“The problem with laser correction is that some people have just pushed the envelope to do too much treatment for the degree of nearsighted, and weakened the cornea,” said Sarah Hays, MD, of VisionFirst. But she offers a new approach for the severely myopic that doesn’t involve operating on the cornea. Hays, who’s performed over 20,000 refractive procedures, is referring to intraocular contact lens implant (ICL) for people who are severely nearsighted and therefore fail as good candidates for laser vision correction. In laser correction, the cornea is adjusted by laser — usually flattened — to better the person’s sight. But with ICL, a customized contact lens is fitted over the natural lens. The process is similar to a cataract operation, complete with surgical setting and an anesthesiologist. With the pupil dilated, about the same size as for a cataract operation, surgeons make a tiny cut, about 2mm, at the limbus and insert a thin flexible lens under the iris. The incision can be much smaller than the lens, because the flexibility of the ICL allows it to be folded as it’s inserted. Once in, it unfolds to lie on top of the natural lens. “Because the normal curvature of the cornea is not altered, patients have a much better quality of night vision than with laser correction,” Hays said. “And they have the unaltered cornea left if they need a little tweaking done with laser.” She emphasized that this is a procedure for younger eyes. Anyone over 45 should consider a refractive lensectomy, because with age the natural lens loses the ability to bring in reading vision. Though the surgery takes about ten minutes per eye, the pre-exams are extensive. “We have a very involved exam, equivalent to an exam for cataract surgery,” Hays said. It takes two visits to do the work-up, a total of about three hours. During the first visit, she makes two little holes in the iris to help fluids from the back of the eye get to front of the eye. “These holes are like release valves, because the plastic lens can block the fluids from draining in the eye and cause an acute episode of glaucoma,” she said. After the procedure, like with laser correction, the patient is “good to go,” Hays said. “In fact, they’re really better off than a lot of LASIK patients the next day.” She explained that the day after laser correction, someone who’s moderately nearsighted can have swelling in the cornea. Because that doesn’t occur with the ICL, they can have much sharper acuity sooner. ICL is not for everyone. “It’s a more involved operation than laser correction,” Hays said. “So if you’re a very good candidate for LASIK and are minimally nearsighted, there’s probably less trauma on your eye to just have laser vision correction.” The break point for nearsighted lies somewhere around 5 diopters. ICL also does not fix presbyopia. But ICL does hold advantages over a refractive lensectomy. “You don’t make the vitrious shift around with an ICL, so you have a lower chance of a retinal detachment then with a refractive lensectomy,” Hays said. “If you take out the natural lens to put in an artificial plastic lens, you increase the space that the vitrious can move around in by about 2mm.” That space increases the chance that the vitrious can tug on the retina and cause a tear and subsequently a detachment. “It’s about a two to three percent chance,” said Hays, who recognized that it was a very small risk, but “if you’re that two percent, it’s worth mentioning.” “This could actually be considered a reversible situation,” Hays said, referring to the possibility of removing the ICL to do normal cataract surgery, and then implanting the most updated lens available. The most likely complication from an ICL implant, beside the slight chance of infection, is damage to the natural lens made from the slip of an instrument. In the U.S. clinical trials, only three out of 300 eyes formed cataracts from instrumental damage, but those were repaired and happened in the first 3 months after the surgery. The procedure is more expensive than LASIK because of the added cost of a surgery suite and the anesthesia. Hays said ICL typically runs $1000 to $1500 more per eye. “Unlike the money someone spends on a big-screen TV or clothes or a vacation, this is something you will use every day for the rest of life,” she said. I think it’s the greatest thing,” said Hays, who’s performed 60 ICL implants so far. “General practitioners should know that if they have a patient who’s extremely nearsighted, isn’t a laser candidate, and lamenting that they wish they had freedom from eyeglasses, there’s something out there that can help them. It’s a great choice.” July 2008