Editorial
Phakic intraocular lenses: Adapting to change
Lentes intraoculares fáquicas: adaptándose a los cambios
F. Gonzalez-Lopez
, R. Bilbao-Calabuig
Corresponding author
Clínica Baviera, Instituto Oftalmológico Europeo, Madrid, Spain
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Gonzalez-Lopez, R. Bilbao-Calabuig" "autores" => array:2 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Gonzalez-Lopez" "email" => array:1 [ 0 => "fgonzalez@clinicabaviera.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Bilbao-Calabuig" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Clínica Baviera, Instituto Oftalmológico Europeo, Madrid, Spain" "identificador" => "aff0005" ] ] "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: adaptándose a los cambios" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Phakic intraocular lenses (IOLs) have traveled a long and winding road since Dannheim, Baron and Strampelli decided in the early 50s to choose the anterior chamber and the iridocorneal angle as the most accessible anatomical space to implant a lens in a phakic eye<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">1</span></a>. The first years of development of phakic IOLs encountered numerous obstacles and drawbacks and were limited by the technology available at the time, a far cry from the surgical microscopes, viscoelastics, sterilization techniques and manufacturing quality of current lenses. Even though in the time of these pioneering and entrepreneurial ophthalmologists ethical concerns were not in the limelight, they were unable to overcome the complications inherent to the first models, and set phakic IOL aside for over 40 years. To some extent, these experiences have continued to influence this procedure to this date. However, the development of the Baikoff ZB (Domilens, Lyon, France) in 1991 and its different versions, as well as other models that successively entered and exited the market, was the last straw for phakic IOLs attached to the iridocorneal angle that generalized the conclusion that it was not the best place after all to support intraocular lens haptics.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Meanwhile, other ophthalmologists were already researching the second most accessible ocular structure to place a phakic IOL, i.e., the iris. In 1980, Worst and shortly afterwards Fechner paved the way for the «iris-claw» or «crab claw» phakic IOLs. This model was always haunted by the controversy about progressive endothelial loss, although it now appears to be mainly resolved by means of maintaining enough safety distance from the corneal endothelium.</p><p id="par0015" class="elsevierStylePara elsevierViewall">However, an additional step was taken to delve deeper into the eye, in the direction of the retropupilar space. In the early 90s, Fenchner at the <span class="elsevierStyleItalic">Moscow Eye Institute</span> proposed the posterior chamber. His first epi-lens silicone model, the forebearer of the PRL (<span class="elsevierStyleItalic">Phakic Refractive Lens,</span> Carl Zeiss Meditec, Jena, Germany), was withdrawn due to producing cataracts. In parallel with this development, a small proportion of pig collagen was added to the silicone to make the lens material lighter, more hydrophilic and permeable to gas and nutrients. This addition increased biocompatibility with adjacent structures by means of depositing on the lens surface a monolayer fibronectin, rendering it “invisible” to the immune system. STAAR (Monrovia, CA, USA) patented this material and named it collamer (collagen copolymer). This was the advent of the ICL (<span class="elsevierStyleItalic">implantable contact lens,</span> STAAR), which would subsequently change its name to <span class="elsevierStyleItalic">implantable collamer lens.</span></p><p id="par0020" class="elsevierStylePara elsevierViewall">In autumn 1993, Pesando, Assetto, Benedetti, Zaldivar and Skorpik implanted the first ICL prototypes (IC2020). Subsequently, a range of models were developed in the following years, enlarging the optic zone, improving refractive calculations, increasing the number of available sizes and redesigning a larger intrinsic vault in order to improve the dome and separate it from the lens. However, it was not until 2011 when a major breakthrough was achieved in the design of ICLs: a central port in myopic lenses which debuted with the V4c model. This 360<span class="elsevierStyleHsp" style=""></span>μm perforation in the center of the optics proved to be a major breakthrough in phakic IOL safety. The concept of the port had been taken up by Shimizu from a previous STAAR, tested by Zaldivar in the late 90s and discarded at the time due to other problems related to ICL design. The central port enabled surgeons to avoid iridotomy/iridectomy, facilitated surgical implantation and above all improved fluidics between the IOL and the lens, drastically diminishing the appearance of cataracts which had been the war horse of epi-lens phakic IOLs. ICL has become by far the most widely used phakic lens, exceeding at this time one million implants the world over.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the meandering path of phakic IOL development, we have learned a lot as surgeons but also many patients have suffered the consequences. For this reason, we should not forget at this point in time that phakic IOLs are supported by 2 healthy and functional ocular structures (cornea and lens), which means that the material used to manufacture phakic IOLs must be completely biocompatible. In addition, we treat refractive surgery patients, most of them young with high expectations for their vision as well as their lives who nowadays are very well informed and therefore demanding. In the last decade we are witnessing several circumstances that have diminished the reputation of LASIK. The “natural” entropy after millions of successful cases and some complications, which have now been magnified through the Internet and social media, as well as the appearance of the SMILE technique with supposedly lower corneal biomechanics alterations and the fact that modifying the cornea could limit surgeons if future treatments need to be conducted on the lens, are some of the causes for said loss of reputation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In addition, the preservation of the biomechanical and optical qualities of the cornea is increasingly impregnating the mindset of refractive surgeons. Phakic IOLs, which allow surgeons to maintain their options for the future in the first half of their patient's lives, preserving the cornea for techniques to be applied in the second half of their lives, appear as an attractive alternative to LASIK and not only in patients that are not candidates to corneal refractive surgeries. Optical quality and image magnification have proved to be serious competitors in this field against photoablation corneal techniques. Lower induction of postoperative ocular dryness and relative reversibility are additional factors for phakic IOLs.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Even so, some issues and problems are yet to be resolved, such as the fact that phakic IOL implant is still a surgeon-dependent intraocular surgery and, even though complication rates are very low, their potential severity must be taken into account. The algorithms for calculating the right size of the lens to be implanted to achieve greater precision and the right vault for epi-lens IOLs are yet to be improved. In relation to this potential lack of precision in size calculations, there is a very low but not entirely absent risk of undesired postoperative rotation when using toric models. In addition, the foreseeable lower incidence of post-implant cataracts in central port models that has already been evidenced in the first years of follow-up must be confirmed in longer-term studies. Issues linked to dysphotopsia associated to the central port and to the optic zone in young myopic patients with large scotopic and mesopic pupils should also be taken into account.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Possibly, with the development of new generation imaging diagnostic devices, in the future we may be able to customize phakic IOLs according to the biometric characteristics of each eye. Lastly, the pathway for correcting presbytia has also opened with the use of diffractive and/or EDOF phakic IOLs, thus increasing the age range for indicating these lenses. Time will tell what is the final destination of this pathway.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Meanwhile, as we await new developments, refractive surgeons must be knowledgeable about what phakic IOLs can offer at present, to define the role they can play in our particular <span class="elsevierStyleItalic">armamentarium</span> and to be ready for what may come in the future. The comprehensive update by Martínez-Plaza et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">2</span></a> and published in this issue of <span class="elsevierStyleSmallCaps">Archivos de la Sociedad Española de Oftalmología</span>will doubtlessly assist us in this matter. An appropriate end to this editorial is a quote by Stephen Hawking: «intelligence is the ability to adapt to change».</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">Félix González-López is clinical consultant for STAAR, TOMEY corp.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Rafael Bilbao-Calabuig is consultant for PHYSIOL.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gonzalez-Lopez F, Bilbao-Calabuig R. Lentes intraoculares fáquicas: adaptándose a los cambios. Arch Soc Esp Oftalmol. 2020. https://doi.org/10.1016/j.oftal.2020.02.015.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:2 [ 0 => array:3 [ "identificador" => "bib0015" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phakic intraocular lenses" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.F. Lovisolo" 1 => "D.Z. Reinstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.survophthal.2005.08.011" "Revista" => array:7 [ "tituloSerie" => "Surv Ophthalmol" "fecha" => "2005" "volumen" => "50" "paginaInicial" => "549" "paginaFinal" => "587" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16263370" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0953620515001442" "estado" => "S300" "issn" => "09536205" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0020" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lentes intraoculares fáquicas: Recientes avances e innovaciones" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:1 [ 0 => "E. Martínez-Plaza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.oftal.2020.02.001" "Revista" => array:2 [ "tituloSerie" => "Arch Soc Esp Oftalmol" "fecha" => "2020" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735794/0000009500000004/v1_202004240656/S2173579420300499/v1_202004240656/en/main.assets" "Apartado" => array:4 [ "identificador" => "5814" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735794/0000009500000004/v1_202004240656/S2173579420300499/v1_202004240656/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579420300499?idApp=UINPBA00004N" ]
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