Anterior chamber implantation of a phakic IOL to correct high myopia was developed in the 1950s by Drs. Strampelli and Barraquer. The procedure is currently gaining popularity, and indications now include patients with lower refractive error in which excimer laser correction is contraindicated. Several potential advantages have been ascribed to phakic IOLs for the correction of refractive errors, including excellent refraction accuracy, preservation of accommodation, rapid visual recovery and reversibility. Concerns remain, however, about the long-term safety and development of complications.

The main complications of AC phakic IOLs include endothelial cell loss, pupil ovalization and chronic subclinical inflammation. The risk of acute glaucoma is well known; a peripheral iridectomy is recommended for this IOL.

CASE REPORT
We examined a 27-year-old female on September 20, 2002 in our department. She presented with myopia and astigmatism, and she asked for a correction of her refractive error.

Her UCVA was 0.05 D in both eyes. BCVA 1.00 D correction in the right eye was -5.00 D spectacle function combined -1.5 cylinder axis 180º; correction in the left eye was -5.00 D spectacle function combined -2.5 cylinder axis 180º; and the AC depth was 3.67 respective 3.40 mm. White-to-white measured 11 mm in both eyes, and the endothelial cell count was 3,676 respective 3,205 cells/min2.

Her history revealed a great tendency to keloid scars, and excimer laser surgery was not recommended. Finally, the patient decided on AC phakic IOL implantation. In November 2002, laser iridotomy was performed on both eyes; gonioscopy confirmed a wide-angle AC.

An ASRi-6-120 Phakic 6 IOL (Opthalmic Innovations International, Ontario, Canada), with an overall diameter of 12 mm and -6.00 D, was implanted into the patient's right eye on March 4, 2003. Biolon (Akorn Inc, Buffalo Grove, Illinois) (ie, a Healon-like [Advanced Medical Optics, Santa Ana, California] substance) viscoelastic material was applied through the corneoscleral tunnel. Because the surgery was uneventful and the eye was quiet the next day, the same operation was conducted on the left eye on March 5, 2003.

That afternoon, the patient was admitted into another department with acute rise of IOP in her left eye, a shallow AC and iris bombe. Her pupil was enlarged and distorted. She was treated with pilocarpin in the left eye and mannitol IV.

The following day, she was admitted in our clinic. Table 1 lists the findings in each eye. After additional laser iridotomy and conservative treatment, the left eye gradually became quiet, and the patient was dismissed on March 12, 2003. Her IOP in both eyes was 14 mm Hg, and visual acuity in the left eye was 0.3 stenopeic.

In February 2006, we decided to reposition the AC phakic IOL in the left eye for synechiae, a distorted pupil, and encapsulation of the iris haptic. The following day, she again presented with increased IOP (ie, 40 mm Hg). We immediately managed the IOP with release of the AC and conservative treatment. Her last visit was in July. Her UCVA in the right eye was 0.90 D and 0.60 D in the left. BCVA was 1.00 D (-0.75 D cylinder axis 160º), in the right and 0.90 D
(-1.50 D cylinder axis 170º) in the left eye. The patient's IOP was 13 respective 14 mm Hg, without any treatment.

Endothelial cell count was lost in both eyes (ie, 39.4% in the right eye and 60% in the left). The patient is satisfied with the outcome in the right eye, however, the left eye persists with blurred vision, visual phenomena in the evening, sensitivity to light, miotics without effect and cosmetic problems (Figures 1 through 4).

DISCUSSION
The Phakic 6 AC IOL is a variation of the Baikoff lens (Bausch & Lomb, Rochester, New York), which itself is a modification of the Kelman Multiflex IOL (Alcon Laboratories, Fort Worth, Texas). The Phakic 6 AC IOL has a new design with a 6-mm optical zone to eliminate glare. The haptics are extremely flexible, so as to not cause compression to the peripheral iris. It is made of PMMA and has a heparin coating.

We have implanted 96 Phakic 6 AC IOLs in 56 patients, 41 of whom were myopic. We experienced only one increase in IOP, occurring in the patient described above. Rise in IOL fter after AC phakic IOL implantation is usually connected with incomplete removal of viscoelastic and/or insufficient iridotomy. Nevertheless, we are unsure why the IOP increased in the left eye of our patient; the right eye was uneventful. Manipulation of the IOL—almost 3 years after implantation—lead to another IOP increase, despite careful viscoelastic removal. We hypothesized that intrinsic factors including increased susceptibility and anatomic factors may be involved.

We have explanted five Phakic 6 IOLs for progressive loss of endothelial cells. Explantations occurred 4 years to 5 years after implantation. We consider that regular follow-up is mandatory, and we recommend explantation of the IOL when the endothelial cell count approaches 1,000 mm2. We hope that new IOLs, in connection with better examination possibilities, will produce better results with fewer risks.

Pavel Rozsíval, MD, is from the department of ophthalmology at Charles University, in Hradec Králové,, Czech Republic. Dr. Rozsival states that he has no financial interest in the products or companies mentioned. He may be reached at rozsival@lfhk.cuni.cz.

Juraj Urminsky, MD, is from the department of ophthalmology at Charles University, in Hradec Králové, Czech Republic. Dr. Urminsky states that he has no financial interest in the products or companies mentioned. He may be reached at urminsky@seznam.cz.