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July/Aug 2020

Lens-Based Refractive Surgery is Here to Stay

When I opened the Instituto Salmantino de Oftalmología (Clínica INSADOF, Figure 1) 20 years ago in Salamanca, Spain, I was an experienced retinal, strabismus, and anterior segment surgeon. But in order to truly become a comprehensive ophthalmology practice and enhance the services I could provide, I needed to find a solution to address my patients’ growing demand for refractive surgery. After extensive training in laser vision correction techniques—LASIK and PRK, the gold standard at that time—the refractive surgery side of Clínica INSADOF grew rapidly.

Figure 1. The interior of the Clínica INSADOF.

In 2002, we performed our first surgeries with the Visian ICL (STAAR Surgical). At that time, we informed patients who were not candidates for laser vision correction that the ICL was an excellent alternative. As with any new surgical technique, we took extreme precautions with the ICL until we overcame our fears. The excellent visual quality and results and the extremely positive patient feedback encouraged us to expand our indications for the Visian ICL, and it quickly became one of our most popular refractive surgery options at the clinic (Figure 2).

Figure 2. The EVO Visian ICL can help practices to grow their refractive surgery volume.

At first, we expanded our Visian ICL usage to include all patients with suspicious topography and dry eye disease. We gradually continued to increase the diopter range for the Visian ICL to include moderate and even low myopia. The addition of these indications further reinforced the Visian ICL as our first choice for any refractive surgery candidate who met the necessary requirements.


Today, the EVO Visian ICL accounts for 85% to 90% of our refractive surgery volume in patients younger than 50 years. Now, we only perform laser vision correction in patients who do not meet the EVO Visian ICL requirements or in those who choose a different procedure. Patients are always counseled about all refractive surgery options so that they can make a well-informed decision (see Counseling Patients).

What caused this inevitable change in our approach to refractive surgery? Our clinic went through a gradual learning curve, including myself as the medical director, based on the ICL’s excellent safety profile,1 effectiveness,1 and its clear advantages compared to corneal surgery.2

Over the past 20 years, we expanded Clínica INSADOF in two phases, and our most recent renovation was completed just months ago. The opportunity to invest in an excimer laser to meet the high demand of refractive surgery patients was discussed, but we decided against it. I have always believed from a medical (and personal) perspective that laser surgery is an aggressive technique because it alters the normal corneal structure and its functionality.

The EVO Visian ICL is a premium refractive surgery option that does not remove corneal tissue. It is also removable in case of any potential complication or to comply with a patient’s future surgical needs. It also has a low complication rate,1 which may even decrease over time to coincide with the surgeon’s learning curve and the number of ICL procedures he or she performs.

Over the years, STAAR Surgical has incorporated changes to the ICL to enhance its value proposition to surgeons and patients alike. These include the addition of the KS-AquaPort, a hole in the center of the myopic ICL to improve aqueous flow (eliminating the need for preoperative peripheral iridotomy),3 release of a toric version to treat astigmatism, and availability of a new model, the EVO+, with an increased optic zone.


The main issue when implanting the ICL is managing the vault between the ICL and the crystalline lens. However, time and experience has given us confidence and helped us to master this part of the implantation technique. Achieving adequate vault reduces some complications,4 while at the same time allowing patients to enjoy the numerous advantages of EVO Visian ICL compared to other refractive surgery techniques.

When attending ophthalmology conferences and meetings, many colleagues ask me how we have achieved such a high volume of ICL lens implants in our clinic. For me, the answer is simple: The procedure does not remove corneal tissue like laser procedures do, and it offers better visual quality with fewer aberrations and dysphotopsias.2 Possible side effects of refractive surgery such as induced dry eye disease are avoided with the ICL, and the potential to remove the lens for future ocular surgeries if needed, in my view, improves the benefits of this technique.5 On a personal note, the ICL also allows me to perform refractive surgery without the economic burden of maintaining an excimer laser, especially today when refractive surgery is not in such demand as before.

Despite being a more expensive procedure, it is amazing how many refractive patients specifically ask for the EVO Visian ICL. Many of these patients have been referred to the clinic by other happy ICL patients. This clearly demonstrates the quality of the product and the powerful influence of patient satisfaction via word of mouth in our small town.

We don’t consider the EVO Visian ICL to be a substitute for laser surgery since both techniques have their space and clear indications. However, we do regard the ICL to be our premium option within refractive surgery. It is our first choice for patients who meet the necessary requirements once properly informed of all available surgical options.

The ICL works at least as well for correcting low myopia or hyperopia as it does in high myopia.6,7 In our experience, patient satisfaction is equally positive in patients with -15.00 D of myopia as it is in patients with -1.00 D of myopia. Additionally, astigmatism management with the Toric EVO Visian ICL is safe, and repositioning, if required, is easy.


All refractive surgery procedures should be considered viable choices. In our clinic, we educate patients on all of their options, and we highlight the importance of each procedure. Among our refractive surgery offerings, we consider the EVO Visian ICL to be an integral vision correction solution for patients, and we recognize its contribution to the overall success of our clinic.


In my experience, the best way to advise patients on any medical decision is to recommend the same procedure that I would recommend to a family member or loved one. I performed LASIK on my sister and my wife in 2000 and 2002, respectively. Both had low myopia and are happy with their surgery results; however, my surgical advice would be different today. Now I would have counseled them on the ICL. Therefore, the EVO Visian ICL is my suggestion to any patient who meets all the necessary requirements for implantation.

Recently, one ophthalmologist and one optometrist from our clinic chose the EVO Visian ICL to correct moderate and low myopia, respectively. Even for low myopia (-2.00 D), the optometrist didn’t consider corneal surgery as an option.

“As a contact lens specialist, I believe we should respect corneal integrity much more than we actually do. In my case, I wasn’t afraid of using vision correction again, but I was afraid of harming my corrected VA, seeing halos, and having a contrast defect in night vision, all of which would result in worse vision quality. As a soft contact lens user for many years, it is important to me to avoid inducing dry eye, which often occurs after LASIK. I wanted my quality of life to improve after such an important surgery and this implies an upgrade with respect to wearing soft contact lens, not a setback.” ­

— María Mercedes, Optometrist Clínica INSADOF and Happy ICL Patient

As a result of the success we have enjoyed with this technology, we encourage all our colleagues to seriously consider the EVO Visian ICL as part of their refractive surgical protocols for any dioptric range and for any patient who meets the necessary requirements. The positive feedback from your future ICL patients will build word-of-mouth referrals while increasing the value of your clinic. Like us, those who incorporate the ICL will quickly realize it is an excellent premium option in today’s refractive surgery market.

1. Packer M. The Implantable Collamer Lens with a central port: review of the literature. Clinical Ophthalmology. 2018:12;2427-2438.

2. Parkhurst G. A prospective comparison of phakic collamer lenses and wavefront-optimized laser-assisted in situ keratomileusis for correction of myopia. Clinical Ophthalmology 2013: 10: 1209–1215.

3. Alfonso JF, Lisa C, Fernández-Vega Cueto L, Belda-Salmerón L, Madrid-Costa D, Montés-Micó R. Clinical outcomes after implantation of a posterior chamber collagen copolymer phakic intraocular lens with a central hole for myopic correction. J Cataract Refract Surg. 2013;39(6):915-921.

4. Kojima T, Maeda M, Yoshida Y, et al. Posterior chamber phakic implantable collamer lens: changes in vault during 1 year. J Refract Surg. 2010;26(5):327-332.

5. Naves JS, Carracedo G, Cacho-Babillo I. Diadenosine nucleotid measurements as dry-eye score in patients after LASIK and ICL surgery. Paper presented at: the American Society of Cataract and Refractive Surgery (ASCRS); April 20-24, 2012; Chicago.

6. Alfonso JF, Baamonde B, Belda-Salmerón L, Montés-Micó R, Fernández-Vega L. Collagen copolymer posterior chamber phakic intraocular lens for hyperopia correction: three-year follow-up. J Cataract Refract Surg. 2013;39(10):1519-1527.

7. Kamiya K, Shimizu K, Igarashi A, et al. Posterior chamber phakic intraocular lens implantation: comparative, multicentre study in 351 eyes with low-to-moderate or high myopia. Br J Ophthalmol. 2018;102(2):177-181.

Ernesto Alonso Juárez, MD
  • Medical Director, Instituto Salmantino de Oftalmología, Salamanca, Spain
  • info@insadof.com
  • Financial disclosure: Lecture fees (STAAR Surgical)

Important Safety Information for the Visian ICL

The Visian ICL is indicated for phakic patients 21-60 years of age to correct/reduce myopia up to -20.00 D with up to 6.00 D of astigmatism; and in patients 21-45 years of age to correct/reduce hyperopia up to +16.00 D with up to 6.00 D of astigmatism. Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/ benefit ratio before implanting a lens in a patient with any of the conditions described in the Directions For Use (DFU). Prior to surgery, physicians should inform prospective patients of possible risks and benefits associated with the Visian ICL. Reference the Visian ICL DFU for a complete listing of indications, contraindications, warnings, and precautions.