Artisan versus ICL in the same Patient : A Slight Aberration makes a big Difference

C l i n M e d International Library Citation: Signes-Soler I, Callejo TM, Piza JG, Estan JJ (2015) Artisan versus ICL in the same Patient: A Slight Aberration makes a big Difference. Int J Ophthalmol Clin Res 2:018 Received: March 08, 2015: Accepted: March 28, 2015: Published: March 31, 2015 Copyright: © 2015 Signes-Soler I. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Signes-Soler et al. Int J Ophthalmol Clin Res 2015, 2:2 ISSN: 2378-346X


Introduction
After keratorefractive surgeries for high myopic refractive errors, there may be various complications including halos, glare, and contrast sensitivity loss due to higher-order aberration induced by the keratorefractive surgery.Over-flattening of the central cornea can cause higher order aberration.IOLs can correct high refractive errors with minimal changes in the shape of the cornea [1].The implantation of phakic IOLs has been demonstrated to be an effective, safe, predictable and stable procedure to correct higher refractive errors [2,3].However, they are not exempt from a high rate of serious, short and long term complications [4].Are the same benefits obtained with different phakic IOLs?Several types of phakic IOLs are available, such as anterior chamber iris-fixated PMMA lens, phakic IOLs (Artisan (OPHTEC)) 180 with UCVA of 20/25 and BCVA of 20/20.Keratometry was 46.5 × 46.75D LE.Endothelial cell density was 2389cells/mm 2 .Biomicroscopy examination showed a centered ICL, vault 1 (Figure 1b), with a wide anterior chamber, permeable iridotomy and clear lens.Intraocular pressure was 13 mmHg.The patient reported good quality of vision in her LE, but symptoms of difficulty in night driving and halos in her RE.CS showed a clear decrease on the high frequencies (Figure 2) in accordance with the patient´s symptoms.The high order aberration data (HOAs), obtained with a Hartmann-Shack aberrometer (Zywave, Bausch & Lomb, Rochester, New York, USA) (Figure 3), was 0.56μm RE and 0.46μm LE (Figure 3).The spherical aberration was -0.13μm RE and -0.08μm LE.The difference was significant (P<0.05).

Discussion
The visual performance of ICL IOL was better than the Artisan IOL for our patient, although both phakic IOLs showed equal and comparable safety, predictability, and efficacy in a study of 68 highly myopic eyes published in 2011 [5].However, the authors did not measure CS and aberrations.
Different degrees of glare associated with this IOL have been reported in the literature.Maloney et al. [6] reported mild to moderate glare in 18 eyes (13.8%) and severe glare in 1 eye (0.8%) of 130 eyes implanted with an Artisan iris-supported phakic IOL.In 3 2,037cells/mm 2 RE and 2,401cells/mm 2 LE.The axial length was 25.11mm LE, ultrasound Pachymetry (DGH Technologies, Exton, Pennsylvania, USA) was 539 micron and anterior chamber depth (ACD) measured from the corneal endothelium with a scanningslit topographer (Orbscan Ilz: Bauch &Lomb, Rochester, NY) was 3.51mm LE.Pupillometry (mesopic conditions) was 3.6mm RE and 3.9LE.Clinical examination revealed that the Artisan IOL was in a stable position with the haptics in the horizontal axis, with no inflammatory reaction in the anterior chamber and clear lens.There was no contact between the Artisan IOL and the crystalline lens, nor did the anterior surface of the iris appear to rub against the posterior surface of the IOL optic.Dilation showed a slight superior descentration of the IOL (Figure 1a).Other ophthalmic examinations were unremarkable.
A phakic intraocular lens of -10D (STAAR) and 12.1mm of diameter, with a 5.8mm of optic zone, was implanted in the posterior chamber of the left eye.ICLs was made of a flexible material proprietary hydrophilic porcine collagen (<0.1%) hydroxyethyl methacrylate (HEMA) termed Collamer.The surgery was performed under topical anesthesia, intraoperative iridotomy with vitreotome, as per the usual technique and without complications.The patient followed the postoperative protocol of antibiotic and steroid eye drops plus visits at 24 hours, one week, and one month.
The patient was followed up periodically.Three months after surgery, the manifest refraction for the left eye was +0.25-0.50×  eyes an optic diameter too small relative to the pupil size was found to be the cause of the visual disturbances and an IOL with a 5.0 mm optic was exchanged for an IOL with a 6.0 mm optic, with no glare noticed afterwards [6].The slight descentration of the IOL in the RE could cause visual disturbance such as diplopia and glare but in our patient a pupil in mesopic conditions of 3.6 mm can hardly explain the symptoms.Furthermore, a small degree of descentration should be more likely found after iris fixation of an Artisan IOL than when an ICL is placed in the posterior chamber of the eye.Marroccos et al. [7] showed that, with objective measurements, there was an increase in both glare and halos which was more prominent in eyes with an ICL than with Artisan (both 5.0 and 6.0), and that symptoms lead to a decreased visual performance at night time, causing visual disturbances in dim light conditions [7].These findings were thought to be due to the edge effects of the small diameter of the ICL and the small optic diameter (4.5 to 5.5mm) in relation to the pupil size (5.3 to 7.4mm).This was attributed to the larger optic (6.0mm versus 5.0mm) and the fixation of the IOL to the iris, which causes less pupil dilation.Conversely, in our patient, the ICL had fewer halos and better quality of vision than with the Artisan.
The contrast sensitivity decreased in the Artisan IOL compared to the ICL IOL for our patient.Stulting et al. [8] after analyzing 3-year results of the Artisan PIOL, did not detect a decrease in the contrast sensitivity.However, in this prospective study, patients with a mesopic pupil greater than the PIOL optic were not included; 80% of the PIOLs had a 6.0 mm optic and only 20% had a 5.0 mm optic [8].In another study the CS decreased in the immediate preoperative exam but returned to baseline three months after surgery under photopic conditions [9].As in our patient, Artisan PIOLs led to a small increase of HOAs under photopic conditions [8,9].For different pupil sizes an increase in HOAs, trefoil and spherical aberration was also found [10].The authors reported a significant correlation between PIOL descentration and postoperative spherical aberration and coma.Different incision sizes may explain differences in trefoil, whereas the optic design seems to affect spherical aberration.
The spherical aberration was found to be in our patient -0.13μm RE and -0.08μm LE.Artisan phakic IOLs are safe and effective for refractive error correction but with a significant increase in 4 th order spherical aberration [11,12] which, according to the authors, could be related to the optic design.
The ICL performed better in terms of endothelial cell density in the short term in our patient, in accordance with Ju et al. [13].The Artisan phakic IOL provided good refractive outcomes but a higher than normal rate of endothelial cell loss.During a 2-year follow up, Benedetti et al. [14] found a 5.4% endothelial cell loss in 60 patients implanted with the Artisan phakic IOL affected with myopia [14].Other authors reported rates between 1.8% [8] and 1.45% [11] per year.
Artisan and ICL phakic intraocular lenses are effective for refractive correction, but the Artisan performed worse in terms of contrast sensitivity than the ICL in our patient.HOAs were also significantly higher in the Artisan lens than in the ICL.Centering of the IOL is very important for the result in vision quality.

Figure 2 :
Figure 2: Contrast sensitivity of both eyes, three months after surgery.