Implantable Contact Lenses
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According to the American Academy of Ophthalmology, about 36 million people wear contact lenses to correct the common refractive errors myopia (nearsightedness), hyperopia (farsightedness), and astigmatism. Contact lenses work by temporarily altering the shape of the cornea, flaws in which are responsible for these refractive errors.
Implantable contact lenses (ICLs), also known as phakic IOLs, correct vision in much the same way that external contact lenses do, except ICLs are surgically placed inside the eye, where they permanently improve vision. Phakic, from the Greek word "phakos," for lens, refers to artificial lenses that operate in conjunction with the patient's natural lenses.
While ICLs function in almost exactly the same way as contact lenses that sit atop the eye, they are also similar to intraocular lenses (IOLs), which are used during cataract surgery to replace the eye's natural lens after it has been fragmented and removed. However, during ICL surgery, the natural lens is kept in the eye and works with the implanted lens to correct vision.
ICLs are inserted through tiny incisions in the cornea and placed behind or in front of the iris (the colored part of the eye) and in front of the natural lens. These thin, pliable lenses can serve as an alternative to laser eye surgery procedures such as LASIK and are often used to correct conditions that laser procedures may be unable to correct, such as extreme myopia. The ICL procedure produces little to no discomfort for the patient and has a 95 percent average success rate.
Currently, the United States FDA (Food and Drug Administration) has only approved implantable contact lenses that treat a wide range of myopia (nearsightedness). Any patient interested in a refractive vision correction procedure for nearsightedness may potentially be a good candidate for implantable contact lenses. ICL insertion allows patients to experience freedom from the eyeglasses and contact lenses that they use to correct myopia. The implantable contact lens refractive procedure is ideal for patients with severe myopia, with dry eye syndrome, or with other contraindications that do not make them good LASIK candidates.
There are currently only two FDA-approved implantable contact lenses on the market. While they are both very similar, each has slightly different candidacy requirements.
Verisyse™ Phakic IOL
The Verisyse™ phakic intraocular lens is often an option for those with moderate to severe myopia who are not candidates for LASIK. Unlike other ICLs, the Verisyse™ lens is placed in front of the iris, and the natural lens is left in the eye, allowing for uninterrupted focusing ability. Made by Abbott Medical Optics, this lens is made from a special, sterile polymethylmethacrylate (PMMA) rigid, clear plastic.
Although it is an implantable contact lens, Visian's "ICL" stands for implantable Collamer® lens, since it is made from the company's proprietary collagen co-polymer, specially designed for biocompatibility by STAAR® Surgical, a leading ICL manufacturer. The Visian ICL™ is foldable, allowing for insertion through a very small incision. It is placed behind the iris and works with the existing lens to correct vision.
General Candidacy Requirements
Patients must meet certain criteria to be a good candidate for implantable contact lenses. Typically, those who benefit the most from ICL surgery:
- Are over 21 years of age, and typically fewer than 45 years of age. While not an absolute rule, most ophthalmologists do not recommend ICL surgery to patients in their 40s because they are likely to experience presbyopia, a condition in which the ocular tissue begins to degrade and interferes with the eye's ability to zoom in, causing progressive farsightedness.
- Have moderate or severe myopia. In general, implantable contact lenses can correct up to -20 diopters (the units optometrists use to measure refractive error, with a positive diopter number referring to hyperopia and a negative value indicating myopia) of myopia. However the exact treatment range varies depending on the brand of implantable contact lens. The Visian ICL™ can correct between -3 and -20 diopters, while the Verisyse™ phakic IOL (intraocular lens) works for patients with between -5 and -20 diopters of myopia. If your myopia is too mild, ICLs may not be a good option for you, since the available lenses would overcorrect your vision.
- Have minor or no occurrence of astigmatism. Currently approved implantable contact lenses can treat up to 2.5 diopters of astigmatism. A toric implantable contact lens - which could treat astigmatism - is pending FDA approval, as is an implantable contact lens for farsightedness.
- Have had an unchanging vision correction prescription for at least six months for the Verisyse™ phakic IOL and one year for the Visian ICL™. Before undergoing any form of refractive error surgery, it is important for your vision to be consistent. If your eye's shape is changing, ICL surgery may not be as effective.
- Are not currently pregnant or breastfeeding. The hormones your body produces during these periods can temporarily change your eyesight, making it unstable.
- Have proper anterior chamber depth. The anterior chamber is the part of your eye between the iris and cornea, typically filled with a fluid called aqueous humor. It is important for your anterior chamber to be of a certain size so that there is room for the implanted contact lens. The minimum requirements for anterior chamber depth vary slightly between the Verisyse™ phakic IOL and Visian ICL™. Your ophthalmologist will determine chamber depth during a comprehensive eye test performed to verify your candidacy for ICL surgery.
- Have a healthy corneal endothelium. The endothelium is the inner layer of corneal cells. It s important that they be healthy enough to support an implantable contact lens for proper ocular function.
- Are not good candidates for LASIK. Patients with dry eyes, severe myopia, thin corneas, and some of the other contraindications for LASIK may be eligible for implantable contact lenses. In addition, patients who are uncomfortable with their corneas being permanently modified will likely opt for an implantable contact lens, since this surgery is reversible.
- Are not allergic to the local anesthetic eye drops used in ICL surgery.
- Do not have any ocular diseases, such as cataracts, glaucoma, lazy eye, macular degeneration, Fuchs Dystrophy, or Amblyopia. These could interfere with surgery or result in harmful complications.
- Have eyes free from infection, as this could be exacerbated or impede successful surgery.
- Have no deformities to your iris, since this could obstruct implantation of the lens.
- Are free from autoimmune conditions such as Lupus, scleroderma, rheumatoid arthritis, or Sjogren's syndrome, a condition in which the body's cells begin attacking its own lubrication glands, especially the eyes. The operation could cause these issues to flare up in your ocular cells.
- Be HIV negative and not suffering from AIDS. A deficient immune system could prevent your eye from healing correctly from surgery and increase your risk for serious infection.
- Have no history of Zoster or Herpes eye infections, since the implantation could disturb your eyes and cause the latent virus to reactivate.
- Are not taking any immunosuppressant drugs or steroids that could slow your healing process after surgery.
- Never have experienced severe eye trauma or retinal detachment, since this could weaken the structure of your eye, increasing your risk for retinal damage or detachment after surgery.
- Have large enough pupils for surgery, as determined by your ophthalmologist. ICL surgery is less effective and more difficult to perform for those with especially small pupils. However, your pupils must not be too large, since this could also interfere with ICL surgery. Your ophthalmologist will be able to analyze your eyes to determine if you fit the criteria for ICLs.
Your ophthalmologist will help you decide whether implantable contact lenses are right for you at your initial consultation.
The cost of implantable contact lenses depends greatly on the surgeon you choose and the area of the country in which your procedure is performed. In general, patients should expect to pay from $1,500 to $5,000 per eye for implantable contact lenses, with the average being $3,500. Typically, this expense includes:
- The price of the lens. American patients have only two lens provider options: Verisyse™ phakic IOLs and Visian ICL™ lenses. The cost will depend upon the brand of the lens and the level of refractive error it needs to correct.
- The initial consultation, during which the surgeon determines your candidacy for ICLs, answers any questions you may have, and plans your surgery. Many ophthalmologists provide free consultations for patients who are considering pursuing this procedure.
- Your surgeon's time and expertise. While it is important to have an affordable doctor, patients should be leery of ophthalmologists who offer ICL surgery at a cost below $1,500 per eye, as this could betray less experience with or expertise in with this procedure.
- The cost of the facility used for your surgery. While ICL surgery is typically an outpatient procedure, it is important that the hospital room or clinic the surgeon uses is properly equipped for this delicate and highly technical procedure.
- Post-operative care to ensure that your eyes are healing properly and to handle any complications that may arise, although these are rare.
- Local anesthesia to numb your eyes in preparation for surgery.
Your ophthalmologist may also provide you with any painkillers or medicated eye drops to assist with your recovery, although you may need to purchase these yourself. Ask your doctor about which expenses will and will not be covered by the clinic so you are fully informed before you go in for surgery. You may also discuss the cost effectiveness of different lens types when planning your procedure.
Many patients are overwhelmed by the cost of ICLs, but you should consider this surgery an investment in your future eyesight and overall wellbeing. In addition, the average American contact lens-wearer spends approximately $500 to $700 per year on lenses and solutions, not including the expense of optometrist appointments or accessories, so ICL surgery could actually save you money in the long-term.
Unfortunately, most insurance providers consider implantable contact lenses an elective or cosmetic surgery, so they will not cover the full cost of the procedure. Some providers may cover a portion of the surgery or the pre-operative examinations and tests. Others may not pay for surgery, but provide more affordable surgeons through your healthcare network. You should contact your health insurance provider about your options and obtain a written record of any costs they are willing to cover.
Many ophthalmologists also offer financing plans to help you pay for the procedure. While some clinics offer zero percent financing, you should be careful to factor the interest rate for financing into your cost calculations for surgery. There are many healthcare financing providers, so you should do your research to get the best rates and payment plans for you before you commit to surgery.
You can also talk to your financial planner or accountant about other strategies to make ICL surgery more economical. For example, you may be able to deduct corrective eye surgery from your taxes, if your medical expenses add up to more than 7.5 percent of your total income. You may also be able to pay for ICL surgery out of a Flexible Spending Account or Health Spending Account, if you have either of these.
If you do not use financing to pay for your ICL surgery, the full amount will most likely be due on the day of your first procedure. Most ophthalmologists prefer to operate on one eye at once for optimal results, so your second lens will typically be implanted about two weeks after your first surgery. You may pay for each eye on the day of the surgery for that eye.
If you are using financing to pay for your surgery, your payment schedule will depend entirely on the company and plan you have chosen. You will pay a monthly fee for between six months and five years. If your financing plan has a fixed rate or zero percent interest, your monthly fees will remain the same, but if your interest fluctuates, you may sometimes owe more or less. Depending on your financing provider, you may be able to pay off your surgery in a lump sum, if you have the necessary funds.
In either case, you should make sure to receive an itemized receipt from your ophthalmologist for ICL surgery. This will help you understand what your charges are so you can contest any errors. You may also need a detailed receipt to send to the lender financing your surgery or your insurance provider, if they will cover any part of your surgical expenses.
How to Choose an ICL Surgeon
The surgeon you work with will in large part determine the success of your ICL surgery and the quality of your vision following the procedure, so it is important to do your due diligence when making this important decision.
To begin, look for ophthalmologists in your area who can perform this procedure. If you are pursuing ICL surgery, you likely already work with an optometrist or ophthalmologist to manage your refractive error, so you should certainly ask these people for recommendations or referrals. You can also ask friends, family members, or colleagues who have ICLs for their suggestions. You should look up ophthalmologists in your area on an Internet search engine, being sure to look at their online patient reviews and check their Better Business Bureau profile for complaints. For any local clinic you are considering, you can get in touch with your County Clerk's office to find out if there are any pending or current legal suits against the surgeons.
Once you've narrowed your search to a few different surgeons, it's important to ask your prospective surgeon right questions, either on the phone or in person. These include:
- Are you certified by the American Board of Ophthalmology? This is a basic requirement for ophthalmologists, so any surgeon who isn't should be immediately disqualified. Also, be sure to check that the surgeon is certified in both general and surgical ophthalmology, as these are separate practices. You want the doctor operating on your eyes to be a specialist in ocular surgery. You can also double check the surgeon's qualifications by looking him or her up in the National Practitioner Data Bank, which has compiled information on American surgical professionals. You can verify his or her credentials with the International Society of Refractive Surgery, the Liaison Committee on Medical Education, and the American Board of Medical Specialties. This may seem like a lot of fact checking, but working with a credentialed surgeon is vital to the success of your surgery, especially since your eyes are relatively fragile organs.
- Do you hold membership in the American College of Surgeons? This is not an accreditation organization, but fellows of the college are some of the highest quality surgeons in their fields, since they have to meet high standards to qualify.
- Do you give lectures or train other surgeons? Often, the best ocular surgeons help to educate younger ophthalmologists or use their expertise as visiting professors at medical schools.
- Do you implant both Visian ICL™ and Verisyse™ phakic IOLs? Are you certified in either or both of these procedures? While they are both implantable contact lenses, the materials, techniques, and outcomes for Visian versus Verisyse are notably different, and each requires unique training to perform successfully. Ideally, your surgeon is capable of using either type so that you can choose which suits your unique needs.
- What do you generally charge for ICL surgery? This is an important question so that you can determine whether this surgeon is an affordable option. In addition, be wary of any surgeons that claim to provide ICLs for less than $1,500 per eye.
- What is included in the cost of surgery? This will help you plan your expenses and get a sense of how much value the surgeon provides. For example, if a surgical space in a high-quality hospital or clinic is included in the cost, this could be a good sign. Be sure to ask about painkillers and medicated eye drops specifically, since you will need to pick these up before your surgery if your surgeon does not provide them.
- How many ICL surgeries have you performed? What is your complication rate? The more procedures your prospective surgeon has completed, the better. If his or her complication rate is higher than five percent, this could be a bad sign, since the average success rate of ICLs are between 95 and 99 percent.
- Where can I find patient testimonials? Although you've likely already looked up online reviews by this point in the selection process, your surgeon should be willing to provide testimonials to evidence his or her experience and ability.
- What kind of post-operative care do you provide? Some surgeons send their patients back to their regular ophthalmologists for follow-up care, but many patients prefer to work with their surgeons as they heal in case more complex issues come up. Some particularly conscientious surgeons will provide check-ups on the progress of your ICLs for life, but this is a rare find given how busy surgeons can get.
- What are the age limits for your surgery? If you are at the edge of either side of the spectrum, this can help you determine your eligibility for ICL at this surgeon's clinic. This question can also help you gauge the surgeon's ethics. Implanting contact lenses for someone under 21 or over 45 is generally inadvisable, and the integrity of surgeons who are willing to deviate from these standards may be suspect.
- What types of anesthesia do you provide? Most patients require only numbing eye drops, but some ophthalmologists also provide the option of oral sedatives or intravenous anesthesia to ease any anxiety or discomfort.
- How soon are your patients generally able to return to their daily routines? Typically, each eye takes about two weeks to fully heal and stabilize, so you should be able to move, exercise, read, and watch television with no problems in about a month. Most patients can return to work between 1 and 3 days after each of the procedures.
- Who will perform my surgery? Most patients assume that the surgeon they speak to will be the one to place their ICLs but, especially at larger clinics, a different doctor might be scheduled to perform your surgery. If you feel strongly about which surgeon you would like for your procedure, make your concerns heard.
- Do you also provide other refractive surgeries? The answer to this question will most likely be "yes," since laser eye surgeries are generally more popular than implantable contact lenses. While there are many reasons to choose an ICL, having other options is a good idea.
This is quite an exhaustive list of questions, so not all may apply to your particular search process. Besides getting answers to your questions, an important part of the interview is gauging the surgeon's personality. If he or she is friendly and happy to talk to you, this can be a sign of what you can expect throughout your surgical process. Especially in a complex field like ocular surgery, it is important to have a doctor that will take the time to listen to your concerns and explain the procedure to you.
The Initial Consultation
Once you've chosen your preferred surgeon, you'll come in for your first appointment, the initial consultation. This appointment will typically last between one and two hours.
Preparing for Your Appointment
To make the most of your time with the surgeon, you should prepare by:
- Gathering your ophthalmology and medical records so the surgeon can review them for any pertinent information. You can usually ask your current general practitioner, optometrist, or ophthalmologist to send your charts to the surgical clinic. In particular, your surgeon will need any documentation about your glasses or contact lens prescription.
- Making a written list of your questions and concerns. It's very easy to forget what you wanted to ask when you're in a hurry with the surgeon, especially if you are anxious about your upcoming surgery. Writing your questions out also gives you the opportunity to do some quick online research for yourself. If you can find a suitable answer online, you might not even need to ask the doctor.
- Clearly determining the goals for your surgery. Would you be all right with continuing to use glasses for reading? Is it very important to you that your procedure is reversible? Are you aiming for perfect 20/20 vision, or would 20/40 be acceptable to you? Is it important for you that your lens not be visible on your eye? Your desired results and expectations will inform the surgeon's recommendations. Of course, it is important to have realistic expectations for any refractive surgery.
- Stopping contact lens use for one week, if you use soft lenses, or two weeks, if you use hard lenses. Contact lenses can temporarily modify your corneal shape, so it is important to have a clean slate for your eye exams. Instead, you should wear an up-to-date glasses prescription and bring your glasses with you to the appointment.
Your surgeon's and your time is valuable, so making proper preparations can help you have a successful, efficient appointment.
To verify that you are a candidate for ICL surgery, determine which type of lens is best for you, and plan your procedure, your surgeon will conduct a comprehensive assessment. This exam generally includes:
- Determining the (in)accuracy of your vision. In addition to basic tests like reading a Snellen Chart (the white page with individual black letters and lines), the surgeon will use either a skiascope, which is a lighted tool, or refractometry, a test using a computer scanner, to determine how myopic (and potentially astigmatic) your eyes are. ICLs can correct the very mild astigmatism that can come with myopia, but there are no FDA-approved lenses for astigmatism at this time.
- Measuring the size of your cornea and pupil. Most patients who are looking into ICLs have thin corneas that disqualify them from LASIK eye surgery, and your pupils must be sufficiently large to hold the implanted contact lens (although overly enlarged pupils increase surgical risks, as well).
- A dilation test to look for any abnormalities within your cornea or iris, as these may preclude your surgery. To do this, the surgeon will give you eye drops that cause your eyes to completely dilate, giving him or her a better view into your eyeball. Be warned that you will not be able to drive for up to six hours after this test, since the dilation eye drops can make your vision blurry and sensitive to light.
- Slit lamp instrument examinations. To be a good candidate for ICL surgery, the inner layers of your eye must be healthy and provide enough space for an internal lens. To analyze your corneal endothelium and anterior chamber depth, your ophthalmologist will use a device called a slit lamp instrument, which shines a flat plane of light at your eye. This bright, focused light, in combination with a powerful microscope, allows the surgeon to assess the interior features of your eyes.
- Mapping your corneal topography. This is a test to assess the shape of your cornea, which involves staring at a complex geometric pattern while the surgeon takes a close-up digital photograph of your eye. The way your eyes reflect the image will allow the ocular surgeon to generate a three-dimensional model of your eye, which can be very helpful in planning surgery.
This comprehensive examination will ensure that you have all the necessary information to choose the surgical option that suits your needs, desired results, and budget.
Either before or after completing your comprehensive eye exam, your surgeon will discuss your surgical options with you. This is the time to go over your pre-written list of questions, taking note of the answers your ophthalmologist provides. Be sure that you understand which type of lens he or she will use in surgery, how long the procedure should take (typically less than 30 minutes per eye), how your two procedures (for each eye) will be scheduled, and what you can expect for recovery.
During the initial consultation, you will likely also meet with other professionals at the clinic. The ophthalmology nurse will be able to discuss specific details of your pre-operative preparation and anesthetic needs. If you plan to finance your procedure, you will need to speak with the front office staff about billing and payment schedules. Before you leave, you should have a list of instructions for your next appointment and set a surgical date.
ICL vs. LASIK
LASIK, or laser in situ keratomileusis, is the most popular refractive error surgery. During this procedure, the ophthalmologist creates a flap in the cornea's epithelium (outermost layer) using either a thin oscillating microkeratome blade or an ultraviolet femtosecond laser. Then, he or she lifts this flap to access the underlying stroma and uses powerful pulses of light from the computer-guided laser to reshape the tissue so the cornea can refract light appropriately, correcting the patient's vision. Finally, the surgeon places the flap back over the eye, where the edges should heal back together. Some ophthalmologists enhance the accuracy of LASIK by using wavefront mapping technology, which bounces light waves off of the eye to create a customized three-dimensional map that the computerized laser uses during surgery.
ICL surgery can correct severe myopia and slight astigmatism
While ICL surgery can correct severe myopia and slight astigmatism, LASIK surgery can be used for patients with mild to moderate myopia, hyperopia, and astigmatism. Both LASIK and ICL are relatively short surgeries, but LASIK can typically be performed on both eyes at once, while ICL usually cannot. Some patients appreciate that LASIK changes the natural structure of their eyes for improved vision, but this also means that LASIK it not reversible. Patients whose vision changes after surgery or who want to restore their original eyesight for whatever reason can simply have their implantable contact lenses removed. Patients' vision tends to stabilize much more quickly after ICL surgery as compared with LASIK, since their corneal tissue has not been directly adjusted. LASIK can take up to six weeks, while some ICL patients experience stable, corrected vision just one day after surgery.
Some LASIK patients also experience regression, in which their corneal tissue gradually grows back to its original shape. Since ICL surgery does not modify the cornea and relies instead on an artificial lens to improve refraction, patients' vision is typically more predictably and permanently corrected. For example, a 2010 research comparison of LASIK and phakic IOLs found that ICL patients were better able to perceive the contrasts between light and dark objects, which is important for depth perception and night vision. In this study, the success, satisfaction, and complication rates for ICL and LASIK were very similar. The biocompatible artificial lenses implanted in ICL surgery also typically offer ultraviolet light protection, helping keep patients safe and comfortable for years to come.
ICL surgery is also an excellent alternative for patients who do not qualify for LASIK. There are several reasons a patient may be ineligible for LASIK, but a good candidate for ICLs. These include:
- Moderate to severe myopia. LASIK is less effective for patients with severe myopia, so most ophthalmologists do not perform it for patients with greater than -8 diopters of nearsightedness. Since ICL surgery can correct up to -20 diopters of myopia, many patients who cannot undergo LASIK can benefit from ICLs.
- Chronic dry eyes. A patient's eyes can be dry due to dehydration, as a side effect of certain medications, or due to allergies. Inadequate moisture makes it difficult for the eyes to heal properly from LASIK, and this surgery can actually cause short- and long-term dry eye in patients, so this procedure could exacerbate this condition. Since it does not require modifying the corneal stroma or healing the epithelium, ophthalmologists often recommend ICL to patients with dry eyes.
- Thin or irregular corneas. The epithelial layer of the corneas must be sufficiently thick to accommodate flap creation, so patients with thin or abnormally shaped corneas are not good candidates for LASIK. ICL surgery does not require the creation of a corneal flap, making it an excellent alternative for patients with corneal issues. In addition, patients who have healthy enough corneas for LASIK may choose ICL surgery because they do not want to take the risk of corneal flap complications, which can occur if the flap heals incorrectly or becomes infected.
- Keratoconus, an ocular disease in which the corneal tissue grows out into a cone shape, which can distort vision and create light sensitivity. Since this disorder affects the corneal tissue, patients with keratoconus cannot undergo LASIK, but they can use ICLs to correct their vision.
Deciding between ICL and LASIK is a personal choice, and it depends on the patient's unique circumstances. Those with mild hyperopia and a healthy cornea will likely choose LASIK, while ICL may be a preferable choice for patients with severe myopia and keratoconus.
There is a cost difference between these two surgeries. Since ICL surgery involves implanting highly advanced synthetic lenses rather than simply modifying the cornea, this procedure is often more expensive. However, with no risk of regression and excellent long-term results, many patients find it to be a worthy investment. In some rare cases, ICL patients choose to further improve their vision by undergoing LASIK as well as ICL surgery.
ICL vs. PRK
PRK, or photorefractive keratectomy, was the predecessor of LASIK and is therefore a very similar procedure. The primary difference between PRK and LASIK is that the surgeon uses a surgical brush, alcohol solution, microkeratome blade, or femtosecond laser to completely remove the epithelial layer of the cornea rather than creating a flap to be replaced after surgery. This allows the surgeon more direct access in order to modify the shape of the stroma for improved refraction. After surgery, the surface of the cornea will grow back over the eye.
Patients with mild to moderate myopia, hyperopia, and astigmatism are good candidates for PRK
As with LASIK, patients with mild to moderate myopia, hyperopia, and astigmatism are good candidates for PRK. Wavefront technology is also available for PRK, making it more precise and personalized. The surgeon's direct access to the stroma means that PRK can correct more severe myopia, up to -12 diopters. PRK patients may experience regression and need enhancements after their initial surgery, just like those with LASIK.
Similar to ICL surgery, one advantage of PRK is that patients who do not qualify for LASIK are often eligible for PRK. Patients with thin or irregular corneas can undergo PRK because the surgeon does need to create the flap. This also means that both PRK and ICL surgery eliminate the risk of flap complication that concerns some patients and surgeons. However, patients with keratoconus and chronic dry eyes are still not eligible for PRK, while they can benefit from contact lens implantation. PRK is generally around the same cost as ICL surgery.
One of the primary disadvantages of PRK as compared to ICL is the healing time. Since the eye has to heal from stromal modification and grow back the outer layer of the cornea, it can take longer for patients to resume normal activities such as reading, driving, or watching television. Since PRK is a more intensive surgery than either LASIK or ICL, patients' vision may not stabilize for up to six months. Some patients pursue enhancements to refine the effects of their PRK or reverse regression. As with LASIK, some ICL patients choose to undergo PRK at a later point to further correct their refractive error.
Many patients pursue ICL surgery over PRK because they want a faster recovery, more rapid eyesight stabilization, and the option to reverse the procedure. In general, implanted contact lenses provide a higher clarity of vision, which some surgeons call "high definition," better contrast perception, and higher quality night vision than LASIK and PRK. This is because the patient's visual improvements depend on their sophisticated synthetic lenses rather than their own body's response to reshaped tissue.
Visual Errors ICL Can Address
Presently, FDA-approved implantable contact lenses can correct moderate to severe myopia (from -5 to -20 diopters, depending on the lens brand), with mild astigmatism (up to 2.5 diopters). By utilizing artificial lenses, ICL surgery can often provide superior clarity, contrast, and night vision as compared with typical human eyesight.
Astigmatism and Hyperopia
Manufacturers are awaiting approval for toric lenses that could correct astigmatism and phakic lenses or hyperopia. Patients wanting to correct moderate to severe astigmatism can pursue PRK, LASIK, LASEK (a combination of PRK and LASIK techniques) or toric intraoral lenses, which are pseudophakic, meaning that they replace the eye's natural crystalline lens. Those with hyperopia can use PRK, LASIK, LASEK, or Refractive Lens Exchange, in which the surgeon removes the natural lens and replaces it with a phakic intraocular lens.
One visual error that most refractive surgeries cannot correct is presbyopia, the gradual degeneration of ocular tissue and the eye's ability to focus on close-up images Presbyopia is often the result of aging, which is why most ophthalmologists will not perform ICL surgery on patients over 45, since this condition could interfere with their results. Patients who want to surgically correct their presbyopia can pursue monovision refractive surgery. Using the techniques of PRK, LASIK, LASEK, or intraocular lenses, the surgeon modifies one eye to see for distance, and one eye to see close objects, making the patient's eyes into their own bifocals. Monovision is successful for most patients, but up to 15 percent cannot adjust to this new visual system.
Patients with cataracts, clouded lenses due to accumulated proteins, are not eligible for ICL surgery, since the proteins in their natural lenses would blur their vision through the implanted contact lenses. However, these patients often benefit from intraoral lens implantation. Ophthalmologists often resolve cataracts by fragmenting and removing the natural lens, replacing it with a pseudophakic IOL, which can serve to correct both the cataracts and refractive errors at the same time.
Before IOL Surgery
At the end of your initial consultation with your chosen ophthalmologist, your surgeon should give you a list of instructions to follow before the day of your surgery. Typically, you will need to:
- Arrange for someone to transport you to and from your operation, since you will not have vision fit to drive immediately following your surgery.
- If your clinic does not provide antibacterial and steroid eye drops or painkillers, you will need to purchase these beforehand. Trying to go to the pharmacy right after surgery would be very uncomfortable.
- As with your eye examination, you will need to stop wearing soft contact lenses one week before surgery and hard contact lenses at least two weeks before your appointment.
- Plan to take a few days off of work, especially in the period between the surgery for your first eye and second eye. Even though most patients recover from the effects of surgery within one to three days, it may be difficult for you to work or focus with only one eye corrected.
- Get the answers to any other questions you have about the surgery or your recovery. The day of surgery is typically too late to make major adjustments to your procedure.
- Take supplements that promote ocular health and tissue growth, such as omega-3 oils and vitamin C.
- Purchase goggles, glasses, or an eye mask to protect your eyes after surgery, if your surgical clinic does not provide these.
- Cover your windows with curtains or paper, since your eyes may be very sensitive to light when you return home from surgery.
- Stop smoking, if you do, as this may impeded your ability to heal well from surgery.
In the 24 hours leading up to your procedure, you should:
- Abstain from alcohol
- Avoid taking ibuprofen, aspirin, or other NSAIDs (non-steroidal anti-inflammatory drugs), since these might interfere with your recovery.
- Use eye drop or oral antibiotics to help prevent infection from surgery, per your ophthalmologist's instructions.
- Wash your face and wear no eye or face makeup to ensure that your ICL placement is as sterile as possible.
- Not eat or drink for at least eight hours if you plan to use intravenous or oral sedation for the surgery.
Most contact lens implantation surgeries are very efficient and smooth. Preparing yourself properly for the procedure makes the process easier for everyone involved. Consult your doctor for any additional tips about how to prepare yourself for ICL surgery.
Most eye surgeons recommend performing an iridotomy two to three weeks before the first surgical date. During this procedure, your surgeon will use a precise yttrium aluminum garnet (YAG) crystal laser to create one to two tiny openings around the rim of the iris. These holes allow the aqueous humor, intraocular fluid, to flow around the lens. The iridotomy is usually performed with just local anesthetic eye drops for your comfort. This procedure prevents intraocular pressure from building within the eye, thus reducing your risk of glaucoma or other complications during or after the surgery. An iridotomy typically takes less than fifteen minutes to perform. You will need someone to drive you home from the clinic, but should be able to resume normal activity shortly after the procedure.
The Surgical Procedure
The outpatient procedure to place implantable contact lenses is performed in less than 30 minutes, recovery time is relatively short, and pain is minor.
The outpatient procedure to place implantable contact lenses is performed in less than 30 minutes
First, your surgeon will conduct a final eye exam to check that you are ready for surgery. Then he or she will put numbing drops in your eyes to ensure that you remain comfortable and safe throughout the lens placement process. If you have chosen to use intravenous sedation, this will also be administered at this time (with oral sedation, you will typically take a pill several hours before surgery so that it can take effect).
Your ophthalmologist will also likely use additional drops to decrease your pupil size so that he or she can better see around your cornea to put the lens in its proper position. You will then be taken to the sterile surgical room in the clinic or hospital. To keep the surgical site clean, your surgeon will place a small device called a speculum in your eyelids to make sure it stays open and put a drape over the rest of your body. The speculum may be slightly irritating, but you should only feel slight pressure with the topical anesthesia.
Next, your surgeon will make an incision to begin implanting your contact lens. The Verisyse™ phakic IOL and the Visian ICL™ lenses require slightly different surgical techniques for insertion.
In the case of the Verisyse™ phakic IOL, your ophthalmologist will make an incision in front of your iris large enough for the lens to fit through it. Then, he or she will insert a viscoeleastic gel solution, which helps the contact lens slide into place. Once the gel is inserted, your surgeon will place the contact lens in front of your iris and ensure that it is in the correct position. The lens will go in your eye's anterior chamber between the cornea and iris. Given this location, your lens will be very slightly visible on your eye if you look closely at it. It has a small clipping device so that it remains secure. Once the phakic IOL is fully and accurately within your eye, your surgeon will aspirate (gently draw out via suction) any leftover gel and suture the incision. These sutures will dissolve over time.
If you have opted for the Visian ICL™ lens, your surgeon will make one to two smaller incisions at the bottom of your cornea and insert the same type of viscoelastic gel as with the Verisyse™ phakic IOL. Your prescription ICL will have been folded into a tiny cartridge that the surgeon will then place behind your iris through one of the small holes. The special flexible Collamer® material of the lens will unfurl within your eye. Your surgeon may make small adjustments to ensure it is in the proper place, with its corners behind your iris in the posterior chamber. Unlike the Verisyse™ phakic IOL, this lens will remain invisible behind your iris. Since the incisions are so minimal, they will not require suturing; your ocular tissues will heal together naturally.
After the placement of either lens, your surgeon will use medicated eye drops on the affected eye to conclude your surgery. You will need to remain in a recovery room for up to an hour until you feel comfortable walking and moving around. You will likely wear sunglasses, goggles, or a mask to shield your eyes from light and stimulus. Once you are ready to leave, the front office staff will give you post-operative instructions and your prescription eye drops and painkillers, if the clinic provides these.
Next, you will return home (driven by a friend or family member) to rest and recover. Many patients notice improved vision the same day as surgery, and you should fully heal within a month.
Of course, your recovery time will depend on your unique circumstances and can vary by patient. Upon returning home from surgery, you will need to rest and make sure to use your steroid and antibacterial eye drops to keep your eyes healthy. You will likely wear protective gear for the first several days after your surgery since your eyes will be sensitive to light and your vision may be blurry. Patients with the Visian ICL™ tend to recover faster than those with the Verisyse™ phakic IOL, since the Collamer® lens requires a smaller incision.
Most patients do not experience much pain, but your eyes may feel irritated; you need to refrain from touching your eyes so you do not disturb them. You will need to avoid strenuous activity or heavy lifting for several weeks to ensure that your eyes have fully healed. The most difficult part of your recovery process will likely be the time between your first and second surgeries, when your vision is only partially corrected. Most patients' eyesight stabilizes in one to four weeks, but some people can see clearly just 24 hours after placement. Given the staggered surgeries, you will likely be feeling and seeing well within four to six weeks, if not sooner.
You will return to your ophthalmologist's office the day after your procedure so that your surgeon can check your healing progress and ensure that the lens has been placed accurately. If your eyes are healing properly, you will return the next week, the next month, three to six months later, and then annually.
Both FDA-approved phakic IOLs (Verisyse™ and Visian ICL™) have a proven track record for delivering excellent results. The Visian ICL™ lens has a 99 percent satisfaction rate, according to a study of patients. It has been used in over 450,000 ICL surgeries around the globe for the past 15 years. The Verisyse™ phakic IOL has been utilized in over 150,000 patients' refractive corrections for more than 20 years. A 2011 study in The Scientific Journal of the Royal College of Ophthalmology found that both lenses are safe and effective for correcting severe myopia and mild astigmatism.
After you have properly healed from ICL surgery and your vision has stabilized, you should be able to see as well as you were able to while wearing glasses or contact lenses before the procedure. In fact, many patients report that their vision is better than it ever had been. The ICL also provides superior clarity of vision, night vision, and contrast compared to both LASIK and PRK. In addition, these lenses provide ultraviolet protection, like sunglasses, to protect your eyes from sun damage.
Implantable contact lenses offer many advantages for patients.
- One of the main benefits of implantable contact lenses is their ability to correct severe degrees of refractive errors.
- ICLs are convenient for patients. They no longer have to deal with the burden of keeping track of their glasses or the clutter of contact lens solutions and supplies.
- People whose work depends on good eyesight, like military personnel or airline pilots, can benefit from the high quality of vision ICL surgery provides.
- Patients are able to more thoroughly enjoy activities, especially water sports like swimming, snorkeling, and scuba diving, for which it would be difficult to wear glasses or contact lenses.
- Unlike traditional contact lenses, implantable contact lenses are protected from normal wear and tear. ICLs are also protected from dust and dirt, which can cause dryness in traditional contacts.
- Patients feel more secure in their decision to get ICL surgery because it is reversible. They feel more comfortable undergoing the surgical procedure knowing that they are not permanently altering their corneal tissue. Should a patient's vision shift in the future, an ophthalmologist can simply remove their current ICL and implant a more appropriate prescription.
- Patients who are ineligible for laser correction surgeries can see clearly without worrying about damage to their eyes.
- Ultraviolet light blocking helps protect patients' general eye health.
- Unless the patient decides to remove the lens at some point, ICLs provide permanent refractive correction.
- Unlike other refractive surgeries, ICL surgery does not cause or exacerbate chronic dry eye, helping to preserve your ocular health.
The ICL procedure provides an effective alternative to other refractive correction surgeries while providing additional advantages such as UV-blocking, "high-definition" clarity, and reversibility.
No surgical procedure is without risk, but patients rarely experience complications with implantable contact lenses. For example, less than one percent of Visian™ ICL patients experience adverse effects, according to a study conducted by the FDA. When complications do occur, they are typically minor and can be corrected. Of course, choosing an excellent surgeon and taking all the appropriate precautions before your ICL surgery will further mitigate your risks.
The adverse effects and complications from ICL surgery can include:
- Over- or undercorrection of vision. Despite your surgeon's efforts to perfectly match the prescription of your contact lens with your particular eyes' needs, your ICL may be slightly weaker or stronger than you would prefer. Patients who experience overcorrection and undercorrection can choose to modify their lenses and redo the surgery, enhance their ICL surgery with another procedure like LASIK, or continue to use glasses and contacts as needed.
- Loss of best vision. This means that the results of your ICL surgery do not provide the same quality or clarity of vision as you have had with glasses or contacts. While this is a risk of all refractive surgeries, it is particularly uncommon for ICLs, which often provide even better vision than your previous best with glasses or contacts.
- Infection. Any operation carries with it a slight risk of infection. However, if your ophthalmologist follows the appropriate safety protocols, like using a gown, speculum, and sterilizing eye drops, you should have a very low risk of infection. If your eye does become infected, this could lengthen your recovery process or, in extreme cases, impair your vision.
- Decreased visual clarity. In most cases, ICL surgery vastly improves the clarity of your vision. However, your ocular tissue may be damaged during surgery, causing your to lose visual acuity permanently.
- Natural lens damage. It is possible for the surgical instruments or ICL to damage your natural lens during surgery. This could cause your natural lens to become opaque, blurring your vision. This complication is extremely rare, but if it does occur, your surgeon may need to remove your crystalline natural lens altogether and replace it with a psuedophakic intraocular lens.
- Increased intraocular pressure. Placing an additional component within your eye can increase your intraocular pressure. If severe, increased intraocular pressure could even cause glaucoma and eventually loss of eyesight. A pre-operative iridotomy and proper surgical technique should prevent this from occurring.
- Iridotomy complications. While unlikely, it is possible to experience complications from the iridotomy performed two to three weeks before ICL surgery. The incisions the surgeon creates in the eye with the YAG laser could lead to increased intraocular pressure, scar tissue growth, bleeding, damage to the cornea, or inflammation.
- Cataract formation. More than half of Americans naturally develop cataracts (clouds of protein in the lens) by the time they reach 65 as a result of aging, but some preliminary research indicates that implantation of contact lenses may slightly increase this risk or cause earlier onset of cataracts. If you develop cataracts after undergoing ICL surgery, your ocular surgeon can remove your ICL, fragment your natural lens, and insert a psuedophakic IOL to restore your vision.
- Retinal detachment. In less than one percent of cases, ICL patients' retinas detached after surgery due to tissue damage. While rare, this is a very serious complication. If you see sudden splotches of light, small dots floating in your vision, or shadows in your vision, contact your ophthalmologist immediately, as retinal detachment must be treated right away and is an ocular emergency, as it can jeopardize your vision permanently. Patients with a higher degree of myopia have an increased (although still small) risk for retinal detachment.
- Corneal edema. In less than one half of one percent of ICL cases, this procedure can damage the corneal endothelium (inner layer of tissue), creating corneal edema, in which fluid gathers in the cornea and clouds eyesight.
- Repositioning. While the Verisyse™ phakic IOL has a clipping mechanism and the Visian ICL™ unfolds, both lenses may shift over time or need to be repositioned. This requires an additional surgery, although it is often much less invasive.
- Loss of eyesight. Either from extreme inflammation, bleeding, glaucoma, unresolved infection, or retinal detachment, loss of eyesight is a risk of ICL surgery. Vision loss is extremely uncommon, and is a potential risk of any refractive surgery.
While all surgical procedures carry certain risks, those associated with ICL surgery are relatively minor, especially when you work with a qualified surgeon. Talk with your ophthalmologist about potential complications and how to lower your risks before undergoing surgery.
Temporary Side Effects
While it is a relatively short and noninvasive surgery, implanting a contact lens can cause some temporary side effects. These may include:
- Halos and glare. As your eyes adjust to the new lens, you may experience heightened glare or rings of light around objects, especially in lower lighting. In most cases, this lasts only a few days. This side effect is much more common in patients who undergo LASIK and PRK. Only about one quarter of ICL patients suffer from these side effects.
- Photosensitivity. Almost all patients are sensitive to light directly after surgery, which is why your surgeon will recommend some form of protective eyewear and you will need to rest following surgery.
- Diplopia. You may experience diplopia, or double vision, as your eye accommodates to the artificial lens placed within.
- Allergic reaction to anesthesia. Some patients experience irritation or inflammation due to an adverse reaction to the topical anesthesia applied in the form of numbing drops before surgery. If you have a known history of allergies to anesthesia, inform your surgeon of this at your initial consultation.
- Irritation. Having undergone surgery, your eyes may feel irritated or itchy as the tissue heals. It is important not to rub or scratch your eyes during the healing process, as this can disrupt your recovery and shift your ICL out of place.
- Poor night vision. Usually as a result of halos and glare, some patients experience decreased night vision for the days or weeks following surgery. However, in the long-term, the vast majority of patients appreciate much better, clearer night vision since they are able to more easily see contrasts.
- Pigment dispersion. Since the contact lens is placed either in front of or behind the iris, implantation can sometimes disrupt your eye's pigment, causing it to spread into your anterior and posterior chambers. This can lead to increased intraocular pressure and pigmentary glaucoma.
- Inflammation. The tissue within your eye may become irritated due to the incisions and placement of the lens. While uncomfortable, this side effect should resolve within a few days. If it does not, speak to your ophthalmologist.
Most patients experience discomfort for only a few days after ICL surgery, which is easily managed by rest and prescribed painkillers. If your symptoms are severe or worsening after contact lens implantation, call your ocular surgeon for a follow-up appointment.
As with any surgical procedure, there are risks involved with implantable contact lenses; however, the occurrence of severe adverse effects is minimal. According to recent research, only about 0.6 percent of ICL patients experience safety risks and complications. In most instances, the percentages of complications that developed with implantable contact lenses were lower than the same complications of intraocular lens surgery. ICL success rates are also typically better than those of LASIK, LASEK, and PRK surgeries.
One of the greatest safety-related benefits of implantable contact lenses is that fact that, unlike LASIK eye surgery, the implantation of an ICL does not physically alter the cornea. This means that ICLs eliminate the risks of permanent corneal damage associated with laser surgeries.
Understanding the average numbers associated with a procedure can help you make an informed decision, but recognize that the statistics for a given surgery may not dictate your exact personal experience. Your ocular surgeon can help you understand your particular chances of success and risks for complication depending on your eyesight and medical history. In addition, it is important to go into ICL surgery with realistic expectations.
The clinical trial for the Verisyse™ phakic IOL noted that 92 percent of the ICL patients achieved 20/40 or better visual acuity without the use of corrective lenses (20/40 is considered to be the standard vision necessary to obtain a driver's license.) Additionally, after three years, 44 percent of the trail participants had 20/20 vision.
In the Visian ICL™ clinical trial, 95 percent of participants achieved 20/40 or better vision. During the three-year follow-up, 59 percent of the ICL patients experienced 20/20 vision. Due to its high success rate, many United States military professionals who suffer from refractive errors use Visian ICL™ lenses, and over 98 percent of these patients have at least 20/20 vision, if not better. Less than one percent of all Visian ICL™ patients were dissatisfied with their surgery and results.
Clinical comparisons between ICL, LASIK, and PRK showed that LASIK patients had a 24 percent reduction in night vision, PRK patients had a 16 percent reduction, and ICL patients' night vision improved.
Be aware that all clinical information about success and complication rates for ICLs applies only to approved patients between 21 and 45. If you are outside of this age range, the results of your surgery could be unpredictable.
Frequently Asked Questions
Many patients have questions about the particulars of ICL surgery and how it will affect them. We list some of the most common questions and their answers below.
Will I be able to handle being awake during surgery?
Since each surgery takes less than thirty minutes and the surgeon administers numbing eye drops, most patients are able to undergo ICL surgery awake without issue. You should only feel slight pressure during your surgery. However, if you are particularly concerned about your stress level, your surgeon can provide an oral sedative or intravenous sedation to help keep you calm, relaxed, and comfortable.
Why can't I do both eyes at once?
Ophthalmologists usually prefer to operate on one eye at a time because this reduces the risk of complications. In addition, this provides your surgeon the opportunity to see how one of your eyes responds and stabilizes to improve his or her technique for the second eye. Performing ICL in one eye at a time also reduces the surgery time, making the process easier for you.
Will people be able to see my implanted contact lens?
This depends on which type you use but generally, no. Since the Verisyse™ phakic IOL is implanted in front of your iris, someone could technically see it if they looked extremely closely at your eyes. The Visian ICL™ is completely invisible because it sits behind the iris.
Will I feel the contact lens?
No, you should not be able to feel the ICL after your surgery. Once your eyes have healed, it will just feel like a part of your eye. Most patients don't sense the lens itself, but they do notice their improved eyesight.
Do I need to do anything to maintain the lens?
You should attend regular check-ups at your ophthalmologist's office, but you do not need to maintain the contact lens on a daily basis. It should not become dry or dirty, like a traditional contact lens would. This is one of the many convenient benefits of ICLs.
Should I ever need glasses or contacts again?
ICL is intended to improve, not perfect. your vision. Some patients with more severe myopia may still need lower prescription glasses or contacts after surgery. In addition, with ICLs, you will still be susceptible to aging-related conditions such as presbyopia and cataracts.
How long will my ICL last?
Your lens is designed to last your entire lifetime within your eye. However, one of the benefits of an ICL is that it is removable, should you ever want to change your prescription or modify your vision, your ophthalmologist can remove it.
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