Taj Nasser, MD, of Tylock George Eye Care, spoke with Ophthalmology 360 about his clinical experience using EVO ICL, which he calls “one of the best inventions” in the field.
Question:
What has been your experience with EVO ICL?
Taj Nasser, MD:
EVO ICL has been one of the best inventions in our field. It really has propelled the phakic IOL space to the next level. Patients are able to enjoy the amazing safety profile, the predictability, and long-term great outcomes that we didn’t have in previous generations. Now with the advent of fenestration, so there’s not 1 but 5 fenestrations within the ICL, it allows the percolation from the posterior chamber to the anterior chamber in a much better way than before with the original material before that. The fact that these fenestrations have been placed in the lens seems to be a small point, but it actually has helped the safety profile for the lens tremendously. In our practice, patients did not like the feeling of the PI that we all know too well. A lot of times patients felt that it was a little bit more of a strenuous process compared to the actual surgery itself.
Not having to deal with PIs has been a tremendous innovation moving forward. When it comes to safety, intraocular pressure, long-term outcomes with cataracts, angle closure, and getting those late night calls that we did with the first-generation or previous generations of ICLs has been just a game-changer for the technology itself. Really excited with how EVO ICL has just allowed our lives and the lives of our patients to become just way, way better than before in terms of the innovation. Now EVO ICL, the material itself has an advantage as well. The collamer material in terms of elasticity, there has been reflection studies that have looked how light enters the eye with collamer material compared to acrylic, and that has been more superior and reflects that light that enters with the crystalline lens. The collamer material is also very flexible. I’ve also had patients that have had ICL within their eyes for 20-plus years, and you remove the ICL and it’s as if it’s brand new. EVO ICL definitely has just an awesome profile altogether.
Question:
How have you handled the sizing for EVO ICL?
Taj Nasser, MD:
Now having trained surgeons regarding sizing and actual procedure from start to finish, one of the biggest questions that comes up is, “Well, sizing, what is the vault that’s going to be predicted?” It really causes a lot of stress that, in my opinion, is a little bit inflated because of just lack of experience regarding the EVO ICL. Now, there’s a safety parameter, and one thing that I see commonly is surgeons get this vault that maybe 200 and not between the 250, 750 range that we see. It’s a big ordeal when in reality it is not. This EVO ICL is way more forgiving with the fenestrations and the safety profile and lots of literature to prove the many different small complications that were existent have essentially been very minor in the grand scheme of things. Now, when you’re seeing a patient and their vault is within a safety range, it’s not the whole bullseye of an intention to get right in the smack down middle between 250 and 750.
There is really no strong data to prove that is exactly the range that you want. There is some forgivability, if it’s a little bit of a hypovault or a hypervault. Within clinical reason, it is totally fine and safe for our patients. A lot of times we end up treating ourselves as the surgeons and not the patient. My advice is always go by the clinical signs. What clinical problem is it causing? How is the pressure? How’s the angle formation and how much of a hypovault there is and monitor the patients closely. Now sizing, there’s lots of different nomograms, lots of different devices. I’m not a fan of saying that there’s only 1 golden rule yet. Hopefully we’ll get there with artificial intelligence and the many awesome research that’s being put into it by many awesome colleagues, but we’re not there yet. Choose a nomogram and choose a device that works well together and don’t alternate between one device and another.
Don’t feel like using Pentacam on Mondays and IOL Master on Tuesdays and other devices. Just stick to 1 nomogram, stick to a diagnostic modality, and I would encourage you to maybe look at more than 1 nomogram to cross-reference if you’re on the border in specific cases. But otherwise sticking to 1 nomogram and 1 diagnostic device will get you through the vast majority of patients and you will get outliers. We’ve published this, we’ve looked at this and presented it where you can expect between 8% or more of outliers depending on which nomogram and your experience you use regardless. We’re hoping to solve that issue, but an outlier by definition does not mean that the ICL has to be explanted immediately.
All of that to say to summarize is yes, ICL sizing tends to be a sore point for surgeons that are getting started with EVO ICL. I just want to encourage you that it is not as big of an ordeal or as stressful of an issue as it may seem, and highly, highly encourage patients or patients to strive towards getting this awesome technology and surgeons to adopt it because it is definitely a life-changing procedure.
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