Late Icl Vault Insufficiency And Cataract: Surgical Solution 17 Years After Primary Implantation

To report successful management of late vault insufficiency and cataract formation 17 years after initial implantable collamer lens (ICL) implantation through lens exchange in a patient with high myopia.

Tertiary referral center specializing in refractive surgery and anterior segment procedures, with comprehensive diagnostic capabilities including anterior segment optical coherence tomography (AS-OCT) for vault assessment and specular microscopy for endothelial cell evaluation.

A middle-aged female with high myopia (OS: -9.00 D, -1.25 × 180°) initially underwent toric ICL V4B implantation (12.50 mm, -15.00/+1.50 × 86°) followed by LASIK for residual astigmatism. Seventeen years post-implantation, she presented with progressive visual decline and night glare. Examination revealed low vault (grade 1, 250 μm) with peripheral lens-crystalline lens touch and nasal peripheral subcapsular cataract. Best-corrected visual acuity (BCVA) was 0.8 (+0.50 +1.50 × 70°), with stable intraocular pressure (10 mmHg) and endothelial cell counts. Surgical intervention consisted of explantation of the original ICL V4B and implantation of a larger ICL V4C (13.20 mm, -10.50 D), oriented vertically via 3.2 mm incision to maximize vault and avoid the previous lens touch zone. 

Postoperatively, vault improved to grade 2 (250-750 μm) with resolution of lens touch. BCVA was 0.8 (cc +0.75). No new cataract progression was observed. Intraocular pressure remained stable at 15 mmHg, and endothelial cell counts were maintained (2469-2578 cells/mm²).

This case demonstrates that vault insufficiency and cataract can occur even 17 years after ICL implantation, emphasizing the necessity of lifelong follow-up in phakic IOL patients. Persistent low vault (250 μm) with lens touch represents an established risk factor for cataract development, particularly in high myopia.  Late ICL exchange with upsizing and reorientation effectively restored anatomical vault relationships without compromising endothelial cell density. Individualized ICL sizing and continuous long-term monitoring remain crucial for optimal outcomes in phakic ICL patients.