Which viscoelastic is best for implantable collamer lens (ICL) implantation?

Viscoelastic Selection for ICL Implantation

The best approach for ICL implantation is to avoid using viscoelastic agents entirely (OVD-free technique), as this method reduces postoperative intraocular pressure spikes, shortens operative time, and maintains equivalent safety outcomes compared to traditional viscoelastic use.

Primary Recommendation: OVD-Free Technique

The evidence strongly supports eliminating ophthalmic viscosurgical devices (OVDs) during ICL implantation:

• The OVD-free technique completely eliminates viscoelastic-related complications without causing additional adverse events, making it the safer choice 1
• Success rates for pure OVD-free procedures reach 94.5%, with most eyes (54.7%) achieving proper lens positioning on the first attempt without any adjustments 2
• Operative time is significantly shorter with OVD-free methods compared to standard viscoelastic techniques 3, 1, 4

Key Safety Advantages

Intraocular Pressure Control

• IOP elevation at 2 hours postoperatively is significantly lower with OVD-free techniques compared to standard viscoelastic use 3, 1
• The OVD-free group shows statistically lower IOP at 1 hour and 2 hours postoperatively, with IOP returning to baseline by 24 hours 2, 1
• Traditional viscoelastic techniques cause significant IOP spikes at 1,2, and 3 hours postoperatively 1

Corneal Safety

• No significant difference in endothelial cell density (ECD) loss between OVD-free and standard techniques at any follow-up interval, including 2-year data showing 1.9% loss with OVD-free versus 2.3% with OVD 4
• Temporal corneal densitometry is significantly lower (better) with OVD-free technique at 1 day postoperatively 1
• ECD remains stable with no statistically significant changes from baseline through 6 months 2

Visual Quality Outcomes

• Ring-shaped dysphotopsia occurs in only 15.15% of OVD-free cases versus 40% with standard viscoelastic, with both severity and annoyance significantly reduced 3
• Visual acuity, refractive outcomes, and safety indices are equivalent between techniques 3, 2, 4

Alternative: Minimal Viscoelastic Technique

If you choose to use viscoelastic (when OVD-free technique is not feasible due to surgical complexity or surgeon preference):

• One-step viscoelastic technique represents the best compromise, showing safety and efficacy with minimal corneal disturbance 5
• This approach causes temporary corneal densitometry increases at 1 day that resolve to baseline by 1 week and continue improving through 3 months 5
• IOP decreases from baseline (16.12 mmHg preoperatively to 14.50 mmHg at 3 months) rather than spiking postoperatively 5

Critical Surgical Considerations

Common pitfalls to avoid:

• Inadequate pupil dilation limits intraocular space for lens manipulation and increases haptic adhesion risk 6
• Forceful separation of stuck haptics causes endothelial cell loss or iris trauma 6
• Surgeon experience directly correlates with reduced vault-related complications and cataract formation (1-2.3% incidence) 6

Implementation Algorithm

1. First choice: Attempt OVD-free technique using balanced salt solution for lens loading and anterior chamber maintenance 4
2. If unsuccessful: Convert to minimal one-step viscoelastic technique rather than traditional multi-step OVD use 5
3. Monitor closely: Check IOP at 1,2, and 3 hours postoperatively, especially if viscoelastic was used 1

The OVD-free approach offers cost reduction, increased efficiency, and elimination of viscoelastic-related complications while maintaining equivalent safety profiles across all measured parameters 4.