elsevierStyleItalic">IPCLDT</span> models), which provides a novel response to one of the main challenges of refractive surgery. Said lenses are available with near vision conditions from +1.5 to +4.0<span class="elsevierStyleHsp" style=""></span>D, in 0.5<span class="elsevierStyleHsp" style=""></span>D steps, throughout the entire myopia range for far vision (and the hyperopia range to +6.0<span class="elsevierStyleHsp" style=""></span>D), as well as the possibility of including toricity up to +8.0<span class="elsevierStyleHsp" style=""></span>D.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Eyecryl phakic</span><p id="par0070" class="elsevierStylePara elsevierViewall">Finally, the <span class="elsevierStyleItalic">Eyecryl Phakic</span> lenses (Biotech Healthcare, Luzern, Switzerland) have a design similar to that of the EVO ICL, with a central port and 4 slightly larger ports in the middle periphery and in 2 of the 4 haptic ends. For the time being they only provide myopic correction between −3.0 and −23.0<span class="elsevierStyleHsp" style=""></span>D, and toric options with cylinders between +0.5 and +5.0<span class="elsevierStyleHsp" style=""></span>D, in 0.5<span class="elsevierStyleHsp" style=""></span>D steps, in a spherical range of −5.0 to −23<span class="elsevierStyleHsp" style=""></span>D. the power calculation for these lenses is made using the online <span class="elsevierStyleItalic">Eyecryl Phakic Calculator</span> (http://www.biotechcalculators.com), or through the cell phone application <span class="elsevierStyleItalic">Biotech Calculators</span>, available for iOS, Android and Windows.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">State-of-the-art of phakic lens implants</span><p id="par0075" class="elsevierStylePara elsevierViewall">As with pseudophakic lenses, the historic evolution of pIOLs has gone from the initial predominance of angle support anterior chamber lenses (already in the pioneering days of the 50s and 60s) to the current predominance of posterior chamber lenses. This evolution took place mainly due to the post-surgery complications of the former as well as progressive endothelial cell loss which in many cases gave rise to corneal decompensation, among other drawbacks. In recent years severe endothelial cell loss of up to 72% has been reported in 9 years follow-up after the implantation of said lenses.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Together with the appearance of safer options, these complications led to the discontinuation of the angle support pIOL and the withdrawal from the market of virtually all models of this type due to lack of demand.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The pIOLs anchored to the iris (<span class="elsevierStyleItalic">Artisan</span>/<span class="elsevierStyleItalic">Artiflex</span>) have become a preferred alternative for a number of refractive surgeons due to the advantages they exhibit for certain indications. Their significant refractive stability has been demonstrated for at least 10 years as well as safety, even with a small central endothelial cell count increase (8.73% per year postop and 3.62% at 10<span class="elsevierStyleHsp" style=""></span>years follow-up) in a study.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It should be noted that these results were obtained with strict inclusion criteria and meticulous surgical technique performed by expert surgeons.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In addition, as proposed in similar increases reported with the use of other refractive surgery techniques, said endothelial cell count increase could be due to an effect derived from discontinuing the use of contact lenses.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In contrast, Jonker et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> recently reported losses of 16.6 and 21.4% between 6<span class="elsevierStyleHsp" style=""></span>months and 10<span class="elsevierStyleHsp" style=""></span>years postop after the implantation of the <span class="elsevierStyleItalic">Artisan</span> pIOL, respectively, in myopic and toric lens groups, as well as explantation rates for such reason of 6 and 4.8%, respectively.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Since its introduction in the 90<span class="elsevierStyleHsp" style=""></span>s, the posterior chamber pIOL implants, particularly the ICL type, have progressively increased in acceptance and reached a leading position in this field. This is due to their demonstrated efficiency, safety, predictability and refractive stability after 10<span class="elsevierStyleHsp" style=""></span>year follow-ups.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,11</span></a> Posterior chamber pIOLs have confirmed the advantage of diminishing the probability of complications such as progressive endothelial cell count loss<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> or others related to angle support of haptics (pupil ovalization, anterior synechiae and chronic ocular hypertension, among others). However, specific complications can arise with greater frequency, such as unexpected rotations of toric models or the induction of cataracts due to being closer to the lens. In what concerns the former, the exact amount of rotation must be known in order to move it under surgery back to the desired axis. Concerns about the appearance of cataracts have been largely mitigated with the latest generation models, probably because they allow more aqueous humor flow and more metabolic exchange. While articles on pIOLs without central ports have reported anterior subcapsular cataract rates of 10.5% after 10<span class="elsevierStyleHsp" style=""></span>years from implantation,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> studies on the most recent models covering up to 5<span class="elsevierStyleHsp" style=""></span>years<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> have not described visually significant cataracts. However, there is no doubt that to determine this rate longer-term studies with large samples are essential.</p><p id="par0090" class="elsevierStylePara elsevierViewall">An additional fundamental aspect to be taken into account in the postop is the perpendicular central distance between the posterior ICL surface and the anterior lens surface, what is known as <span class="elsevierStyleItalic">vault</span>. Numerous authors comment that the ideal vault is approximately between 250 and 750<span class="elsevierStyleHsp" style=""></span>μm,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> considering values under 100<span class="elsevierStyleHsp" style=""></span>μm and over 1000<span class="elsevierStyleHsp" style=""></span>μm as risk values.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> When lens size calculations are not exact, we could find 2 cases: a small lens, that would produce a smaller than expected vault, or an oversized lens that would produce an excessively large vault. In the first case, the lens could give rise to early cataracts and rotation, with the ensuing release of pigment and reduction of the corrective effect of astigmatism if the lens were toric, while in the second case the lens could produce anterior displacement of the iris which could lead to anterior chamber narrowing, angle closure, pigment dispersion and secondary glaucoma in addition to producing clinically significant pupil midriasis or endothelial damage. In what concerns spherical oversized lenses, the extraction/replacement thereof could be considered although each smaller size step usually diminishes the vault approximately 400<span class="elsevierStyleHsp" style=""></span>μm. Alternatively, lens orientation change to the vertical position could be considered in order to achieve a reduction of the vault (expecting an approximate reduction of 200<span class="elsevierStyleHsp" style=""></span>μm because in the majority of the population the sulcus-sulcus diameter is greater in the vertical than in the horizontal meridian).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In an attempt to avoid possible mistakes in lens size calculations, various authors have proposed using the angle-angle distance measured with adequate anterior segment OCT or ultrasound biometry, the horizontal distance of the sulcus (with ultrasound biometry) and/or the anteroposterior distance between the anterior lens surface and the horizontal line joining both iridocorneal angles, known as <span class="elsevierStyleItalic">lens rise</span>, which prompted the proposal of formulae such as the NK formula to improve this calculation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Further evidence of the development of posterior chamber pIOL is the emergence of new brands (IPCL<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>, Eyecryl<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>) with potentially advantageous innovations in their design. However, published evidence on the efficacy and security of these devices, particularly in the mid-and long-term, is still scarce.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Innovations in the design of phakic lenses</span><p id="par0105" class="elsevierStylePara elsevierViewall">One of the problems associated to posterior chamber pIOLs is the risk of pupil blockage and accordingly the need to perform one or more peripheral iridotomies before or during surgery, which in turn is an additional source of possible complications.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The drive to do away with this requirement has led to design developments in the past decade, mainly the inclusion of an orifice or micro-ports in the central zone of the optic. The efficacy and safety of said central orifice has been demonstrated in short term IOP control,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> although some rare cases of pupil blockage have also occurred with these models.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Aqueous humor flow through said port is more natural than when it passes through a peripheral iridotomy,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and it would improve the replacements thereof in the space between the optic and the lens, with possible positive impact in physiology.</p><p id="par0110" class="elsevierStylePara elsevierViewall">For the time being, the above innovation has been implemented only in negative power optics (with or without toricity) and not in positive optics for hyperopia. As in the latter the central thickness is greater, the cylindrical duct of the port would probably cause dysphotopsia phenomena causing discomfort in users.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In the ICL and the Eyecryl devices, said orifice is a circular (or cylindrical, in 3D terms) and has diameters of 360 or 320<span class="elsevierStyleHsp" style=""></span>μm, respectively. The design of the IPCL is conic with a diameter from 380 to 420<span class="elsevierStyleHsp" style=""></span>μm, and a further 2 are added in the upper periphery of the optic (the latter can be also implemented in positive lenses). To date no studies have been published reporting the possible influence of this conic design with multiple ports on aqueous humor circulation or vision quality, although the manufacturer affirms that light dispersion will be lower than in the ICL optics.</p><p id="par0115" class="elsevierStylePara elsevierViewall">An additional trend is to manufacture lenses with increasingly large diameters in the optic zone. This would diminish dysphotopsia phenomena related to the incidence of light on the optic edge, particularly in young patients with spontaneously large pupils in low lighting conditions. In this regard, the hydrophilic acrylic material of the IPCL which is slightly stiffer than the ICL and has a refraction index of 1.465 enables the construction of thinner and less arched lenses. In turn, this facilitates larger optic zone diameters depending on the power. Diameters of up to 7.5<span class="elsevierStyleHsp" style=""></span>mm have been achieved in customized IPCLs. However, it should be taken into account that the larger the optic zone diameter, the larger will be the lens elevation or vault with at least theoretical postoperative risks related to narrow angle or pigment dispersion.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Current limits and indications for pIOL implantation</span><p id="par0120" class="elsevierStylePara elsevierViewall">When considering the implant of a pIOL it is very important to conduct a detailed pre-op examination to determine as much as possible all irrelevant intraocular structures in order to respect them and avoid complications, as well as the anatomical or age parameters that could come to bear on the indication.</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Iridian anchor phakic lenses</span><p id="par0125" class="elsevierStylePara elsevierViewall">In the case of pIOLs anchored to the iris <span class="elsevierStyleItalic">(Artisan/Artiflex)</span>, the main concern continues to be corneal endothelium preservation.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The minimum central interior chamber depth that was established for implantation was 2.8<span class="elsevierStyleHsp" style=""></span>mm from the corneal endothelium to the anterior lens surface. However, due to the anatomy of the cornea and the larger thickness of myopic lenses in the peripheral zone, the lens will become closer to the endothelium at the edges, and this critical distance is equally if not more important than the central distance. At present, the manufacturer recommends a minimum central anterior chamber depth of 3.0<span class="elsevierStyleHsp" style=""></span>mm and a critical distance over 1.0<span class="elsevierStyleHsp" style=""></span>mm to implant an <span class="elsevierStyleItalic">Artisan</span> lens, and 3.2<span class="elsevierStyleHsp" style=""></span>mm and 1.3<span class="elsevierStyleHsp" style=""></span>mm, respectively for the <span class="elsevierStyleItalic">Artiflex</span>.</p><p id="par0130" class="elsevierStylePara elsevierViewall">For both types of lenses, the minimum presurgery endothelium count is 2800<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">2</span> and convex iris, typical in hypermetropic patients, are contraindicated in order to avoid possible synechiae.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Even so, due to the physiological relationships between older age and lower endothelial count, this number should be considered on a case-by-case basis. Equally or more important than the baseline condition of the endothelium is the education of patients in good habits such as avoiding rubbing their eyes and avoid sleeping face down or on their side facing down because this could compress the ocular globe producing indentation of the cornea and endothelial damage due to repeated proximity to the lens. It is important to remind patients about these details in the annual checkup visits.</p><p id="par0135" class="elsevierStylePara elsevierViewall">An additional parameter to be taken into account, particularly in optics anchored to the iris, is the distance between the anterior lens surface and the horizontal line that joins the iridocorneal angles. This distance, known as <span class="elsevierStyleItalic">lens rise</span>, increases about 20<span class="elsevierStyleHsp" style=""></span>μm/year. In order to avoid complications for this reason during at least 15<span class="elsevierStyleHsp" style=""></span>years, lens rise should not exceed 300<span class="elsevierStyleHsp" style=""></span>μm at implantation.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Posterior chamber phakic lenses</span><p id="par0140" class="elsevierStylePara elsevierViewall">In what concerns ICL lenses with a central port (EVO/EVO+), limits for their implantation have been recently increased in Europe. At present, eyes with an endothelial count of 2000<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">2</span> and central anterior chamber depth of at least 2.8<span class="elsevierStyleHsp" style=""></span>mm from the endothelium (previously the minimum distance was 3.0<span class="elsevierStyleHsp" style=""></span>mm) are apt for implantation in patients between 21 and 60 years of age. The previous limit was 45<span class="elsevierStyleHsp" style=""></span>years. This broader age range gives rise to the possibility of implanting these lenses in presbytia patients with a lens without significant visual opacities. In this regard, the manufacturer recently released the results of a multicenter clinic trial on a new model <span class="elsevierStyleItalic">(EVO<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Visian ICL EDOF)</span> in presbytia patients in an effort to be granted the CE certificate for launching in Europe (available at : https://www.businesswire.com/news/home/20190731005908/in/STAAR-Surgical-Announces-Submission-Presbyopia-Clinical-Trial).</p><p id="par0145" class="elsevierStylePara elsevierViewall">As for the IPCL lenses, the minimum required central interior chamber depth is 2.8<span class="elsevierStyleHsp" style=""></span>mm. The recommended age range is 21−45<span class="elsevierStyleHsp" style=""></span>years for correction with the standard IPCL models, extending to 55<span class="elsevierStyleHsp" style=""></span>years for the <span class="elsevierStyleItalic">IPCL Presbyopic</span> lenses. The same chamber depth of 2.8<span class="elsevierStyleHsp" style=""></span>mm is also recommended for the <span class="elsevierStyleItalic">Eyecryl Phakic</span> lenses although these only cover a myopic range with or without astigmatism. It should be noted that these recommendations are not supported by published clinic studies, at least at this time.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Special indications for phakic lenses</span><p id="par0150" class="elsevierStylePara elsevierViewall">In addition to conventional refractive indications, pIOLs could be considered in some special situations such as the following.</p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Corneal ectasia</span><p id="par0155" class="elsevierStylePara elsevierViewall">Corneal ectasia pathologies such as keratocone, pellucid marginal degeneration and keratoglobe, generally associate irregular myopia and astigmatism. Provided that the irregular component of astigmatism does not have a substantial influence in visual quality or has been corrected by different means, pIOLs represent a very good option for correcting these ametropias and achieve high satisfaction degrees for patients.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> These cases, who are generally not good candidates for keratorefractive surgery (excepting when they have good tolerance for contact lenses), pIOLs are a first line alternative. The larger anterior chamber depth associated to ectasia constitutes an advantage for the implementation of pIOLs.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> In patients with extremely large corneas (megalocornea) it might not be possible to implant posterior chamber pIOLs due to the lack of sufficiently large models, leaving pIOLs attached to the iris as the only option.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Several studies on pIOL implants in patients with keratocone that remained stable for at least 2 years reported good results for safety, effect thickness, predictability and stability of the procedure.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a> In addition to diminishing ametropia, said implants improved uncorrected visual acuity (UVA) as well as BCVAWS with generally modest residual correction involving visual quality improvements. A recent study on patients with keratocone implanted with ICL reported, after a 5<span class="elsevierStyleHsp" style=""></span>year follow-up, that 19 out of 23 eyes (82.5%) had BCVAWS of 0.5 (6/12 in the Snellen scale) or better, and had gained one or more BCVAWS lines. Safety rates were positive (1.47<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.32 and 1.24<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.34. respectively).<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In unstable keratocones, the combination of stabilizing techniques or those that correct irregularity such as corneal cross-linking or intracorneal annular segments with the implantation of pIOL has demonstrated efficiency in terms of visual acuity, refractive error reduction and keratometric flattening.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28,29</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">After keratoplasty</span><p id="par0170" class="elsevierStylePara elsevierViewall">In many cases, keratoplasty gives rise to significant ametropia that requires correction in order to achieve the best results for patients. Regular or irregular astigmatism is the most relevant refractive error after keratoplasty, be it penetrating or deep anterior laminar keratoplasty (DALK), followed by myopia.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> pIOLs can be implanted to correct said ametropia, with the posterior chamber type being the best choice due to involving lower subsequent endothelial damage risk.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Endothelial keratoplasty has a known tendency to induce hyperopia.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> This has been attributed to a negative lenticle effect in grafts with the stromal layer (DSEK/DSAEK). However, hyperopia has also occurred in cases of Descemet-endothelial keratoplasty without stromal tissue (DMEK), possibly due to other changes induced in the shape of the cornea (i.e., due to central edema reduction). Even though said changes can be compensated when calculating the pseudophakic lens that is frequently associated in these techniques, pIOLs are an option in residual defect cases, as will be discussed below.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Residual refractive defects in pseudophakia</span><p id="par0180" class="elsevierStylePara elsevierViewall">Present day cataract surgery and lens refractive surgery with pseudophakic lens implants have demonstrated excellent results for efficacy, safety and predictability of refractive correction. This is due to the standardization of surgical techniques and the growing precision of biometric technologies and algorithms for calculating lens power. However, due to the multiplicity of possible random error sources, absolute precision cannot be achieved in all cases, to the extent that unexpected deviations occasionally arise in what has come to be known as “the refractive surprise”. Growing patient demand for emetropia and total freedom from spectacles for all distances has raised the level of requirements or the reduction of acceptable error margins, particularly in surgery with refractive purposes and generally with the use of multifocal lenses.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Option treatments in the presence of residual refractive defect in pseudophakia include, apart from correction with spectacles or contact lenses, laser keratorefractive surgery, changing the pseudophakic lens and implanting an additional lens, as well as some other less extended options such as conductive keratoplasty among others.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The secondary implant of an additional lens in the posterior chamber, known as <span class="elsevierStyleItalic">piggyback,</span> was described over 25<span class="elsevierStyleHsp" style=""></span>years ago by Gayton and Sanders,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> and it continues to be proposed as the most predictable, simple and less risky option<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> than the exchange of the existing lens.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> This does not exclude the possibility of complications, either generally in other intraocular surgeries or specifically in the presence of 2 lenses in the posterior chamber, including intraocular pressure increase,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> pupil blockage, pigment dispersion syndrome<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> and inter-lenticle opacification.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The lens types that can be used for additional or piggyback implants can be classified in 3 groups: 1)<span class="elsevierStyleHsp" style=""></span>Standard lenses for pseudophakia with adequate design for pre-capsular implant (in the ciliary sulcus). These are generally 3-piece foldable acrylics lenses such as the <span class="elsevierStyleItalic">Sofport</span> (Bausch & Lomb), <span class="elsevierStyleItalic">MA60AC</span> (Alcon) or <span class="elsevierStyleItalic">Three-piece Tecnis Acrylic</span> and <span class="elsevierStyleItalic">Sensar</span> (Abbott Medical Optics) among others. 2)<span class="elsevierStyleHsp" style=""></span>Lenses designed specifically for piggyback implants in sulcus, such as <span class="elsevierStyleItalic">Sulcoflex</span> (Rayner), <span class="elsevierStyleItalic">Add-On IOL</span> (HumanOptics) or <span class="elsevierStyleItalic">1<span class="elsevierStyleHsp" style=""></span>st<span class="elsevierStyleHsp" style=""></span>Add-On</span> (1<span class="elsevierStyleHsp" style=""></span>st Q GmbH). 3)<span class="elsevierStyleHsp" style=""></span>Lenses designed for phakic refractive implant, either posterior chamber such as the ICL and equivalent or the iris affixed type (<span class="elsevierStyleItalic">Artisan</span>/<span class="elsevierStyleItalic">Artiflex</span>) which, in addition to the classic anterior chamber location, can also be implanted behind the pupil. Apart from the spherical and toric additional correction, some of these models include the possibility of adding multifocality, which would justify their implant even in monofocal emetropia situations.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Several studies on additional implants for correcting residual refractive defect in pseudophakia<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39–41</span></a> have been published in recent years. In the case of pIOLs, which is the object of this review, Kamiya et al.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> recently published a study with 35 eyes of 28 pseudophakic patients who were implanted with a secondary ICL lens. Mean uncorrected visual acuity (UVA) (LogMAR) improved significantly from 0.77<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.42 preop to 0.24<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.38 postop (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). Out of the 21 eyes with planned emetropia, 66% had UVA values of 1.0 (20/20 in the Snellen scale) and 89% of 0.5 (20/40 in the Snellen scale) or better. Two eyes presented complications, one had ICL dislocation that required explant and the other developed posterior capsule opacification that required laser Nd:YAG capsulotomy. ICL could be advantageous for piggyback implants vis-à-vis other models for several reasons, including their forward arched shape that avoids contact between both implanted lenses, smaller central thickness and the special biocompatibility of its material.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Amblyopia</span><p id="par0200" class="elsevierStylePara elsevierViewall">Cases with amblyopia that cannot have treatment with spectacles (for example, due to anisometropia), do not tolerate contact lenses and keratorefractive surgery is not indicated, pIOL implant is an option that provides advantages such as precision and stability of refractive correction, fast recovery, reversibility and—in posterior chamber pIOLs—avoidance of endothelial damage risks. Some authors propose this implant as primary indication in pediatric patients with unilateral high myopia in order to treat or prevent amblyopia.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> This is justified on account of the higher optical quality in comparison with keratorefractive surgery, less high order aberration and higher contrast sensitivity as well as improvement in BCVAWS commonly observed in myopic patients with the use of ICL.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> In addition, other authors also reported that ICL implants can improve vision in adult amblyopic eyes due to high myopic anisometropia.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Bilensectomy</span><p id="par0205" class="elsevierStylePara elsevierViewall">In the year 2000, Joseph Colin introduced a new term, <span class="elsevierStyleItalic">bi-lensectomy,</span> to define the extraction of a pIOL together with the lens (phacoaspiration or phacoemulsification) and the implant of a pseudo-phakic lens.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> This procedure is indicated for pIOL users in the presence of : a)<span class="elsevierStyleHsp" style=""></span>significant BCVAWS reduction due to lens opacification ; b)<span class="elsevierStyleHsp" style=""></span>diminished endothelial cell count below 1500<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">2</span>, or c)<span class="elsevierStyleHsp" style=""></span>in the presence of other pIOL-related complications such as marked pupil ovalization, ocular hypertension, etc.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Cataract is the main cause of bi-lensectomy,<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> and due to its frequency in the general elderly population (on average around 72−75<span class="elsevierStyleHsp" style=""></span>years) and its precocious expression in patients with high myopia (on average around 60−65<span class="elsevierStyleHsp" style=""></span>years), it is likely that the majority of patients with pIOL will eventually require bi-lensectomy. On the other hand, the implantation of a posterior chamber pIOL would accelerate said process.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">In eyes with presbytia and high myopia, bi-lensectomy is probably more accepted than the <span class="elsevierStyleItalic">bioptics</span> procedure (keratorefractive surgery after pIOL implantation) as it is very likely that cataract surgery will be necessary a few years later. In the presence of a pIOL, biometres will frequently conduct a false inspection of the anterior lens surface. For this reason, when calculating the pseudophakic lens to be implanted it is convenient to utilize an ultrasound biometer or in any case an optical biometer that will enable the examiner to manually manipulate the automatic segmentation these devices carry out. In addition, as usually applied for myopic eyes, it is recommended to apply the theoretical SRK/T formula<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> or, in this or any other circumstances, new generation formulae such as the Barrett universal<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">II</span> or the Olsen formula.</p><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Surgical technique</span><p id="par0215" class="elsevierStylePara elsevierViewall">Bi-lensectomy can be conducted under topical or peribulbar anesthesia according to surgeon preferences. The surgical technique requires some specific maneuvers that will depend on the pIOL type to be expanded and, once these are determined, can be carried out safely and efficiently. Adequate use of viscoelastics is important to protect the corneal endothelium and other intraocular structures, particularly during the explanting maneuvers.</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0220" class="elsevierStylePara elsevierViewall">To date very few studies have reported visual results after bi-lensectomy. Alió et al.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> found that this technique was more complicated in cases with angle support pIOLs due to the presence of iris synechiae. When bi-lensectomy was indicated due to cataract associated to the presence of pIOL, less complications arose with the microincision (MICS) technique when compared to coaxial phacoemulsification in which intraoperative iris prolapse was a recurring event.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Possibly, these complications are related to the material and the design of angle supports lenses, and therefore it could be expected that their frequency may diminish with current pIOLs.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Another study performed bi-lensectomies in 24 eyes with pIOLs anchored to the iris.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> All the interventions were successful excepting 2<span class="elsevierStyleHsp" style=""></span>cases (8%) with high myopia and axial length over 30<span class="elsevierStyleHsp" style=""></span>mm that had postoperative retina detachment.</p><p id="par0230" class="elsevierStylePara elsevierViewall">Bi-lensectomy results in ICL-type posterior chamber pIOLs were good in terms of safety, stability and predictability<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a> producing high satisfaction levels in patients and absence of complications in the early postoperative period (follow-up of 3<span class="elsevierStyleHsp" style=""></span>months)<span class="elsevierStyleSup">51</span>. Surgery with these lenses has been described as relatively easy because their flexibility facilitates explant.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a></p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0235" class="elsevierStylePara elsevierViewall">In recent years, many clinic researchers have produced a considerable volume of scientific evidence demonstrating that pIOLs are a safe, efficient and predictable option yielding good results in the medium and long-term for correcting a range of refractive defects. Despite being initially indicated only for medium and high ametropia and/or in patients that cannot undergo keratorefractive surgery, the implantation of said lenses can be considered more frequently in eyes with minor ametropia.</p><p id="par0240" class="elsevierStylePara elsevierViewall">The popularity of these implant lenses has led to the development of an increasing range of types and models, with improved design and possible advantages. At present, 6 types of pIOL are available in Europe: one with angle support, two with iris attachment and three posterior chamber pIOLs, each one with several variants. The third group includes models with specially large optic zone diameters as well as some that enable presbytia compensation. The success of pIOLs in conventional ametropia has led to their use in special situations such as stable cornea ectasia, after keratoplasty, significant residual refractive defects in pseudophakia or in eyes with amblyopia.</p><p id="par0245" class="elsevierStylePara elsevierViewall">To end, bi-lensectomy should be considered in eyes with pIOL implants as a surgical technique that will probably become necessary due to the eventual development of age-related cataracts, apart from the situations that may require this intervention due to complications associated to the pIOL. Fortunately, the latter have become increasingly rare due to developments in the conception, materials and design of pIOLs and improvements in the process of selection, preparation, surgery and postoperative follow-up of patients.</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0250" class="elsevierStylePara elsevierViewall">This study was partly funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Ministry of Economy and Competitiveness of Spain</span> (Carlos III Health Institute) through the Cooperative Research Thematic Network <span class="elsevierStyleGrantNumber" refid="gs0005">RETICS RD16/008/0001</span> and <span class="elsevierStyleGrantNumber" refid="gs0005">RD16/0008/0012</span> (Oftared).</p><p id="par0255" class="elsevierStylePara elsevierViewall">EM-P was funded by the <span class="elsevierStyleGrantSponsor" id="gs0010">Junta of Castilla and León</span> and <span class="elsevierStyleGrantSponsor" id="gs0015">the European Social Fund</span> (<span class="elsevierStyleGrantNumber" refid="gs0015">EDU/574/2018</span>).</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interests</span><p id="par0260" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:17 [ 0 => array:3 [ "identificador" => "xres1328693" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1224525" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1328692" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1224524" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Angle support anterior chamber phakic lenses" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Iris support anterior chamber phakic lenses" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Posterior lens phakic lenses" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Visian implantable contact lens" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Implantable phakic contact lens" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Eyecryl phakic" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "State-of-the-art of phakic lens implants" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Innovations in the design of phakic lenses" ] 10 => array:3 [ "identificador" => "sec0050" "titulo" => "Current limits and indications for pIOL implantation" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Iridian anchor phakic lenses" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Posterior chamber phakic lenses" ] ] ] 11 => array:3 [ "identificador" => "sec0065" "titulo" => "Special indications for phakic lenses" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Corneal ectasia" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "After keratoplasty" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Residual refractive defects in pseudophakia" ] 3 => array:2 [ "identificador" => "sec0085" "titulo" => "Amblyopia" ] ] ] 12 => array:3 [ "identificador" => "sec0090" "titulo" => "Bilensectomy" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Surgical technique" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Results" ] ] ] 13 => array:2 [ "identificador" => "sec0105" "titulo" => "Conclusions" ] 14 => array:2 [ "identificador" => "sec0110" "titulo" => "Funding" ] 15 => array:2 [ "identificador" => "sec0115" "titulo" => "Conflict of interests" ] 16 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-12-20" "fechaAceptado" => "2020-02-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1224525" "palabras" => array:6 [ 0 => "Phakic intraocular lenses" 1 => "Myopia" 2 => "Hyperopia" 3 => "Presbyopia" 4 => "Keratoconus" 5 => "Bi-Lensectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1224524" "palabras" => array:6 [ 0 => "Lentes intraoculares fáquicas" 1 => "Miopía" 2 => "Hipermetropía" 3 => "Presbicia" 4 => "Queratocono" 5 => "Bilensectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Phakic intraocular lenses (pIOL) are recommended when counselling refractive surgery candidates presenting with high ametropia or ocular surface and/or corneal conditions that contraindicate corneal refractive surgery. This review aims to present the state-of-the-art regarding pIOL models currently available in Europe, addressing their newer indications and recent design innovations. These include, in the case of posterior chamber pIOLs, the addition of a central hole to improve aqueous humour circulation, the availability of larger optical zones, and multifocal optics for the compensation of presbyopia. The review also highlights their good safety and efficacy results, as well as the role of patient education to ensure adequate outcomes in the medium-long term. The indications of pIOLs in special situations, as well as bi-lensectomy, a procedure that most pIOL patients may eventually require as they age and develop cataracts, are also addressed.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Las lentes intraoculares fáquicas (LIOf) son la opción de primera elección en la corrección de ametropías elevadas y en los casos en los que la superficie ocular o la córnea no son idóneas para realizar técnicas queratorrefractivas. Esta revisión pretende actualizar y detallar el estado actual de los seis modelos de LIOf disponibles en Europa, precisar la ampliación de sus indicaciones y describir las innovaciones de diseño que se han dado en los últimos años. Éstas han consistido, en las LIOf de cámara posterior, en habilitar un microporo central para mejorar la circulación del humor acuoso, y disponer de mayores diámetros de zona óptica, así como de ópticas multifocales para compensar la presbicia. Se constatan los excelentes resultados de seguridad y eficacia que se obtienen, recordando la importancia de la educación de los pacientes para asegurarlas a medio-largo plazo. Finalmente revisamos las indicaciones especiales de LIOf, así como la bilensectomía, procedimiento que eventualmente requerirá una mayoría de pacientes con LIOf, a medida que desarrollen cataratas por la edad.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Martínez-Plaza E, López-Miguel A, Holgueras A, Barraquer RI, Alió JL, Maldonado MJ. Lentes intraoculares fáquicas: recientes avances e innovaciones. Arch Soc Esp Oftalmol. 2020;95:178–187.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Add: addition; CYL: cilindro; D: diopters; SPH: sphere ; HEMA: hydroxyethylmethacrylate ; mm: millimetres; PMMA: polymethylmethacrylate.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Brand \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Material \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Model \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diopter power (D) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ZO diameter (mm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Overall diameter (mm) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="12" align="left" valign="middle">anterior chamber</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="4" align="left" valign="middle">angle support</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle"><span class="elsevierStyleItalic">ZSAL-4-PLUS</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">PMMA</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99 A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">Flat-concave : SPH: −3.0 to −20.0 (0.5 steps)Concave-convex: SPH: −2.5 to −4.5 (0.5 steps)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">5.8</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99 B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99 C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99 D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="8" align="left" valign="middle">Iris anchor</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="5" align="left" valign="middle"><span class="elsevierStyleItalic">Artisan</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="middle">PMMA</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">206 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −1.0 to −23.5 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">204 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −1.0 to −15.5 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">203 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: +1.0 to +12.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Toric to 0° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">SPH: +14.0 to −22.0; CYL: −1.0 to −7.5 (0.5 steps)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">5.0</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">8.5</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Toric to 90° \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="middle"><span class="elsevierStyleItalic">Artiflex</span></td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="3" align="left" valign="middle">Polysiloxane (PMMA haptics)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">401 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −2.0 to −14.5 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="middle">6.0</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="middle">8.5</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Toric to 0° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">SPH −1.0 to −13.5; CYL: −1.0 to −5.0 (0.5 steps)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Toric to 90° \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Posterior chamber \t\t\t\t\t\t\n \t\t\t\t</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle"><span class="elsevierStyleItalic">Visian ICL</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">Collamer (collagen copolymer + HEMA)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">V4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: +0.5 to +10.0 (0.25 steps, from +0.5 to +2.75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.9 to 5.8<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.6 to 13.2 (0.5/0.6 steps) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">V4c (EVO) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −0.5 to −18.0 (0.25 steps, from −0.5 to −3.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.9 to 5.8<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="middle">12.1 to 13.7 (0.5/0.6 steps)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">V5 (EVO+) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −0.5 to −14.0 (0.25 steps, from −0.5 to −3.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.0 to 6.1<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Toric (all 3 models) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CYL: from +0.5 to +6.0 (SPH ―18.0 to +10.0. excl. 0.25 steps. incl. 0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.9 to 5.8<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> / 5.0 to 6.1<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">IPCL</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">Hybrid hydrophilic acrylic</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">V2.0<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>(IPCL, IPCLTIPCLD, IPCLDT)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −0.5 to −22.0; customized to −30.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">5.75 to 6.20<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">11.5 to 14.0 (0.25 steps)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: +0.5 to +6.0; customized to +15.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CYL: +0.5 to +8.0; customized to +12.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presbyopic (trifocal diffractive-refractive)Add: +1.5 to +4.0 (0.5 steps)SPH: +0.5 to +6.0 and −0.5 to −30.0 (0.5 steps)CYL: +1.0 to +8.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="middle"><span class="elsevierStyleItalic">Eyecryl Phakic</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="middle">Hydrophilic acrylic</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PKC120NH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −3.0 to −23.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="middle">4.65 to 5.50<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="middle">12.012.513.013.5</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PKC125NH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −3.0 to −23.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PKC130NH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −3.0 to −23.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PKC135NH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −3.0 to −23.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tóricas (PC1nnT) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SPH: −5.0 to −23.0; CYL: +0.5 to +5.0 (0.5 steps) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2277514.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Optic zone diameters varies with the dioptric power of the lens.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Models in extreme power ranges are described as “customized”.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Classification of phakic intraocular lenses available in Europe.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:51 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Posterior chamber phakic intraocular lens implantation: comparative, multicentre study in 351 eyes with low-to-moderate or high myopia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. 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