Westmont, IL, USA), taking care to ensure that the optic does not cross the optic during this manoeuvre.

In the case of the TICL implantation, corneal marking of the intended axis of placement of the TICL is performed at the start of the surgery. This axis is determined by the manufacturer and the refractive surgeon will have to mark the axis according to the instructions provided by the manufacturer. After the TICL is inserted in the eye, the TICL is rotated to the intended axis prior to the tucking of the footplates.

Viscoelastic is then removed from the anterior chamber by irrigation with balanced salt solution (BSS, Alcon Cusi, Barcelona, Spain) and the pupil miosed with intracameral Acetylcholine 1% (Acetilcolina 1%, Alcon Cusi, Barcelona, Spain). The corneal incision is hydrated and 0.1 ml of 1% Cefuroxime injected in the anterior chamber before the end of surgery.

Post-Operative Care

Post-operative treatment consists of Maxidex (Dexamethasone 0.1%, Alcon Cusi, Barcelona, Spain) one drop, three times daily for 2 weeks, Oftacilox (Ciprofloxacin 0.3%, Alcon Cusi, Barcelona, Spain) three times daily for 7 days and Votaren eye drops (Diclofenac Sodium 28mg in 0.3mL, Norvartis Pharmaceuticals, Barcelona, Spain) every 12h for 6 weeks.

5.4.1.5 Results

Lackner et al. evaluate long-term results after insertion of implantable contact lenses (ICLs) in 75 phakic eyes (65 myopic, 10 hyperopic eyes) of 45 patients aged 21.7–60.6 years [35]. Their study showed that the ICL was effective in correcting myopia and hyperopia. After ICL implantation, mean UCVA up to the end of individual observation time was Snellen 0.36 ± 0.36 for myopic patients and Snellen 0.58 ± 0.28 for hyperopic patients. Improvement in BCVA was also observed in myopic eyes. Mean post-operative BCVA was 0.73 ± 0.26 in these eyes compared to the mean pre-operative BCVA of 0.49 ± 0.23. However, the main complication was the development of subcapsular anterior opacifications of the crystalline lens which was noted in 25 eyes (33.3%).

Uusitalo et al. also showed that the ICL was effective in the treatment of myopia in 38 eyes of 22 patients [63]. All but three patients (5 eyes) are able to manage

most activities without spectacles. The mean spherical equivalent refraction at the last examination ±1.00 D of the targeted refraction in 31 eyes (81.6%) and within ±0.50 D in 27 eyes (71.1%) and the refraction remained stable with a statistically insignificant change (p > 0.05) at each interval during the follow-up.

Schallhorn et al. compared the Visian Toric Implantable Collamer Lens (TICL) and photorefractive keratectomy (PRK) in the correction of moderate- to-high myopic astigmatism [57]. Their prospective, randomised study evaluated 43 eyes implanted with the TICL (20 bilateral cases) and 45 eyes receiving PRK with mitomycin C (22 bilateral cases) with mod- erate-to-high myopia (−6.00 to −20.00 diopters (D) sphere) measured at the spectacle plane and 1.00–4.00 D of astigmatism. This study showed that after 6 months, the TICL performed better than PRK in terms of safety (BSCVA), efficacy (UCVA), predictability and stability. Contrast sensitivity was also noted to be better in the TICL group.

5.4.2 Summary

We can see that we have the lens and the technology to perform minimal invasive surgery for phakic intraocular lens implantation today. Currently, we are able to insert these PIOLs through a sub-3 mm sutureless incision and advances in PIOL technology and diagnostic equipments have improved the safety profile of PIOLs in general. In our centre, our first choice PIOL is the Kelman-Duet PIOL as it is safe and requires a smaller incision. The Visian ICL is preferred in eyes with smaller cornea–iris angles or if significant astigmatism is present.

5.5 Lens and Cataract Surgery

Cataract surgery is one of the most common surgeries in ophthalmology and presbyopia is the most common refractive problem affecting all adults above the age of 45 years. The expectations of cataract patients have increased with time. Most patients now expect a swift recovery after surgery and expect to be able to see both far and near without the use of spectacles. Cataract

surgery and intraocular lens technology have evolved substantially. The trends we see are:

1.Minimising incisions during cataract surgeries

2.Increasing popularity of multi-focal intraocular lenses

3.Improved performance of pseudophakic intraocular lenses

(a)Aspheric intraocular lenses

(b)Toric intraocular lenses

Today, the technology is available to achieve excellent refractive outcomes in post-cataract patients and to meet their expectations of being spectacle-free postoperatively. Micro-incisional cataract surgery allows cataract surgery to be performed through incisions smaller than 2.0 mm. Many types of multi-focal lenses are available in the market and some can be inserted through incisions smaller than 2.0 mm. Newer intraocular lenses also afford improved visual performance by incorporating aspheric designs. Toric lenses also now allow astigmatism to be corrected without additional surgical procedure like limbal-relaxing incisions.

5.5.1Surgery: Micro-Incisional Cataract Surgery (MICS)

Micro-incisional cataract surgery (MICS) is defined as surgery performed through incisions of less than 2.0 mm. Current techniques and intraocular lens technology allow cataract removal through a 1.7 mm incision. The advantages of smaller incisions are:

1.Reduced surgical trauma

2.Reduced surgically induced astigmatism

3.More rapid visual rehabilitation

We conducted a randomised study comparing the outcomes of MICS vs. coaxial phacoemulsification in 100 eyes of 50 patients with nuclear or corticonuclear cataract grades of 2+ to 4 (Lens Opacities Classification System III) in our centre [3]. The final incision size was 1.7 ± 0.21 mm in the MICS group and 3.1 ± 0.25 mm in the coaxial group. Vectorial analysis of surgically induced astigmatism in the MICS group showed that in 35% of the eyes, a change of less than 0.25 D was induced by the surgery; in 50%, the change was between 0.25 and 0.5 D; and in 15%, it was between 0.5 and 1.0 D. None of the eyes in the MICS group showed a vectorial change of more than 1.0 D. While in the coaxial phacoemulsification group, 20% of eyes showed a vectorial change of 0.25–0.5 D; 30% showed a change of 0.5–1.0 D; and 50% showed changes of more than 1.0 D (Fig. 5.17). Surgically induced astigmatism calculated by vectorial analysis showed that in the MICS group, a mean vectorial astigmatic change of 0.36 ± 0.23 D was induced compared with 1.20 ± 0.74 D in the coaxial phacoemulsification group (p < 0.01). There was no statistical difference in the 3 months UCVA (p = 0.74), BCVA (p = 0.85) and mean percentage of endothelial-cell loss between the two groups (p = 0.33). No intraoperative complications were reported in either group. This study showed that MICS allows cataract surgery through a smaller incision and causes minimal surgically induced astigmatism. The latter point is of great importance for refractive surgeons and the implantation of multi-focal intraocular lenses.

We also assessed the visual outcomes of 45 eyes which underwent MICS surgery with the Acri.Smart 48S (Carl Zeiss Meditec AG, Jena, Germany) intraocular lenses in our centre [6]. The mean corneal incision size was 1.46 ± 0.19 mm (range 1.4–1.9 mm) for all the eyes. Six months after surgery, 71.3% of the patients

Fig. 5.17 Graph comparing surgically induced astigmatism in MICS vs. coaxial phacoemulsification