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Pseudophakic mirror telescopic implant can benefit AMD patients
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Low vision, which does not improve with regular spectacle correction, is often seen in older patients with age-related macular degeneration. Improving visual acuity with a telescopic lens has been tried recently. The mirror telescopic IOL magnifies the image only on the central retina. It is designed as a secondary implant for pseudophakic eyes but is used also for primary phakic implantation when a regular IOL is implanted first and the telescopic part is added on during the same procedure.
The fact that AMD patients can be helped by magnifying the image has been well known for decades, but still, the majority of patients cannot adjust to external telescopes and basically do not reach their maximum visual potential. The concept of implanting an entire telescope inside a human eye was first suggested by Isaac Lipshitz, MD, when he developed the Implantable Miniature Telescope (IMT, VisionCare) in the 1990s The first mirror telescopic implant was the Lipshitz Macular Implant (LMI, OptoLight), and a newer secondary intraocular telescopic implant, the OriLens (OptoLight), recently received the CE mark. We had performed the first LMI surgery and were honored to be asked by Dr. Lipshitz to perform the first OriLens surgery in the world. My special guest in this column is Dr. Lipshitz, who has devised the pseudophakic telescopic IOL for patients with low vision.
Amar Agarwal, MS, FRCS, FRCOphth
OSN Complications Consult Editor
There are several new treatments for wet AMD, such as various intraocular injections and radiation. But we have to keep in mind that these treatments are intended to help only a part of the relatively small group of wet AMD patients, which constitutes only 10% to 15% of AMD patients. The 85% to 90% of AMD patients who have the dry type have no medical treatment at all, other than taking vitamins as a preventive measure. Furthermore, wet AMD patients who are subject to those various treatments may have improved vision, but even if the treatment is successful, their retinas become similar to the retinas of dry AMD patients. They are not cured of the disease, which may progress, and in the majority of cases, they still do not see very well and need optical implants such as the mirror telescope.
OriLens
The OriLens (Figures 1 to 3) looks like a regular PMMA IOL. Its optic is 5 mm on 6 mm in diameter, with a loop diameter of 13.5 mm, and it contains loops that have a similar configuration as a regular IOL. The only significant difference compared with a regular secondary IOL is its central thickness; the OriLens is slightly thicker. The central thickness of the mirror telescope is only 1.25 mm. It is designed so that its loops are positioned in the sulcus. The amount of magnification is approximately 2.5× (250%), depending on the parameters of the eye. The implant contains miniature mirrors that are embedded inside it. These mirrors are configured, designed and accurately positioned in order to create a precise telescopic effect on the macular area. When the OriLens is implanted inside the eye, the central image, which is normally directed toward the macula, is blocked when reaching the implant. It first meets the posterior ring-shaped mirror, and then it is reflected to another central mirror, and finally it is projected as a magnified image toward the macular area. The OriLens is CE certified and currently distributed to doctors and medical centers in Europe and all other non-FDA regulated countries.
Figure 1. The OriLens has been coated with viscoelastic and inserted through the clear corneal incision, which has been extended just enough to allow implantation.
Images: Agarwal A, Lipshitz I
Figure 2. First postoperative day photograph showing the OriLens well centered with a clear cornea and a quiet eye.
Figure 3. Anterior segment optical coherence tomography showing the OriLens in the sulcus above the bag-implanted IOL.
Implantation
Prof. Agarwal has been an investigator in the development of the mirror telescopic technology and was the first surgeon worldwide to perform the mirror telescopic implantation on human eyes. He said that the surgery was relatively easy but was not a small-incision surgery. The implantation can be done under any type of anesthesia, and any type or location of incision can be used. The size of the incision was 5.5 mm, and a peripheral iridectomy should be done either before or during the implantation. The loops were positioned in the sulcus using viscoelastic, and the incision was sutured. Prof. Agarwal and Marie-José Tassignon, MD, PhD, of Antwerp, Belgium, commented that the postop treatment was similar to a regular cataract, but the patient has to be followed up more frequently on the first 10 days to avoid any synechia. Medication is the same as in normal cataract, but pupil-dilating agents should be used as well. The main concern should be the positioning of the implant compared with the pupil. Postop refraction should be done manually — no autorefractors can be used — after the sutures are removed.
Results
The Table shows the visual results of the OriLens implantation. There was an improvement in vision between 2.5 to 4 ETDRS lines in these eyes.
Complications are not frequent, but as in any surgery, complications with OriLens implantation may occur. The main concern is the positioning of the OriLens in relation to the pupil. At the end of the surgery, it is vital that the central mirror is positioned in the center of the pupil and the annular (posterior) mirror surface is fully exposed, pointing outside toward the cornea. In order to verify this, the pupil should be constricted, and the posterior surface of the central mirror should clearly be seen centrally through the pupil. Any postop inflammation should be treated promptly so that no synechia is formed and no epithelial edema is noted.
Advantages
The implanted telescope moves naturally with eye movements, and there are no relative movements between the eye and the telescope, as with the external telescope. There is no need for head movement, and the patient’s eye screens the reading material or the object in a normal way. Implantable optical telescopes for AMD are complementary to other available treatments.
The OriLens can be used for any type of AMD as long as the eye improves its vision when the patients are tested preoperatively with a 2.5× magnification external telescope. The use of the OriLens should not preclude the use of other retinal, medical or surgical treatment.
The patient selection criteria are bilateral AMD of any type and at any stage; preop visual acuity between 20/60 to 20/800; no eye condition other then cataract, AMD or pseudophakia; and improvement of visual acuity by three ETDRS lines when tested with a 2.5× magnification external telescope. The patient should be easy to communicate with, be available for follow-up for 1 year, be motivated to improve his or her vision and understand the risks involved with the procedure.