ICL

Implantable Collamer Lens

ICL Intraocular Lens (Phakic Implant): What Is the Ideal Age for Surgery?

ICL (Implantable Collamer Lens) surgery is an excellent option for correcting high myopia, hyperopia, and astigmatism without altering the cornea. But at what age is it recommended?

What is the ICL?

The ICL (EVO Visian) is a biocompatible collagen lens that is implanted inside the eye, between the iris and the lens.

Advantages vs. LASIK/PRK:

Corrects very high myopia (up to -18D).

Reversible (can be removed if necessary).

Does not cause chronic dry eye.

Ideal Age for ICL

Optimal Range: 21 to 45 years

Considerations

<21 years

NO, prescription can still change.

21-40 years

Ideal, maximum long-term benefit.

40-50 years

Depends. If there is no advanced presbyopia.

50+ years

Not recommended. Best option: Multifocal IOL for cataract surgery.

Why Is This Age Ideal?

Stable prescription: In young adults (20-40), myopia no longer progresses.

Clear lens: The ICL does not treat cataracts (if opacity is already present, it is better to operate with a conventional IOL).

Maximum visual benefit: You enjoy more years without glasses.

Over 45? We evaluate:

If presbyopia is present, monovision or multifocal lenses may be required.

If cataracts are incipient, it is better to wait and use a premium IOL.

Advantages of the ICL in Young Adults

Athletes: Impact resistant (ideal for contact sports).

Thin corneas: Safe option when LASIK is not feasible.

Superior visual quality: Better night vision than LASIK for high myopia.

What is a phakic ICL?

The ICL (Implantable Collamer Lens) is a phakic intraocular lens (i.e., it is implanted without removing the eye's natural lens) designed to correct severe refractive errors, such as:

Myopia (up to -18 diopters).

Astigmatism (up to 6 diopters).

It is an alternative to laser surgery (LASIK/PRK) for patients with thin corneas, dry eyes, or very high prescriptions who are not candidates for ablative techniques.

Key Features of the ICL

1. Material: Collamer®

Biocompatible: A collagen and polymer composite that reduces the risk of inflammation or rejection.

UV Protection: Filters ultraviolet rays.

Optical Transparency: Does not affect visual quality.

2. Design: Ultra-thin and flexible: It is implanted folded through a microincision (2–3 mm).

Anatomical Position: Placed in the posterior chamber, between the iris and the lens.

Toric Version: To correct astigmatism (must be aligned along a specific axis).

3. Current Models

EVO Visian ICL: Includes a central hole (360 µm) that improves aqueous humor flow, reducing the risk of glaucoma.

Advantages vs. Other Options

Reversible: Can be removed if necessary.

Does not alter the cornea: Ideal for thin or irregular corneas.

Immediate Results: Visual improvement in 24–48 hours.

Wide Correction Range: Includes extreme myopia.

Video Animation Explaining the ICL Intraocular Lens

Surgical Steps for ICL Implantation

1. Preoperative Preparation

Corneal topography and biometry: To calculate the exact size of the ICL.

Gonioscopy: To evaluate the space between the iris and the lens (posterior chamber).

Mydriasis: Pupillary dilation with drops (e.g., cyclopentolate + phenylephrine).

2. Anesthesia

Topical (anesthetic drops) + mild sedation.

3. Corneal Incisions

2–3 microincisions (1–2.8 mm) for:

ICL insertion.

Iris irrigation and manipulation.

4. Viscoelastic Injection

Protects the endothelium and maintains the anterior chamber.

5. ICL Implantation

Loading the lens into the injector:

The (folded) ICL is inserted through the main incision.

Poster chamber release:

It is gently unfolded behind the iris and in front of the lens.

Positioning:

The haptic legs should be under the iris (in the ciliary sulcus).

In toric ICLs, the lens is rotated to the axis calculated preoperatively.

6. Viscoelastic Removal

Careful aspiration to avoid postoperative ocular hypertension.

7. Hydrosealing the Incisions

Assess whether sutures are required.

Loading and Implantation of an ICL (Implantable Collamer Lens)

Importance of Correct Loading of an ICL (Implantable Collamer Lens)

The ICL lens (such as the EVO Visian ICL from STAAR Surgical) is a safe and reversible option for correcting high myopia, hyperopia, and astigmatism, especially in patients who are not candidates for LASIK or PRK. Proper fitting is crucial to:

Avoid complications:

Lens rotation (in astigmatism).

Contact with the lens (risk of cataracts).

Elevated intraocular pressure (if there is insufficient space).

Ensuring optimal visual results:

Centered position on the iris.

Correct axis alignment (in toric lenses).

Minimizing intraoperative manipulation:

Reduces trauma to the corneal endothelium and iris.

The success of the ICL depends on:

Accurate size selection (based on ocular anatomy).

Meticulous surgical technique (avoiding rotation or decentering).

Protection of the endothelium and lens.

Why is ICL surgery more expensive than LASIK?

ICL (Implantable Collamer Lens) surgery is significantly more expensive than LASIK due to factors such as the technology used, the complexity of the procedure, high-quality materials, and customization requirements. Below, we explain the detailed reasons:

1. Intraocular Lens (ICL) Cost

Premium Material: ICLs are made of Collamer, a patented biomaterial (collagen + polymer) that is biocompatible and allows nutrients to pass through.

Custom Manufacturing:

Each lens is manufactured according to the patient's exact eye measurements (high-precision biometry).

Advanced Technology:

Toric ICLs (for astigmatism) require millimeter-precise alignment.

2. Surgical Complexity

Intraocular Procedure: The ICL is placed inside the eye (between the iris and the lens), which requires:

Topical anesthesia + sedation.

Small corneal incision (2–3 mm).

Precise positioning to avoid contact with the lens or corneal endothelium.

Potential risk: Greater than LASIK (although lower in expert hands).

3. More Complex Preoperative Studies

Before ICL, advanced tests are required, which make the procedure more expensive:

High-resolution biometry (IOLMaster, Lenstar).

Endothelial microscopy (to count corneal cells).

Gonioscopy (evaluate chamber angle).

Corneal topography (to rule out keratoconus and measure White-to-White (WW)).

In LASIK, only topography and pachymetry are required.

4. Closer Postoperative Follow-up

ICL requires intraocular pressure monitoring (risk of glaucoma).

Possible need for adjustments if the lens decenters.

Long-term follow-ups to detect early cataracts (although this is rare with modern ICLs).

5. Advantages That Justify the Higher Cost

Treats very high myopia (up to -18D) that LASIK cannot correct.

Reversible (the lens can be removed if necessary).

Does not alter the cornea (ideal for thin or irregular corneas).

Better night vision than LASIK for high prescriptions.

Is it worth the cost?

Yes, if you have very high myopia, thin corneas, or are not a candidate for LASIK.

No, if your prescription is low and your cornea is suitable for LASIK or SMILE.

Limitations of ICL (Implantable Collamer Lens) Intraocular Lenses in Refractive Surgery

ICL lenses (such as the EVO Visian ICL) are an excellent option for correcting high myopia, hyperopia, and astigmatism, but not all patients are ideal candidates. These are the main reasons:

1. Strict Anatomical Requirements

Insufficient Anterior Chamber Space

The ICL requires a minimal space between the iris and the lens (≥2.8 mm).

If the eye is very small (axial length <20.5 mm), the lens may rub against the lens, increasing the risk of early cataracts.

Narrow Chamber Angle

If the angle between the iris and the cornea is <30 degrees (gonioscopy), there is a risk of acute glaucoma due to pupillary block.

Weak Corneal Endothelium

≥2,000 cells/mm² are required to ensure safety. Fewer cells → risk of corneal edema.

2. Out-of-Range Refractive Errors

Myopia: Up to -18 diopters (EVO ICL).

Hyperopia: Up to +10 diopters.

Astigmatism: Up to 6 diopters (toric ICL).

Beyond these limits, alternatives such as PRK or alternative phakic intraocular lenses are needed.

3. Excluding Ocular Diseases

Early or Advanced Cataract

The ICL is placed in front of the lens. If opacity is already present, it is best to remove it and use a conventional intraocular lens.

Uncontrolled Glaucoma

The ICL could increase intraocular pressure (IOP) in eyes with compromised drainage.

Chronic uveitis or proliferative diabetic retinopathy

Risk of severe inflammation or macular edema.

4. Age and Physiological Changes

Patients over 45 years: Presbyopia ("farsightedness") may require multifocal lenses instead of ICLs.

Patients under 21 years: Prescription may not be stabilized.

5. Absolute Contraindications

Pregnancy/breastfeeding (hormonal changes affect measurements).

Uncontrolled autoimmune diseases (lupus, rheumatoid arthritis).

Allergy to Collamer material (collagen + copolymer).

Alternatives if you are not a candidate for ICLs: PRK or LASIK: For healthy corneas with moderate prescriptions.

Multifocal intraocular lenses: If there is associated presbyopia.

Cross-linking + PRK: For mild keratoconus with myopia.

ICL Lens for Keratoconus: A Revolutionary Solution for Clear and Stable Vision

Keratoconus is a progressive corneal disease that causes distorted vision due to thinning and deformation of the cornea. While treatments such as crosslinking (CXL) and intracorneal rings help slow its progression, many patients continue to experience poor visual acuity even with glasses or contact lenses.

This is where the phakic intraocular lens (ICL) (Implantable Collamer Lens) comes in, a safe and effective option for keratoconus patients who desire significant visual improvement without altering the cornea.

What is an ICL Lens and How Does it Help with Keratoconus?

The ICL is a lens made of collamer material (biocompatible and flexible) that is implanted inside the eye, between the iris and the lens, without the need to remove corneal tissue.

Key Benefits in Keratoconus

✅ Corrects high levels of myopia, hyperopia, and astigmatism associated with keratoconus.

✅ Does not weaken the cornea (unlike LASIK or PRK, which are contraindicated in keratoconus).

✅ Provides more stable and clear vision than rigid contact lenses for irregular corneas.

✅ Is reversible (can be removed if eye conditions change).

✅ Integrated UV protection (Collamer material blocks harmful rays).

Who Is a Candidate for ICL in Keratoconus?

✔ Patients with stable keratoconus (no recent progression, ideally after CXL).

✔ High myopia or astigmatism not well corrected with glasses or contact lenses.

✔ Cornea too thin or irregular for laser surgery.

✔ Age between 21-45 years (before cataract onset).

Contraindications:

❌ Actively progressing keratoconus (crosslinking must be performed first).

❌ Very narrow anterior chamber of the eye.

❌ Severe ocular diseases (advanced glaucoma, retinopathy).

ICL Implantation Procedure

Complete preoperative study:

Corneal topography.

Pachymetry.

Biometry to calculate the exact lens power.

Corneal endothelial assessment.

Outpatient surgery (15-20 minutes per eye):

Anesthesia drops/sedation.

Painless microincision (<3 mm).

Foldable ICL implantation.

Rapid recovery:

Useful vision in 24-48 hours.

Postoperative drops for 1-2 weeks.

Expected Results

90-100% improvement in visual acuity (many patients achieve 20/20 or better).

Reduction or elimination of dependence on glasses/contact lenses.

Superior visual quality compared to rigid lenses in irregular corneas.

Comparison: ICL vs. Other Options for Keratoconus Treatments

Rigid Contact Lenses (RPG)

Advantages: Improves vision in irregular corneas

Disadvantages: Discomfort, risk of infection

Intracorneal Rings

Advantages: Flattens the cornea

Disadvantages: Does not fully correct refractive error

Crosslinking (CXL)

Advantages: Slows progression

Disadvantages: Does not improve vision on its own

Corneal Transplant

Advantages: Solution for advanced cases

Disadvantages: Risk of rejection, long recovery

ICL

Advantages: Maximum visual quality without touching the cornea

Disadvantages: Higher cost