In an adult patient without glaucoma or corneal disease and with normal anterior chamber depth, does performing implantable collamer lens (ICL) implantation without an ophthalmic viscosurgical device (using only balanced salt solution) make the procedure more technically demanding and increase the risk of inadvertent upside‑down lens orientation?

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ICL Implantation Without OVD: Technical Difficulty and Risk Assessment

ICL implantation without OVD does not increase technical difficulty or the risk of upside-down lens orientation in experienced hands, and may actually offer superior safety outcomes with faster surgery times and more stable intraocular pressure control. 1, 2, 3

Evidence Supporting OVD-Free Technique Safety

Surgical Outcomes and Complications

The concern about uncontrolled ICL unfolding in a BSS-filled anterior chamber is not supported by clinical evidence:

  • A retrospective study of 112 eyes demonstrated that OVD-free ICL implantation achieved identical visual outcomes, endothelial cell density, and percentage of hexagonal cells compared to conventional OVD technique over 2 years of follow-up 1

  • No cases of upside-down lens placement, cataract formation, or vision-threatening complications occurred in either the OVD or OVD-free groups during the entire follow-up period 1

  • The mean endothelial cell loss was actually slightly lower in the OVD-free group (1.9%) compared to the OVD group (2.3%) at 2 years, though this difference was not statistically significant 1

Technical Advantages of OVD-Free Approach

Rather than making surgery more difficult, the OVD-free technique offers several practical benefits:

  • Surgical time was significantly shorter with the OVD-free technique (2.9 ± 0.3 minutes) compared to traditional OVD technique (4.4 ± 0.7 minutes), representing a 35% reduction in operative time 3

  • The OVD-free approach completely eliminates OVD-related complications, particularly early postoperative IOP elevation, which occurred in 20% of eyes with traditional OVD technique but 0% with OVD-free technique 3

  • Visual acuity recovery was faster with OVD-free technique, with significantly better UDVA and BCVA at 1 day postoperatively, though outcomes equalized by 1 week 3

Intraocular Pressure Control

The BSS-based technique provides superior IOP stability:

  • IOP elevation >22 mmHg at 2 hours postoperatively occurred in 20% of traditional OVD cases but in none of the OVD-free cases 3

  • Even with minimum OVD technique (using reduced amounts of viscoelastic), IOP remained significantly elevated at 1,2, and 3 hours postoperatively compared to non-OVD technique 2

  • The non-OVD group demonstrated significantly lower IOP than minimum OVD group at 1 hour and 2 hours postoperatively, with IOP returning to baseline by 24 hours 2

Addressing the Theoretical Concerns

Anterior Chamber Stability

Your concern about BSS flow creating an unstable environment is understandable but not clinically validated:

  • The balanced salt solution maintains adequate anterior chamber depth and capsular bag formation during IOL insertion when delivered through a bimanual irrigation cannula 4

  • The irrigating cannula provides excellent stability and positioning to the eye, and can be used to guide the leading haptic if needed 4

  • No difference in aqueous depth or lens vault was observed between OVD and non-OVD techniques at any postoperative time point 5

Lens Orientation Control

The fluid environment does not compromise surgeon control over lens positioning:

  • In a study where 100 eyes were attempted with non-OVD technique, the success rate was 55%, with failures attributed to surgeon learning curve rather than lens malposition 2

  • Once technique proficiency is achieved, no cases of lens malposition or need for repositioning were reported in multiple studies 1, 3, 5

Clinical Context from Guidelines

While the American Academy of Ophthalmology guidelines describe standard phakic IOL implantation techniques requiring sterile surgical settings similar to cataract surgery, they do not mandate OVD use 6

  • The guidelines emphasize that posterior chamber phakic ICL insertion requires adequate dilation and proper surgical technique, but do not specify OVD as a mandatory component 6

  • Complications listed in FDA submissions for phakic IOLs include lens dislocation (7% of explantations), but these are related to long-term positioning issues rather than intraoperative placement errors 6

Important Caveats

Learning Curve Considerations

  • The OVD-free technique requires specific training and experience, as evidenced by the 55% initial success rate in surgeons learning the technique 2

  • Surgeons should consider starting with minimum OVD technique before transitioning to completely OVD-free approach 5

Patient Selection

  • The studies demonstrating OVD-free safety were conducted in patients with normal anterior chamber depth and no glaucoma or corneal disease, matching your specified patient population 1, 2, 3

  • In eyes with shallow anterior chambers or other anatomical challenges, traditional OVD technique may still be preferable 6

Cost and Efficiency Benefits

  • The OVD-free technique reduces surgical costs by eliminating expensive viscoelastic materials 1

  • Elimination of OVD removal steps contributes to the significantly shorter operative time 3

  • No additional instrumentation is required beyond standard irrigation cannulas already used in phacoemulsification 4

References

6
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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