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Digital Supplement | Sponsored by STAAR Surgical

Perfect Your Surgical Technique With These Intraoperative Pearls

The procedure is simple and quick, and the lens is removable by a doctor if needed.

It’s incredibly rewarding to have a patient tell you after surgery that the vision you gave them is the best vision they’ve ever had. In my experience, this reaction istypical of EVO ICL lens (EVO) patients. I’m used tohearing them express that their vision after surgery exceeds theirexpectations. Now that EVO is approved in the United States and surgery is a moreefficient process, their overallexperience is better as well. Patients nolonger need to come in approximately 2 weeks before theprocedure for a laser peripheraliridotomy, meaning there is no morewaiting forexcellent results. Patient feedback isexcellent because the procedure is quick, and postsurgicalcomfort is high.

I was the first surgeon in Colorado to implant EVO. I truly believe in EVO because of the lens material and extensive data.1,2 I like that it is now a single procedure because there is no longer the need to create a hole in the iris to facilitate aqueous flow. Explantation is extremely rare, but patients like knowing that the lens is removable by a doctor if needed. Sharing the simplicity of the surgical approach with them has led to higher adoption rates in our practice and to more word-of-mouth referrals.

EVO is a great choice for vision correction for a wide range of patients, including those with moderate to high myopia (-3.00 to -20.00 D), thin corneas, or concerns about dry eye syndrome. Most of the patients I see for consultations were referred by one of our practice’s refractive surgery optometry specialists. By the time they are seen by me, they have general knowledge of the EVO procedure and other refractive surgery techniques. They know surgery, in my hands, takes about 10 minutes per eye and is painless.They also know that postoperative recovery is rapid and patients recover quickly postsurgery.3,4 During the preoperative examination, I then use very high–frequency ultrasound biomicroscopy to measure the eye accurately so that I know exactly what size EVO is appropriate for the patient. (Editor’s note: For more on sizing, see “Mastering the Preoperative Exam,” pg 3.) There is no guesswork.

It’s also important to let patients know what to expect after surgery. I tell them that they might notice a very short-lasting circle of light centrally when their pupils are dilated but that it will typically clear within the first night to 1 week postsurgery.

Pearls for surgical technique

The opening in the middle of EVO is a game-changer for many reasons. In addition to eliminating the need for a preoperative peripheral iridotomy, which removes the burden placed on patients to report for a supplementary procedure a couple weeks before surgery, it also simplifies the surgical procedure. Here I share three intraoperative pearls and one postoperative pearl.

  • Pearl No. 1. Load EVO into the IOL injector as close to the time of implantation as possible. I started using a Lioli injector (AST Products) recently. This disposable, single-use injector makes loading a lot easier, especially for clinicians who are just starting with the EVO procedure.
  • Pearl No. 2. strong> Before EVO, it could be hard to determine when all the OVD was removed from behind the lens. With EVO, however, you have a visible cue: You can see the moment it is all gone because a flow of balanced salt solution travels through the central hole. In my personal experience, when I don’t see that sign, I add more balanced salt solution to the eye. It is important to not irrigate through the central hole.
  • Pearl No. 3. The first 24 hours after surgery is crucial to confirm that the lens was properly sized for the patient’s eye. I like to therefore follow-up with EVO patients personally. All patients have my personal cell phone number, and we text back and forth, which helps to build their trust in me.


EVO surgery is straightforward, but incorporating these simple yet effective pearls can help enhance your technique and support a positive patient experience.

1. Packer M. The EVO ICL for moderate myopia: results from the US FDA clinical trial. Clin Ophthalmol. 2022;16:3981-3991.

2. Packer M. The Implantable Collamer Lens with a central port: review of the literature. Clin Ophthalmol. 2018;12:2427-2438.

3. Kohnen T. Phakic intraocular lenses: Where are we now? J Cataract Refract Surg. 2018;44(2):121-123.

4. Wei R, Li M, Zhang H, Aruma A, Miao H, Wang X, et al. Comparison of objective and subjective visual quality early after implantable collamer lens V4c (ICL V4c) and small incision lenticule extraction (SMILE) for high myopia correction. Acta Ophthalmol. 2020;98(8):e943-e950.

Eva Kim, MD
  • Medical Director, ICON Eyecare, Denver
  • eva.kim@iconeyecare.com"
  • Financial disclosure: Consultant
    (Alcon, ArcScan, STAAR Surgical)