Who is the ideal candidate for EVO ICL?
Neda Nikpoor, MD, an ophthalmologist at Jenkins Eye Care in Honolulu, Hawaii, spoke with Ophthalmology 360 about her experience using EVO ICL and who the ideal patient is for this implantable lens.
Question:
Can you provide a brief background on EVO ICL?
Neda Nikpoor, MD:
EVO ICL is an implantable columnar lens, which basically means it’s like a contact lens that’s designed to sit inside the eye. Unlike laser vision correction, like LASIK, PRK, and SMILE, EVO is not changing anything about the anatomy of the patient’s eye, and so compared to Visian, which was the ICL that we had before, this one’s different in that there’s holes actually built into the lens to create a path for aqueous to flow. We don’t have to make a PI anymore, so all we’re doing is making an incision and slipping in the lens. It’s approved for patients between the ages of 21 and 45, with a refractive error of -3 to 315, but can reduce up to -20, and it can treat 4 diopters of astigmatism.
Question:
Who is the optimal patient for EVO ICL?
Neda Nikpoor, MD:
How do we choose patients? Who’s an ideal candidate for the EVO ICL? Well, in theory, anybody who’s within the refractive error range of -3 to -20 is a great candidate. I would say from my own personal experience, in the beginning, I was much more comfortable implanting these lenses in patients who were not candidates for laser vision correction. That’s where I started, and I think for a lot of people that’s where they start. For me, and for a lot of people who look at corneal aberrations induced by laser vision correction, anything over -8, I think is just too much laser for the cornea and can induce problems with night vision and quality of vision through all the higher order aberrations that we induce over -8. For sure, anybody over -8 is a good candidate. But there’s a lot of studies that show superiority in patients, even -6 to -8.
Generally, for me, I prefer and strongly recommend EVO for anybody whose prescription is over -8, I also really like EVO for anybody who has any corneal irregularity that would give me pause. Any irregular topography, any dry eye that’s clinically significant, even if the patient’s well controlled on medication, it’s debatable whether you want to go and do a laser correction for somebody who is say, on a prescription dry eye medicine and well controlled, because you could offer them an alternative that’s not going to worsen their dryness. I have patients all the time who are in the -3 to -6 range, who are actually laser vision correction candidates, but have some level of ocular surface disease that they don’t want to worsen, and then those are actually really great patients for EVO.
Then, officially, the FDA approval is for an ACD of over 3, but personally I can comfortably go down to 2.8, and that’s been very well discussed, and well described, and is commonly performed. In certain cases, you can actually go below 2.8, which I’ve done, if everything else looks good, if the angles look good, if the UBM… I do a UBM ultrasound for these patients, and recently I’ve started using Roger Zaldivar’s AI calculator, ICL Guru, and if I use ICL Guru even in an ACD of 2.6, for example, and it predicts that there’s going to be open angles and a normal vault and not an over vault, then I’m comfortable going down even below a 2.8, even though that is off-label.
Question:
What has been your personal experience in using EVO ICL?
Neda Nikpoor, MD:
My experience with EVO has been amazing, so I started using Visian straight out of training, and it was great, but I really reserved it for patients who were absolutely not laser candidates, and once EVO came out, the data looked really so much safer in terms of IOP issues, angle closure, it basically eliminated that risk, and it significantly reduced the risk of cataract formation. Because of that, I adopted using EVO for patients who are actually laser candidates and maybe didn’t want to go through the healing of PRK, if they weren’t laser candidates, or who had some underlying dry eye or something that we didn’t want to worsen. I’ve actually had patients who just really like the way that it sounds, and they really like that it’s a reversible procedure, and they like that nothing is changing about their eye, and it keeps all these options open to them later down the road, should any new technology come out or should anything change about their eye?
I’ve actually put in a lot of EVO lenses in patients who are laser candidates, and I’ve been really, really pleased, and my patients have been super happy. I think one of the things that’s really fun as a surgeon is when you get patients who are high myopes over -8, and they’ve been told for many, many years, there’s nothing that can be done, and you’re able to correct their vision, and they see, usually, better than they’ve ever seen in glasses and contacts, which was really amazing. They’re some of my favorite patients. But then, even the patients who were under -8, I’ve been really pleased and am happy that my patients are reporting that their eyes are comfortable and their vision is very clear within just a few days after surgery, they’re actually doing really, really well. It’s been a fun procedure to do because patients are generally really happy.
Question:
What advice do you have for colleagues who are considering EVO ICL for their patients?
Neda Nikpoor, MD:
I would say for anybody who’s considering using the EVO ICL, it’s always scary to adopt a new technique and a new surgery, but it’s really a quite elegant, very simple surgery. If it’s the surgery that’s scaring you, then I would say don’t worry, it’s literally just the last step of cataract surgery, and most of us are good cataract surgeons, so if you can put in an IOL, you can put in an ICL. There’s a little bit of nuance to it, but it’s really not that challenging. The trainers are awesome, and the support from people at the company is incredible. Scott Barnes, who’s the CMO, is so available and so willing to help, that I think as you go along, and you have clinical questions, and you start pushing the envelope a little bit, doing things that are maybe outside the FDA range, and you’re wondering, am I safe doing this? What can I do?
The support from people at the company and from other people who do a lot of work with the company like myself is really robust. They, I think, are actually starting a peer-to-peer program that I’m going to be participating in, and so people will be able to reach out to me or other people who work with STAAR, and do a lot of ICLs directly. There’s really just a lot of support out there. We’ve also written a white paper with Scott Barnes, and myself, and George Waring, and a number of other people who have a lot of experience. There’s a white paper that’s out there that helps provide some pearls, and there’s also wet labs at ASCRS and all the major meetings, and so there’s lots of ways that you can learn if you’re nervous. I think once you start, you’ll be blown away that the outcomes are amazing, and patients are really, really happy, and then you’ll just want to keep doing more.
Question:
What are you most excited about for ASCRS 2025?
Neda Nikpoor, MD:
There’s a lot going on at ASCRS that I’m excited about. On the topic of ICLs, we’re doing a refractive wet lab that I’ll be helping with and an EVO after hours. For people who are already users, they can come to the booth, and we’ll do like a Q&A, which is really fun. We’ve done that online, that is available on Zoom, and people can join that, but we’re actually doing one in person, at the booth, so that should be really fun. Then, there’s a bunch of evening events that companies are throwing, STAAR is throwing one, RSI is throwing one called Lollapalooza, which should be pretty fun, that Neda Shamie and I are basically live recording a podcast episode, for our podcast Neda Squared. We’re going to be doing that at the Lollapalooza event, so it should be a lot of fun, I’m excited for this meeting.
