如何選擇中央孔型ICL的大小

專家簡介

Kimiya Shimizu

日本山王醫院眼科中心主任，1976年在日本北里大學醫學院獲得MD學位，1984年在東京大學獲得PhD學位。從1985年起在武藏野紅十字醫院擔任主任，1998-2016年在北里大學醫學院任教授和主席。擅長白內障和屈光手術。

我首次植入ICL是在1997年，同年我開展了LASIK手術，而開展SMILE手術是在2010年。由於ICL植入術後的視覺效果優於LASIK手術及SMILE手術，因此我在2008年停止了LASIK手術，又在2015年因為併發症持續上升停止了SMILE手術。

對於ICL植入術有三個問題尚待解決。首先，需要解決周邊虹膜切除術（PI）；第二點：解決遲發性白內障的問題；以及第三點：選擇ICL大小的問題。為克服前兩個問題，我們通過光學研究和動物實驗開發了中央孔型ICL（KS-AquaPORT）

2007年，我在世界範圍內首次植入了5例中央孔型ICL（KS-AP）。我們做了對照研究，一隻眼植入中央孔型ICL，另一隻眼植入傳統ICL。2016年，我在Medicine雜誌上發表了一篇關於傳統V4 ICL和中央孔型ICL的5年對照研究。總共有來自32位患者的64隻眼，最後在白內障發展上有差異：一位植入傳統ICL的患者發展為白內障，而植入中央孔型ICL的則沒有出現這種情況。

2007~2015年，共有128位患者的292隻眼接受了中央孔型ICL植入術，他們獲得了良好的視覺表現。至於說併發症，我曾以為白內障會暴發出現，但到目前為止還未發現。而且，從我開始使用中央孔型ICL，其他併發症也未出現。

目前，尚待解決的問題是如何選擇ICL的大小？拱頂過低會導致晶體旋轉和白內障；而過高則會導致青光眼，瞳孔受限以及睫狀疼痛。

對於ICL大小的選擇，我們採用晶體製造商推薦的在線計算系統——「STAAR」。晶體的尺寸由「前房深度」和「WTW」（WTW是指角膜水平直徑White to White）決定。對於WTW的測量，我們採用眼前節分析設備（例如：Orbscan和卡尺）直接測量。理想的拱頂高度是0.5~1.5CT。然而，在實際的臨床應用中，我們觀察到：即使我們採用傳統的計算系統，也有病例的拱頂低於0.5CT或高於1.5CT。

為防止這些病例，我們必須測量STS（Sulcus to Sulcus）距離。由於STS的測量方法尚未建立，我們用WTW代替。但問題是STS真的同WTW相關嗎？

當我們通過測量WTW來選擇ICL大小的時候，僅有44.4%的患者結果理想，許多患者並沒有在理想的拱頂範圍，大多數拱頂位置略高，平均拱頂高度為1.5CT。

我們經常看到報道稱「STS和WTW的相關性很弱」或「兩者沒有相關性」。但畢竟，測量STS是獲得合適ICL尺寸理想方法。我們通過對日本北里大學描述睫狀體的掃頻OCT研究發現：STS和WTW沒有相關性，但ATA（Angle to Angle）和WTW具有相關性。

正因為我們發現這種相關性，我們通過前節OCT測量ATA來決定選擇ICL的大小。這種檢查，收縮瞳孔很重要，因為瞳孔收縮狀態房角更加清晰。我們計算理想ICL大小為ATA距離+0.7mm。採用測量ATA來選擇ICL大小，有90.1%的患者拱頂結果在理想範圍。平均拱頂高度在1CT而且SD較小。

總而言之，中央孔型ICL晶體有較好的視覺表現，不需要行虹膜周切，無併發症。我們通過測量ATA來獲取理想拱頂高度。現在，在2017年，ICL所涉及的三大問題都得到了解決，我目前所有的屈光手術都選擇中央孔型ICL植入術。

How to select the size of ICL KS-AquaPORT

I first implanted ICL in 1997. I started LASIK in 1997 at the same time with ICL and then started SMILE in 2010. The visual performance of ICL was superior to that of LASIK and SMILE, so I stopped LASIK in 2008 and stopped SMILE in 2015 because complications continued to arise.

There are three problems of ICL remain unsolved so far; Firstly need of Peripheral Iridotomy (PI), secondly late onset cataract, and thirdly the selection of ICL size. To overcome these first two concerns, I developed Hole ICL (KS-AquaPORT) through optical study and animal study.

In 2007, I implanted five cases of KS-AquaPORT (KS-AP) for the first time in the world. We did comparative study, one eye with KS-AP and the other eye with conventional ICL. In 2016, I reported 5 years comparative study of conventional V4 ICL and KS-AP in the journal 「Medicine」. For the results of 64 eyes of 32, the difference is cataract. One patient developed cataract in the conventional ICL but no cataract was developed in KS-AP.

For all the cases of KS-AP, total of 292 eyes of 128 patients from 2007 to 2015, the visual performance is excellent. As for complication, outbreak of cataract had been deeply concerned, but I haven』t seen any so far. Furthermore, I』ve never seen any complications since I started to use this lens, KS-AP.

Now, the last frontier is how to select ICL size. Low vault leads to rotation and cataract? High vault leads to glaucoma, limitation pupil movement, and ciliary pain?

For the selection of ICL size, we use online calculation system recommended by the lens manufacturer, 「STAAR」. The lens size is decided by entering 「Anterior Chamber Depth」 and 「WTW」 which is corneal diameter for the eye to be operated. For the measurement of WTW, we use direct measurement by anterior ocular analyzing device such as Orbscan and caliper. The ideal vault we wet is from 0.5 CT to 1.5 CT. However, in the actual clinical settings, we observe cases that shows lower than 0.5CT or higher than 2.0CT, even we use conventional calculation system.

To prevent these cases, it is necessary to measure STS (Sulcus to Sulcus). Since measurement method of STS has not yet been established, we use WTW instead. But the question is STS really correlated to WTW?

When we select ICL size by WTW, only 44.4% cases resulted in ideal vault. Many cases were out of it. There were a number of high vault, the mean vault was 1.5 CT.

As we often see reports stating that 「correlation between STS and WTW is weak」 or 「has no correlation」, it is ideal to directly measure STS to obtain appropriate ICL size after all. We studied the correlation between ATA and STS by swept source OCT of Kitasato University which was able to describe ciliary body. We found that STS and WTW has no correlation, but ATA and WTW has a correlation.

Since we found this correlation, we select ICL size by ATA using anterior OCT. In this examination, pupil constriction is important because the angle is clearer when pupil is constricted. We calculated the ideal ICL size as ATA+ 0.7mm. Using ATA to select ICL size, 90.1% cases resulted in ideal vault. The mean vault was 1 CT and they had small SD.

In conclusion, KS-AP has better visual performance, no PI, and no complication. We got ideal vault by ATA measurement. Now, in 2017, three concerns of ICL are solved. All refractive surgery I perform is ICL, KS-AquaPORT.

（來源：《國際眼科時訊》編輯部）

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