Persistent Toric Icl Rotation Managed With Non-Toric Icl Implantation And Prk: A Patient-Centered Approach

The purpose of this study is to explore a patient-centered approach for managing persistent rotational instability of toric Implantable Collamer Lenses (ICLs) in cases where weakened zonular support is suspected. It aims to evaluate the efficacy and outcomes of a combined strategy involving the explantation of toric ICLs, replacement with non-toric ICLs, and subsequent photorefractive keratectomy (PRK) for residual refractive error correction. The study highlights the importance of individualized treatment plans in achieving optimal visual outcomes and patient satisfaction.

This study was conducted in a tertiary eye care center specializing in refractive surgery. The center serves a diverse patient population, offering advanced diagnostic and surgical options for complex refractive cases. All procedures, follow-ups and evaluations were carried out under the supervision of experienced refractive surgeons using state-of-the-art equipment, including high-resolution slit-lamp biomicroscopy, optical coherence tomography (OCT), and wavefront-guided excimer laser systems.

This study included two patients with three eyes who underwent Implantable Collamer Lens (ICL) implantation. Initially, toric ICLs were implanted to correct refractive errors. Postoperative BCVA was 20/40 on day one, but it decreased to 20/60 in bothe eyes (first patient) and 20/80 in one eye (second patient) by the first week. Slit-lamp examinations showed more than 10-degree rotation of the toric ICL in all eyes. After repositioning the ICLs, rotation persisted, suggesting weakened zonular support. The toric ICLs were then replaced with non-toric ICLs based on the spherical equivalent, resulting in postoperative vision of 20/60.Three months later, PRK was performed to correct residual refractive errors, leading to BCVA of 20/20.

Initially, the BCVA was 20/40 in all eyes, but it decreased to 20/60 in the first patient’s eyes and 20/80 in the second patient’s single eye by the first postoperative week. Slit-lamp examinations revealed a toric ICL rotation of more than 10 degrees in all three eyes. Despite repositioning the toric ICLs, the rotation persisted, prompting the replacement of the toric ICLs with non-toric ICLs based on the spherical equivalent. Three months later, photorefractive keratectomy (PRK) was performed to address residual refractive errors, resulting in final BCVA of 20/20 in all three eyes. The persistent rotation was attributed to weak zonular support, likely caused by previous trauma or other underlying factors.

This study highlights the challenges of managing persistent rotational instability in toric ICLs, particularly in patients with compromised zonular support, possibly due to past trauma. Despite initial improvements in visual acuity, the rotation of toric ICLs led to the decision to replace them with non-toric lenses, followed by PRK to correct residual refractive errors. The results demonstrate that a patient-centered approach, involving careful monitoring and timely intervention, can lead to satisfactory visual outcomes. This case underscores the importance of considering zonular integrity in ICL surgery and offers valuable insights into managing rotational instability through tailored surgical strategies.