Phakic IOL Follow-up: What to Watch For

Phakic presbyopic IOLs are mainly indicated for presbyopic patients who want spectacle independence but still have a clear crystalline lens and are not ideal candidates for laser or lens exchange surgery. According to Kjell Gunnar Gundersen MD, PhD, these lenses come with a spectrum of complications not dissimilar to those of monofocals.

So, what kind of follow-up do these kinds of patients require? Dr Gundersen suggested follow-up at day 1, week 1, month 1, and 3 to 12 months to evaluate for potential complications such as IOP spikes, iritis, toxic anterior segment syndrome, endophthalmitis, and pupillary block with persistent IOP rise.

Long-term follow-up every 12 months should evaluate endothelial cell loss and corneal decompensation, pigment dispersion glaucoma, retinal tears, dysphotopsia, and lens tilt and decentration, he added.

Dr Gundersen noted that there is a limited number of publications in the literature on presbyopia-correcting posterior chamber IOLs, with small study cohorts and short observation times. Moreover, PubMed is not as reliable as it was previously. On the other hand, a more extensive review by Reinstein (et al.) on posterior chamber phakic IOLs (PIOLs) provides an ample overview of the safety profile, he noted, as it considers the accuracy, precision, and the defocus curve of these lenses.¹

The incidence of cataract in implantable phakic contact lens (IPCL)-implanted patients is on average reported to be 0.95% of cases. The cataract formation rate drops to 0.46% in newer lens designs, with no cases requiring explantation due to cataract during the reported follow-up. According to Xu and Song (et al.), the risk of retinal detachment remains low and comparable to highly myopic controls in long-term follow-ups.²

When trying to avoid refractive lens exchange in high myopes, phakic IOLs seem to be a very safe option. Considering endothelial cell loss, Visian ICL (STAAR Surgical) trial data showed a 3.3% mean endothelial cell loss at one year and roughly 9.7% rate at four years, including both surgical trauma and progressive loss. Similarly, the IPCL showed 5.5% loss in the first year and less than 1.5% in the following two years.³ If the patient starts with a good endothelial cell count, a dramatic decrease can be avoided, he said.

The incidence of secondary glaucoma after posterior chamber phakic IOL implantation is very low, but reported cases vary by definition, follow-up time, and ICL design. Glaucoma monitoring should begin immediately after surgery and maintained in the long term.

When counselling patients, it is reasonable to insist on annual life-long monitoring of IOP, vault, endothelial cell disease, lens status, and retina, as well as discussing the basic monofocal lens for standard PIOLs and stressing that presbyopic optics are newer, with limited long-term data.

“At the moment, only a few presbyopic PIOL series have a robust follow-up beyond two years, with most evidence gathered in more than five years coming from non-presbyopic versions of the same platforms,” Dr Gundersen concluded.

Dr Gundersen presented during the 2026 ESCRS Winter Meeting in Helsinki.

Kjell Gunnar Gundersen MD, PhD is a practising ophthalmologist at the iFocus Eye Clinic in Haugesund & Stavanger, Norway. KGg@ifocus.no

1. Reinstein DZ, MacGregor C, Archer TJ, Gupta R, Potter JG. Curr Opin Ophthalmol, 2024 Mar 1; 35(2): 138–146. doi:10.1097/ ICU.0000000000001018. Epub 2023 Dec 6. PMID: 38059758.

2. Xu W, Song Z, Huang Y, Tao Y, Wang J, Wang L, Li Z. Front Med (Lausanne). 2020 Dec 15; 7: 582633. doi:10.3389/ fmed.2020.582633. PMID: 33425935; PMCID: PMC7793859.

3. Subudhi P, Patro S, Agarwal P, Khan Z, Subudhi BNR, Mekap C, Padhi A. Clin Ophthalmol, 2020 Oct 30; 14: 3681–3689. doi:10.2147/OPTH.S270690. PMID: 33162752; PMCID: PMC7642691.