September 2016




Femto laser-assisted cataract surgery with ICL in situ

by Douglas Grayson, MD, FACS

Catalys OCT

Figure 1. Catalys OCT imaging clearly delineates separation of ICL and the anterior lens capsule.

Capsulotomy beneath ICL

Figure 2. Catalys softening pattern just prior to laser engagement showing accurate placement of capsulotomy beneath ICL. Source: Douglas Grayson, MD, FACS

Interesting case demonstrates that laser can successfully be used for cataract surgery in a young patient who also requires ICL removal

I recently performed surgery on a 36-year-old high myope who developed a cataract just a few months after being implanted with collamer phakic IOLs (Visian Implantable Collamer Lens [ICL], STAAR Surgical, Monrovia, California) to correct his –16 D of myopia. This posterior chamber lens, which sits just beneath the iris and above the crystalline lens, is a good option for refractive correction of high myopes. However, lens opacification is a known complication, occurring in at least 1% to 6% of eyes with the ICL, with an even higher incidence in high myopes.1

This patient, unfortunately, was a person who seems to form cataracts very quickly after phakic IOL surgery. He had been well counseled by the original cornea surgeon about the risk of cataract so he understood the need for the subsequent ICL removal and cataract surgery. For a number of reasons, I wanted to use the femtosecond laser in this case. I’ve performed more than 6,000 procedures with the Catalys femtosecond laser (Abbott Medical Optics, Abbott Park, Illinois). In young patients, there is a higher rate of anterior capsule tear with manual capsulotomy, which I wanted to avoid. The accuracy of the femtosecond laser capsulotomy also decreases the chance of eccentric fibrosis for improved lens centration. In an ICL patient who has already undergone a procedure that involves some trauma to the endothelium, I wanted to minimize the use of ultrasound energy and keep the cataract procedure as atraumatic as possible. The laser could also make very accurate incisions to correct the small amount of astigmatism this patient had.

However, the sequence of events for surgeons whose femtosecond laser is in a separate laser room can be tricky since the ICL must be removed under sterile conditions. Doing that first and then taking the patient out of the OR for the laser portion seemed impractical, so I decided to try performing the femtosecond laser treatment with the ICL in situ. Had the ICL caused some disturbance in the laser’s ability to image the lens and capsule, I would likely have gone to the OR to remove the ICL and do manual phaco.

Fortunately, the laser accurately identified the ICL and the anterior capsule below it (Figure 1), so I proceeded with femtosecond treatment. The laser was able to create a complete capsulotomy without interference from the ICL and soften the lens as planned (Figure 2). Following laser treatment, removal of the ICL was no more difficult than usual. I cut the ICL nearly in half and then slowly rotated it out. Although there were some iris-corneal synechiae, there were no obvious problems with poor vaulting, position, or sizing that would have led to capsule touch and cataract formation. I remove one or two ICLs per year and find that they can be more challenging to remove than an IOL because the phakic lens is cumbersome and thin, shredding easily. Its position just under the iris also demands that care be taken not to damage the iris during removal.

The femto laser-treated crystalline lens was easily aspirated. I find that a disposable silicone capsule guard I/A tip (Bausch + Lomb, Bridgewater, New Jersey) is a useful adjunct in such cases due to its soft tip and larger port that allows for aspiration of slightly thicker nuclei after femto fragmentation. I implanted a +9 D monofocal lens. The patient was 20/25 uncorrected at 1 week postop. I sent him back to the cornea specialist for the fellow eye, which had had an ICL implanted more recently and still had some residual corneal edema. I would have liked to implant a presbyopia-correcting lens to provide more functional near vision for this young patient, but our options at the time of this procedure have a limited power range. In conclusion, this was an interesting case because many of us would consider the presence of an ICL to be a relative contraindication to femtosecond laser-assisted cataract surgery. Surgeons should check the image resolution and surface fits carefully. Provided they are accurate, my experience has been that ICL patients can benefit from the advantages of the femtosecond laser.


1. Packer M. Meta-analysis and review: effectiveness, safety, and central port design of the intraocular collamer lens. Clin Ophthalmol. 2016;10:1059–77.

Editors’ note: Dr. Grayson practices in New York and New Jersey at Omni Eye Services. He has no financial interests related to this article.

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