Phakic IOL (ICL) for Keratoconus

The Visian ICL is an artificial lens that is implanted into your eye to correct high degrees of nearsightedness. It is a type of implant known as a phakic intraocular lens (IOL). Although it is often called the Implantable Contact Lens, ICL officially stands for Implantable Collamer Lens.

Good candidates for the ICL procedure are between the ages of 21 and 45 and are highly nearsighted. Often, phakic intraocular lenses are suggested when LASIK or PRK are not appropriate options because of severe myopia, a thin cornea, or if you have keratoconus.

The ICL can correct high degrees of nearsightedness associated with keratoconus. Sometimes, if there is also astigmatism and corneal irregularity, we will suggest Intacs, topography-guided PRK, or CK to further improve vision correction after the ICL procedure.

THE ICL Procedure

THE ICL Procedure

The implantation procedure for the Visian ICL involves a procedure similar to that of cataract surgery.

The main difference is that, unlike cataract surgery, the ICL procedure does not require the removal of the eye’s natural crystalline lens. Unlike LASIK or PRK in which the cornea is reshaped by a laser to improve vision, the ICL procedure does not involve the cornea; rather, it involves the placement of a permanent lens within the eye.

About one to two weeks prior to the insertion of the ICL, a YAG laser iridotomy will be performed by Dr. Hersh. During this procedure, a YAG laser is used to make one or two small openings near the edge of your iris, which is the colored part of the eye. These openings serve as outlets that will allow the fluid in your eye to circulate around the lens.

The actual ICL procedure will take about 30-60 minutes. ICL implantations are done under topical anesthesia with eye drops to minimize discomfort. Often, a mild sedative is given to make you more relaxed.

Once you are comfortable, the procedure is started by creating two small openings at the edge of your cornea that will be used to position the lens. Next, a gel-like substance is placed inside your eye to protect the natural lens during ICL placement. After placement of the gel, a small opening will be made, through which the lens will be inserted.

Before the Visian ICL procedure, the proper power and size of your implant were selected based on your examination measurements. The proper ICL is then inserted into your eye using a small cartridge that is placed through the incision.

As the lens is inserted, it will gently unfold in your eye. Once it has fully unfolded, the four corners of the lens will be placed behind your iris. This makes the lens invisible to both you and others. Because the incision made during surgery is so small, sutures are typically not needed following ICL surgery, but one or two small sutures may be placed.

Visian ICL example

After your procedure, eye drops will be administered to help prevent infection and inflammation. You will continue to use these drops for a week or two after your procedure.

You should not drive immediately after ICL surgery, so it is important that you arrange for transportation home. You will return to our office after your ICL surgery in order for Dr. Hersh to assess corneal pressure and check that you are doing well.

Vision starts to return the day after the procedure. We will see you for an examination the day after your surgery. It is important to follow your postoperative instructions, especially regarding the needed use of antibiotics and anti-inflammatory medications during the week following the procedure. You should contact us if you experience severe eye pain or a sudden decrease in vision.

After your procedure, you may need adjustments to your specialty contact lenses and/or glasses prescription. Due to the healing involved, we recommend waiting at least one month before you are refit for contact lenses or update your glasses.

ICL combined with Topography Guided PRK

Because the ICL does not correct the corneal irregularity and visual static of keratoconus, sometimes it is suggested that we perform topography-guided PRK before the ICL procedure.
The goal of this is too smooth the corneal optics to improve the ultimate vision after ICL implantation.  The following is a report of a patient who received TG-PRK and corneal crosslinking followed by ICL surgery.

Topography-Guided PRK, Collagen Crosslinking, and Phakic IOL Implantation in Keratoconus

Jessica J. Lee BA,  Peter S. Hersh MD

A 38-year-old man had been diagnosed with keratoconus 5 years before the presentation and had been stable by history.  On examination, uncorrected distance visual acuity (UDVA) was counts fingers in both eyes. Corrected distance visual acuity (CDVA) was 20/20 in the right eye with a manifest refraction of -9.50-1.25 x 060 and 20/20 in the left eye with -8.00-3.50 x100.

Corneal topography showed a mild keratoconus pattern in the right eye with 45.7 D maximum K and ­­a more notable irregularity in left eye with 49.2 D maximum K.  Inferior-Superior topography difference at the 6 mm zone on the axis of maximum K was 9.5D in the left eye as seen below.

                               Left eye shows worse keratoconus with higher (redder) cone and top-bottom asymmetry

TG-PRK combined with corneal collagen crosslinking was performed on the left eye.  The goal was to decrease astigmatism and topographic abnormalities in preparation for ICL implantation.

Data was imported to the Wavelight laser from repeated and reliable topography measurements.  The laser pattern of the TG-PRK is seen below.  The redder areas are regions where more tissue is removed and correspond to the high (red) areas of the patient’s corneal topography.

After the laser procedure, collagen crosslinking was performed. Riboflavin 0.1% was administered topically to achieve complete stromal saturation and then the cornea was aligned and exposed to UV-A (365nm) light.

Postoperatively,  the topography map showed flattening of the inferior cone and smoothing of the central optical zone. Inferior-Superior topography difference at the 6 mm zone on the axis of maximum cone height had decreased to 4.5D, indicating a 5D improvement in corneal symmetry.

The actual keratoconic cone height had decreased to 47.0 D. Glasses’ corrected vision was 20/20 with very high nearsightedness of -11.25 sphere.

                                        After TG-PRK (Note smoothing of topography)                    Before TG-PRK     

The patient underwent uncomplicated placement of a phakic IOL in both eyes 3 months after the PRK/CXL procedure.

Implanted lens powers were -11.00 D in the right eye and -12.0 D in the left eye.  Three months after ICL surgery, vision without glasses or contact lenses was 20/20 in the right eye and 20/16 in the left eye.


For some patients with keratoconus, a stepwise surgical strategy aimed at different components of the disorder – in this case, high myopia, astigmatism, topography irregularity, and prevention of disease progression – may be rewarded by improved visual function.

In assessing patients for adjunctive procedures, it is important to ascertain the patient’s candidacy for all of the procedures that will be undertaken.  For example, the patient must have adequate corneal thickness for both TG-PRK and CXL and also have an adequate anterior chamber depth for ICL insertion.

In addition, the patient must also be educated and prepared for at least 3 months of blurry vision because of the period of stabilization required between TG-PRK/CXL and ICL insertion.

For an individual with high myopia, moderate astigmatism, and keratoconus, preparatory TG-PRK/CXL for ultimate phakic IOL insertion may improve uncorrected visual function substantially.

This patient achieved 20/20 acuity in both eyes.  However, it is important to have a full discussion with potential candidates about the expected outcomes in their particular case.


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Thank you so much Doc! When I first came to you I was 20/50 now I'm 20/10. I'm ready to have a great year!

Randy Foye
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My experience at The Cornea and Laser Eye Institute has been amazing. All of the staff have been helpful and courteous...

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Dr. Hersh and his staff were excellent. I was comfortable from the time I walked in until the time I left after the procedure.

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