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Figure 1.
A, Iris perfusion in an eye with phakic intraocular lens and pupil ovalization (grade 2), 10 seconds after intravenous indocyanine green injection. Sectorial iris perfusion defects can be seen at the iris periphery (asterisk) and at the pupil margin (arrow). B, The same eye at 22 seconds after injection shows normal perfusion in the periphery (asterisk) but lacks sectorial iris vessel–filling at the pupil margin (arrow).

A, Iris perfusion in an eye with phakic intraocular lens and pupil ovalization (grade 2), 10 seconds after intravenous indocyanine green injection. Sectorial iris perfusion defects can be seen at the iris periphery (asterisk) and at the pupil margin (arrow). B, The same eye at 22 seconds after injection shows normal perfusion in the periphery (asterisk) but lacks sectorial iris vessel–filling at the pupil margin (arrow).

Figure 2.
A, Sectorial iris perfusion defect (asterisk), 11 seconds after intravenous indocyanine green injection in an eye with pupil ovalization (grade 1). Arrow indicates pupil margin. B, Iris perfusion is normal 20 seconds after injection.

A, Sectorial iris perfusion defect (asterisk), 11 seconds after intravenous indocyanine green injection in an eye with pupil ovalization (grade 1). Arrow indicates pupil margin. B, Iris perfusion is normal 20 seconds after injection.

Figure 3.
A, Mild pupil ovalization (grade 1) in an eye with anterior chamber phakic intraocular lens before indocyanine green angiography. B, Sectorial iris perfusion delay is seen 10 seconds after indocyanine green injection (asterisk), especially at the pupil margin (arrow). C, Iris perfusion looks normal 20 seconds after indocyanine green injection.

A, Mild pupil ovalization (grade 1) in an eye with anterior chamber phakic intraocular lens before indocyanine green angiography. B, Sectorial iris perfusion delay is seen 10 seconds after indocyanine green injection (asterisk), especially at the pupil margin (arrow). C, Iris perfusion looks normal 20 seconds after indocyanine green injection.

Figure 4.
Iris perfusion in an eye with phakic intraocular lens, 11 seconds after indocyanine green injection. Normal iris perfusion (grade 0) is seen in the peripheral iris tissue and at the pupil margin.

Iris perfusion in an eye with phakic intraocular lens, 11 seconds after indocyanine green injection. Normal iris perfusion (grade 0) is seen in the peripheral iris tissue and at the pupil margin.

Table. 
Demographic Data of Patients
Demographic Data of Patients
1.
Seitz  BTorres  FLangenbucher  ABehrens  ASuarez  E Posterior corneal curvature changes after myopic laser in situ keratomileusis. Ophthalmology 2001;108666- 673
PubMedArticle
2.
Comaish  IFLawless  MA Progressive post-LASIK keratectasia: biomechanical instability or chronic disease process? J Cataract Refract Surg 2002;282206- 2213
PubMedArticle
3.
Ou  RJShaw  ELGlasgow  BJ Keratectasia after laser in situ keratomileusis (LASIK): evaluation of the calculated residual stromal bed thickness. Am J Ophthalmol 2002;134771- 773
PubMedArticle
4.
O'Brien  TPAwwad  ST Phakic intraocular lenses and refractory lensectomy for myopia. Curr Opin Ophthalmol 2002;13264- 270
PubMedArticle
5.
Strampelli  B Sopportabilia di lenti acriliche in camera anteriore nella afachio o nei vizi di refrazione. Ann Ottalmol Clin Ocul 1954;8075- 82
PubMed
6.
Barraquer  J Anterior chamber plastic lenses: results of and conclusions from five years’ experience. Trans Ophthalmol Soc U K 1959;79393- 424
PubMed
7.
Perez-Santonja  JJAlio  JLJimenez-Alfaro  IZato  MA Surgical correction of severe myopia with an angle-supported phakic intraocular lens. J Cataract Refract Surg 2000;261288- 1302
PubMedArticle
8.
Baikoff  GArne  JLBokobza  Y  et al.  Angle-fixated anterior chamber phakic intraocular lens for myopia of -7 to -19 diopters. J Refract Surg 1998;14282- 293
PubMed
9.
Uusitalo  RJAine  ESen  NHLaatikainen  L Implantable contact lens for high myopia. J Cataract Refract Surg 2002;2829- 36
PubMedArticle
10.
Saxena  RLandesz  MNoordzij  BLuyten  GP Three-year follow-up of the Artisan phakic intraocular lens for hypermetropia. Ophthalmology 2003;1101391- 1395
PubMedArticle
11.
Baikoff  G Phakic anterior chamber intraocular lenses. Int Ophthalmol Clin 1991;3175- 86
PubMedArticle
12.
Mimouni  FColin  JKoffi  VBonnet  P Damage to the corneal endothelium from anterior chamber intraocular lenses in phakic myopic eyes. Refract Corneal Surg 1991;7277- 281
PubMed
13.
Allemann  NChamon  WTanaka  HM  et al.  Myopic angle-supported intraocular lenses: two-year follow-up. Ophthalmology 2000;1071549- 1554
PubMedArticle
14.
Villarrubia Cuadrado  AGallardo Galera  JMBergillos Arillo  M  et al.  Intraocular phakic lens ZSAL-4 for high myopia correction. Arch Soc Esp Oftalmol 2002;77661- 667
PubMedArticle
15.
Ravalico  GBotteri  EBaccara  F Long-term endothelial changes after implantation of anterior chamber intraocular lenses in cataract surgery. J Cataract Refract Surg 2003;291918- 1923
PubMedArticle
16.
Ardjomand  NFellner  PKölli  HVidic  B Phake IOL Implantation zur Korrektur hoher Myopie. Spektr Augenheilkd 2003;17222- 226Article
17.
Alio  JLde la Hoz  FPerez-Santonja  JJRuiz-Moreno  JMQuesada  JA Phakic anterior chamber lenses for the correction of myopia: a 7-year cumulative analysis of complications in 263 cases. Ophthalmology 1999;106458- 466
PubMedArticle
18.
Perez-Santonja  JJIradier  MTBenitez del Castillo  JMSerrano  JMZato  MA Chronic subclinical inflammation in phakic eyes with intraocular lenses to correct myopia. J Cataract Refract Surg 1996;22183- 187
PubMedArticle
19.
Werner  LApple  DJIzak  AM  et al.  Phakic anterior chamber intraocular lenses. Int Ophthalmol Clin 2001;41133- 152
PubMedArticle
20.
Ardjomand  NKolli  HVidic  BEl-Shabrawi  YFaulborn  J Pupillary block after phakic anterior chamber intraocular lens implantation. J Cataract Refract Surg 2002;281080- 1081
PubMedArticle
21.
Easty  DLChignell  AH Fluorescein angiography in anterior segment ischaemia. Br J Ophthalmol 1973;5718- 26
PubMedArticle
22.
Saunders  RABluestein  ECWilson  MEBerland  JE Anterior segment ischemia after strabismus surgery. Surv Ophthalmol 1994;38456- 466
PubMedArticle
23.
Wolf  EWagner  RSZarbin  MA Anterior segment ischemia and retinal detachment after vertical rectus muscle surgery. Eur J Ophthalmol 2000;1082- 87
PubMed
24.
Anderson  DMMorin  JD Experimental anterior segment necrosis and rubeosis iridis. Can J Ophthalmol 1971;6196- 201
PubMed
25.
McDonnell  PJGreen  WRMaumenee  AEIliff  WJ Pathology of intraocular lenses in 33 eyes examined postmortem. Ophthalmology 1983;90386- 403
PubMedArticle
26.
Jimenez-Alfaro  IGarcia-Feijoo  JPerez-Santonja  JJCuina  R Ultrasound biomicroscopy of ZSAL-4 anterior chamber phakic intraocular lens for high myopia. J Cataract Refract Surg 2001;271567- 1573
PubMedArticle
27.
Colin  J Phase II clinical results for the AcrySof Phakic ACL.  Abstracts of the XXI Congress of the European Society of Cataract and Refractive Surgery September 9, 2003 Munich, Germany
28.
de Souza  RFAllemann  NForseto  A  et al.  Ultrasound biomicroscopy and Scheimpflug photography of angle-supported phakic intraocular lens for high myopia. J Cataract Refract Surg 2003;291159- 1166
PubMedArticle
29.
Lege  BAMBauer  MHNeuhann  THaigis  W “White-to-white” measurement: IOL-Master vs Orbscan II vs surgeon.  Presented at: XXI Congress of the European Society of Cataract and Refractive Surgery September 9, 2003 Munich, Germany
30.
Lovisolo  CF ICL: ten year experience.  Presented at: XXI Congress of the European Society of Cataract and Refractive Surgery September 9, 2003 Munich, Germany
31.
Marinho  APinto  MCVaz  FGuimaraes  SFerreira  N ICARE: A new anterior chamber phakic IOL.  Presented at: XXI Congress of the European Society of Cataract and Refractive Surgery September 9, 2003 Munich, Germany
Clinical Sciences
August 01, 2005

Pupil Ovalization After Phakic Intraocular Lens Implantation Is Associated With Sectorial Iris Hypoperfusion

Author Affiliations

Author Affiliations: Department of Ophthalmology, Medical University Graz, Graz, Austria (Drs Fellner, Vidic, El-Shabrawi, and Ardjomand); Moorfields Eye Hospital, London, England (Drs Ramkissoon, Fu, and Ardjomand).

Arch Ophthalmol. 2005;123(8):1061-1065. doi:10.1001/archopht.123.8.1061
Abstract

Objective  To investigate iris perfusion in patients with and without pupil ovalization after phakic intraocular lens implantation.

Methods  Comparative retrospective randomized case series of 6 participants, each with a regular pupil, and 6 participants with pupil ovalization after phakic intraocular lens implantation for high myopia were included in the study. Indocyanine green angiography was performed between 20 and 40 months (mean ± SD, 26 ± 6.1 months) after lens implantation.

Results  Iris perfusion defects were found in 5 of 6 patients with pupil ovalization. No perfusion deficits were noted in patients with round pupils.

Conclusion  Iris ovalization after phakic intraocular lens implantation may be associated with a lack of iris perfusion and with secondary ischemia. Patients with these lenses and pupil ovalization should be followed regularly.

Treatment of myopia with ablative corneal refractive surgery is limited by the amount of tissue that can be removed secondary to risks of keratectasia resulting from corneal thinning.13

Implantation of phakic intraocular lenses (IOLs) is a method of correcting high refractive errors with preservation of accommodation4 while avoiding ablation of corneal tissue. Since the introduction of phakic IOLs,5,6 IOL types have changed and are generally safer.7,8 Three phakic intraocular lenses are now available: angle-supported anterior chamber IOLs, iris-claw lenses, and posterior chamber IOLs.7,9,10

Corneal endothelial cell loss, once a major problem early in the development of phakic IOLs, is less of a concern now.7,8,1117 However, there is still some concern about the implantation of an IOL in a functionally healthy eye.

Complications such as cataracts, postoperative uveitis, postoperative elevated intraocular pressure, decentration, symptomatic halos, and pupil ovalization have been reported.7,8,13,17,18 Pupil ovalization has been reported to occur in 40% of patients using the NuVita MA20 (Bausch & Lomb Surgical, San Dimas, Calif) phakic IOLs13 and in 18% of patients with the ZSAL-4 (Morcher, Stuttgart, Germany) anterior chamber angle-supported phakic IOLs.7

Since pupil ovalization may be a result of iris ischemia,7,19 we investigated iris perfusion in 12 patients both with and without pupil ovalization after phakic IOL implantation according to indocyanine green (ICG) angiography findings.

METHODS

Twelve patients with various anterior chamber angle-supported phakic IOLs (NuVita and ZSAL-4) underwent ICG angiography. Six patients had developed varying degrees of pupil ovalization within the phakic IOL axis, while 6 patients with phakic IOLs had no obvious iris ovalization on slitlamp examination.

Institutional review board approval was not necessary, but explanation of the benefits and risks of ICG angiography were offered prior to patient consent.

Phakic IOL implantation for high myopia treatment was performed in all cases. The demographic data of the patients are presented in the Table.

The surgical technique has been previously described.16,20 Phakic IOL implantation was typically performed under retrobulbar anesthesia. Two hours prior to the procedure, the pupil was constricted with 2% pilocarpine eye drops. A 7-mm corneal incision was made and the phakic IOL was inserted into the anterior chamber after injection of viscoelastic material (Amvisc; Bausch & Lomb). The lens length was selected by adding 1 mm to the horizontal white-to-white distance. The viscoelastic material was removed with a Simcoe irrigation-aspiration cannula, iridotomy was performed, and the corneal incision was closed with 3 interrupted stitches (10-0 nylon; Ethicon Inc, Cornelia, Ga). The pupils were constricted and appeared round at the conclusion of the procedure. Dexamethasone ointment was applied at the end of the operation and the eye was patched until postoperative day 1.

Postoperative treatment included the use of betamethasone/neomycin drops 4 times per day, and the treatment tapered over a period of 5 weeks. All patients were seen on postoperative day 1, after 1 week, 1 month, 3 months, 6 months, and then at 6-month intervals thereafter.

All procedures were performed by a single surgeon (B.V.) in the Department of Ophthalmology at the Medical University Graz in Graz, Austria.

The diagnosis and determination of the degree of pupil ovalization were done at the slitlamp. Three different degrees of pupil ovalization were recorded: grade 0 indicated no pupil ovalization, grade 1 indicated mild pupil ovalization (pupil deviation not reaching the edge of the phakic IOL optic), and grade 2 indicated severe pupil ovalization (pupil deviation reaching the edge of the phakic IOL optic in at least 1 point).17

The patients underwent ICG angiography (Heidelberg Retina Angiograph; Heidelberg Engineering, Heidelberg, Germany) of the iris. Patients received an intravenous bolus injection of 5 mL of 20% ICG (ICG-Pulsion; Pulsion Medical Systems, München, Germany). The angiograms were recorded with a digital camera (Sony Electronics Inc, Park Ridge, NJ) and analyzed in slow motion using Adobe Premiere Pro software (Adobe, Vienna, Austria) by 3 of the investigators (P.F., B.V., N.A.). A perfusion deficit was diagnosed if a sectorial absolute or early iris hypofluorescence was noted.

Three different grades of iris hypofluorescence were recorded: grade 0 indicated normal iris perfusion within 10 seconds after intravenous ICG injection, grade 1 indicated sectorial delay of filling iris vessels within the first 20 seconds after intravenous bolus injection of ICG, and grade 2 indicated a persistent lack of sectorial iris vessel perfusion.

RESULTS

All patients had a round pupil at the end of the operation and at the follow-up at 6 months. Iris perfusion time was within 10 seconds in normal eyes and myopic eyes with phakic IOLs without iris ovalization. Three of 6 patients demonstrated iris ovalization of grade 2 from 20 to 27 months after lens implantation (Figure 1). Of these 3 patients, 1 patient had an iris perfusion defect of grade 1 (sectorial delayed iris perfusion but normal iris vessel pattern 22 seconds after intravenous ICG injection) and 2 patients had an iris perfusion defect of grade 2. Of 3 patients with mild pupil ovalization (grade 1), 2 patients demonstrated a delayed iris perfusion defect of grade 1 (sectorial delayed iris perfusion but normal iris vessel pattern 20 seconds after intravenous ICG injection; Figure 2 and Figure 3) and 1 patient had a normal iris perfusion (grade 0). None of the aforementioned patients had obvious iris atrophy.

All patients with phakic IOLs and round pupils also underwent ICG angiography and demonstrated normal iris perfusion (grade 0; Figure 4). All iris vessels were visible 10 seconds after intravenous ICG injection (Table).

COMMENT

Whereas refractive errors of low and moderate myopia may often be treated by corneal refractive surgery, those of high myopia are often treated with phakic IOL implants or clear lens extraction.4

Anterior chamber IOLs introduced in the 1950s and 1960s were associated with damage to the corneal endothelium often resulting in corneal decompensation.5,6 Anterior chamber phakic IOLs experienced a renaissance in the 1990s with the development of better and thinner designs.11,17 Concerns about rigid anterior chamber phakic IOLs still exist since complications, including uveitis, cataracts, pigment dispersion, elevated intraocular pressure, and pupil ovalization, have been reported.7,8,17,19 Pupil ovalization after phakic IOL implantation has been thought to be related to iris ischemia induced by haptic compression of the iris root vessels since it is associated with iris retraction, iris atrophy, and low-grade inflammation.7,17,19 This study shows, for the first time, iris perfusion defects in patients with phakic IOLs.

We described all cases of slitlamp-evident ovalization of the pupil as pupil ovalization, whereas Alio et al17 classified pupil ovalization as pupil deviation in the meridian of the placement of the phakic IOL haptic that reaches the edge of the phakic IOL optic in at least 1 point. No quantitative grading for pupil ovalization has been published yet, and our grading has been adapted to distinguish between mild and severe pupil ovalization.

In this study, we used ICG angiography to investigate iris perfusion in eyes with phakic IOLs with and without pupil ovalization approximately 2 years after IOL implantation. Indocyanine green angiography is an infrared-based dye imaging technique introduced for retinal and choroidal disorders. Further advances in videoangiography have allowed for precise assessment of degree and timing of perfusion in ocular vasculature. The use of fluorescein or ICG to assess perfusion of anterior ocular structures has been previously described.21,22 The ICG was used rather than sodium fluorescein for angiography because fluorescein may be difficult to visualize in patients with heavily pigmented iris tissue.23

The ICG angiograms showed mild to severe iris perfusion defects in 5 of 6 eyes with pupil ovalization. In 3 eyes, iris perfusion in some segments was delayed for several seconds after intravenous injection of ICG but was normal at the 22- to 25-second time period. In 2 other eyes, we found permanent iris perfusion defects, especially at the pupil margin. Though the ovalization was in the axis of the IOL, perfusion defects were not only seen at the axis of the larger diameter of the ovalization but also elsewhere in the iris.

The ICG angiography results were normal in 1 eye with mild ovalization 20 months after implantation and in eyes without pupil ovalization.

All patients with pupil ovalization and 2 patients with round pupils showed cell deposits on the IOLs. This may be related to breakdown of the blood-aqueous barrier, as previously described in anterior segment ischemia.22 However, uveitis was not observed and no patient was receiving topical medication at the time of angiography.

Anterior segment ischemia has been described as occurring after different ocular surgery procedures such as strabismus or retinal detachment surgery.21,22 Iris atrophy, uveitis, and even phthisis bulbi have been described with anterior segment ischemia.22 Experimentally induced anterior segment ischemia results in rubeosis iridis in a rabbit model. Histopathologic examination of eyes with anterior chamber IOLs has revealed iris ghost vessels.24,25 Iris atrophy was not noticed in any of our patients, particularly not in those with sectorial iris vessel–filling defects.

One difficulty with the phakic anterior chamber IOL implantation surgical technique is the accurate measurement of phakic IOL size. The general recommendation for the IOL length is the largest corneal diameter plus 1 mm17,26; however, this is an estimation and may not reflect the proper anterior chamber diameter. Anterior chamber depth measurement using ultrasound biomicroscopy, optical coherence tomography, or Scheimpflug photography could be useful for phakic IOL size measurement and may reduce the pressure on the iris roots through better IOL intraocular fit. New foldable phakic IOLs are commercially available now, and these lenses have the additional advantage of reducing the haptic pressure in the chamber angle.2731

The long-term relevance and associations of iris perfusion defects, which are demonstrated on ICG videoangiography, and subsequent development of iris ischemia are still unclear. However, these patients may require regular follow-up, and IOL explantation may be considered in patients with extensive pupil ovalization associated with symptoms of chronic anterior uveitis.

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Article Information

Correspondence: Navid Ardjomand, MD, Department of Ophthalmology, Medical University Graz, Auenbruggerplatz 4, A-8036 Graz, Austria (navid.ardjomand@meduni-graz.at).

Submitted for Publication: June 11, 2004; final revision received November 16, 2004; accepted November 16, 2004.

Financial Disclosure: None.

Previous Presentation: Presented at the annual meeting of the European Society of Cataract & Refractive Surgery, Munich, Germany, September 9, 2003.

References
1.
Seitz  BTorres  FLangenbucher  ABehrens  ASuarez  E Posterior corneal curvature changes after myopic laser in situ keratomileusis. Ophthalmology 2001;108666- 673
PubMedArticle
2.
Comaish  IFLawless  MA Progressive post-LASIK keratectasia: biomechanical instability or chronic disease process? J Cataract Refract Surg 2002;282206- 2213
PubMedArticle
3.
Ou  RJShaw  ELGlasgow  BJ Keratectasia after laser in situ keratomileusis (LASIK): evaluation of the calculated residual stromal bed thickness. Am J Ophthalmol 2002;134771- 773
PubMedArticle
4.
O'Brien  TPAwwad  ST Phakic intraocular lenses and refractory lensectomy for myopia. Curr Opin Ophthalmol 2002;13264- 270
PubMedArticle
5.
Strampelli  B Sopportabilia di lenti acriliche in camera anteriore nella afachio o nei vizi di refrazione. Ann Ottalmol Clin Ocul 1954;8075- 82
PubMed
6.
Barraquer  J Anterior chamber plastic lenses: results of and conclusions from five years’ experience. Trans Ophthalmol Soc U K 1959;79393- 424
PubMed
7.
Perez-Santonja  JJAlio  JLJimenez-Alfaro  IZato  MA Surgical correction of severe myopia with an angle-supported phakic intraocular lens. J Cataract Refract Surg 2000;261288- 1302
PubMedArticle
8.
Baikoff  GArne  JLBokobza  Y  et al.  Angle-fixated anterior chamber phakic intraocular lens for myopia of -7 to -19 diopters. J Refract Surg 1998;14282- 293
PubMed
9.
Uusitalo  RJAine  ESen  NHLaatikainen  L Implantable contact lens for high myopia. J Cataract Refract Surg 2002;2829- 36
PubMedArticle
10.
Saxena  RLandesz  MNoordzij  BLuyten  GP Three-year follow-up of the Artisan phakic intraocular lens for hypermetropia. Ophthalmology 2003;1101391- 1395
PubMedArticle
11.
Baikoff  G Phakic anterior chamber intraocular lenses. Int Ophthalmol Clin 1991;3175- 86
PubMedArticle
12.
Mimouni  FColin  JKoffi  VBonnet  P Damage to the corneal endothelium from anterior chamber intraocular lenses in phakic myopic eyes. Refract Corneal Surg 1991;7277- 281
PubMed
13.
Allemann  NChamon  WTanaka  HM  et al.  Myopic angle-supported intraocular lenses: two-year follow-up. Ophthalmology 2000;1071549- 1554
PubMedArticle
14.
Villarrubia Cuadrado  AGallardo Galera  JMBergillos Arillo  M  et al.  Intraocular phakic lens ZSAL-4 for high myopia correction. Arch Soc Esp Oftalmol 2002;77661- 667
PubMedArticle
15.
Ravalico  GBotteri  EBaccara  F Long-term endothelial changes after implantation of anterior chamber intraocular lenses in cataract surgery. J Cataract Refract Surg 2003;291918- 1923
PubMedArticle
16.
Ardjomand  NFellner  PKölli  HVidic  B Phake IOL Implantation zur Korrektur hoher Myopie. Spektr Augenheilkd 2003;17222- 226Article
17.
Alio  JLde la Hoz  FPerez-Santonja  JJRuiz-Moreno  JMQuesada  JA Phakic anterior chamber lenses for the correction of myopia: a 7-year cumulative analysis of complications in 263 cases. Ophthalmology 1999;106458- 466
PubMedArticle
18.
Perez-Santonja  JJIradier  MTBenitez del Castillo  JMSerrano  JMZato  MA Chronic subclinical inflammation in phakic eyes with intraocular lenses to correct myopia. J Cataract Refract Surg 1996;22183- 187
PubMedArticle
19.
Werner  LApple  DJIzak  AM  et al.  Phakic anterior chamber intraocular lenses. Int Ophthalmol Clin 2001;41133- 152
PubMedArticle
20.
Ardjomand  NKolli  HVidic  BEl-Shabrawi  YFaulborn  J Pupillary block after phakic anterior chamber intraocular lens implantation. J Cataract Refract Surg 2002;281080- 1081
PubMedArticle
21.
Easty  DLChignell  AH Fluorescein angiography in anterior segment ischaemia. Br J Ophthalmol 1973;5718- 26
PubMedArticle
22.
Saunders  RABluestein  ECWilson  MEBerland  JE Anterior segment ischemia after strabismus surgery. Surv Ophthalmol 1994;38456- 466
PubMedArticle
23.
Wolf  EWagner  RSZarbin  MA Anterior segment ischemia and retinal detachment after vertical rectus muscle surgery. Eur J Ophthalmol 2000;1082- 87
PubMed
24.
Anderson  DMMorin  JD Experimental anterior segment necrosis and rubeosis iridis. Can J Ophthalmol 1971;6196- 201
PubMed
25.
McDonnell  PJGreen  WRMaumenee  AEIliff  WJ Pathology of intraocular lenses in 33 eyes examined postmortem. Ophthalmology 1983;90386- 403
PubMedArticle
26.
Jimenez-Alfaro  IGarcia-Feijoo  JPerez-Santonja  JJCuina  R Ultrasound biomicroscopy of ZSAL-4 anterior chamber phakic intraocular lens for high myopia. J Cataract Refract Surg 2001;271567- 1573
PubMedArticle
27.
Colin  J Phase II clinical results for the AcrySof Phakic ACL.  Abstracts of the XXI Congress of the European Society of Cataract and Refractive Surgery September 9, 2003 Munich, Germany
28.
de Souza  RFAllemann  NForseto  A  et al.  Ultrasound biomicroscopy and Scheimpflug photography of angle-supported phakic intraocular lens for high myopia. J Cataract Refract Surg 2003;291159- 1166
PubMedArticle
29.
Lege  BAMBauer  MHNeuhann  THaigis  W “White-to-white” measurement: IOL-Master vs Orbscan II vs surgeon.  Presented at: XXI Congress of the European Society of Cataract and Refractive Surgery September 9, 2003 Munich, Germany
30.
Lovisolo  CF ICL: ten year experience.  Presented at: XXI Congress of the European Society of Cataract and Refractive Surgery September 9, 2003 Munich, Germany
31.
Marinho  APinto  MCVaz  FGuimaraes  SFerreira  N ICARE: A new anterior chamber phakic IOL.  Presented at: XXI Congress of the European Society of Cataract and Refractive Surgery September 9, 2003 Munich, Germany
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