Risk Factors Associated With Night Vision Disturbances
After Phakic Intraocular Lens Implantation
DONG HUI LIM, IN JEONG LYU, SUNG-HO CHOI, EUI-SANG CHUNG, AND TAE-YOUNG CHUNG

PURPOSE: To investigate the incidence and severity of
night vision disturbances after implantable collamer lens
surgery and to analyze the risk factors.

DESIGN: Retrospective, noncomparative study.

METHODS: Medical charts from 50 eyes of 25 patients
who underwent implantable collamer lens implantation
were retrospectively reviewed. The incidence and severity
of night vision disturbances were evaluated using ques-
tionnaires administered 6 months after surgery. Univar-
iate simple and multiple logistic regression analyses were
used to detect risk factors associated with postoperative
night vision disturbances. Potential risk factors included
in the analysis were keratometric value, anterior chamber
depth, postoperative residual refractive error, higher-
order aberrations, preoperative and postoperative mesopic
pupil size, the difference between preoperative and postop-
erative mesopic pupil size, the difference between mesopic
pupil size and implantable collamer lens optic zone diam-
eter, white-to-white diameter, sulcus-to-sulcus diameter,
and postoperative implantable collamer lens vaulting.
The power, size, optic zone diameter, and toricity of the
implantable collamer lens were also included as variables.

RESULTS: The incidence of night vision disturbances
was 34.0% for halos and 26.0% for glare. Halos were
found to be significantly related to the difference between
mesopic pupil size and implantable collamer lens optic
zone diameter (P [ .013), white-to-white diameter of
the cornea (P [ .028), and implantable collamer lens
optic zone diameter (P [ .030). For glare, toricity of
the implantable collamer lens was revealed as a significant
risk factor (P [ .047).

CONCLUSIONS: Although not severe, the incidence of
night vision disturbances after implantable collamer lens
implantation was not negligible. Possible risk factors for
night vision disturbances include implantable collamer
lens optic zone diameter, the difference between mesopic
pupil size and implantable collamer lens optic zone diam-
eter, and white-to-white diameter of the cornea for
causing halos, and the toricity of the implantable collamer
Accepted for publication Sept 5, 2013.
From the Department of Ophthalmology, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, South Korea
(D.H.L., I.J.L., S.H.C., E.S.C., T.Y.C.); and Happy Eye Clinic,
Gwangju, South Korea (S.H.C.).
Inquiries to Tae-Young Chung, Department of Ophthalmology,
Samsung Medical Center, Sungkyunkwan University School of
Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, South Korea;
e-mail: tychung@skku.edu
0002-9394/$36.00 Ó 2014 BY ELSEVIER INC. ALL
http://dx.doi.org/10.1016/j.ajo.2013.09.004
lens for causing glare. (Am J Ophthalmol 2014;157:
135–141. Ó 2014 by Elsevier Inc. All rights reserved.)
P
HAKIC INTRAOCULAR LENS (IOL) IMPLANTATION IS
a well-known refractive surgery, along with photore-
fractive keratectomy (PRK), laser-assisted subepi-
thelial keratomileusis (LASEK), and laser in situ
keratomileusis (LASIK). Implantable collamer lenses
(Visian ICLs; STAAR Surgical, Nidau, Switzerland) are
sulcus-placed posterior chamber phakic intraocular lenses.
They are particularly important for patients with a thin
cornea or a high level of myopia. These patients are not
ideal candidates for corneal refractive surgery. Implantable
collamer lens implantation has been accepted as a safe and
effective surgical procedure with low risk of chronic ante-
rior chamber inflammation, iris atrophy, and endothelial
cell damage when compared with anterior chamber iris-
fixed phakic intraocular lenses.1–4
Postoperative night vision disturbances are a major
factor in causing decreased visual satisfaction after refrac-
tive surgery. Halos are bright circles that appear to surround
a light source, such as oncoming car headlights. Glare
consists of difficulties seeing in the presence of bright light,
such as car headlights at night. Several studies have been
conducted about night vision disturbances after corneal
refractive surgery.5–10 A few studies reported that
implantable collamer lens implantation is superior to
LASIK in terms of visual outcomes, including visual
quality.11–16 However, no prior reports have focused on
postoperative night vision disturbances after implantable
collamer lens implantation.
Herein, we report the incidence and severity of night
vision disturbances after implantable collamer lens implan-
tation and analyze the risk factors associated with night
vision disturbances.
PATIENTS AND METHODS
THE MEDICAL CHARTS FOR 25 INDIVIDUALS (50 EYES) WHO
underwent implantable collamer lens implantation (ICL
V4 model) at Samsung Medical Center between October
2010 and December 2011 were retrospectively reviewed.
The exclusion criteria included history of previous ocular
surgery, anterior segment abnormality, and additional
corneal ablation surgeries to correct excessive astigmatism
RIGHTS RESERVED. 135
or residual myopia, all of which could influence the pres-
ence of night vision disturbances. All patients included
in the study were aged 18 years or older and in good general
health. Institutional review board approval was obtained
from the Samsung Medical Center Institutional Review
Board, and all procedures adhered to the Declaration of
Helsinki.
Comprehensive ocular examinations were performed
before and after surgery, including uncorrected visual
acuity (UCVA) and best-corrected visual acuity (BCVA)
using a Snellen chart. Examinations also included manifest
and cycloplegic refraction, slit-lamp biomicroscopy,
noncontract tonometry, fundus examination, noncontact
specular microscopy (SP-8000; Konan Medical, Inc, Nish-
inomiya, Hyogo, Japan), corneal topography (Orbscan IIz;
Bausch & Lomb, Rochester, New York, USA), WaveScan
imaging (Abbott Medical Optics, Santa Ana, California,
USA), and ultrasound biomicroscopy (UBM) 835
(Carl Zeiss Meditec, Dublin, California, USA). UBM was
performed to measure the horizontal sulcus-to-sulcus
(STS) diameter preoperatively and to check implantable
collamer lens vaulting postoperatively. UBM with
a 50-MHz transducer and a fluid-filled eye cup was conduct-
ed under standard room lighting after instillation of propar-
acaine (Alcaine; Alcon, Fort Worth, Texas, USA). Pupil
sizes were obtained preoperatively and postoperatively by
WaveScan imaging under mesopic conditions with an illu-
mination of 50 lux. Independent technicians performed the
UBM, WaveScan, and Orbscan imaging.
Implantable collamer lens power calculations were
performed with formulas provided by STAAR Surgical
Co, based on keratometry, corneal thickness, anterior
chamber depth with Orbscan, and cycloplegic refraction.
We determined the implanted implantable collamer lens
size based on the horizontal STS diameter acquired by
UBM, which was described in our previous study.17
Two peripheral iridotomies were performed using an
argon and neodymium–yttrium-aluminum-garnet laser
2 weeks before surgery to prevent postoperative pupillary
block. The iridotomies were located superiorly approxi-
mately 90 degrees apart. They were covered by the upper
eyelid to avoid transillumination defects and to prevent
light scattering.
Operations were performed by 2 skilled surgeons (E.S.C.
and T.Y.C.) at Samsung Medical Center. Under topical
anesthesia, a 3.0-mm temporal clear corneal incision was
made with a diamond knife. Sodium hyaluronate 1.0%
(Hyal 2000; LG Life Sciences, Seoul, South Korea) was
injected into the anterior chamber, and the implantable
collamer lens was inserted through the temporal incision
with an injector (MicroSTAAR injector; STAAR Surgical
Co). Toric implantable collamer lenses were implanted in
eyes with a preoperative cylindrical power greater than
1.00 diopters (D) at the spectacle plane. If eyes had 0.50-
1.00 D of astigmatism superiorly, we implanted a spherical
implantable collamer lens and adopted a superior clear
136 AMERICAN JOURNAL OF OPHTHALMOLOGY
TABLE 1. Demographics of Patients Who Underwent
Implantable Collamer Lens Implantation
Parameter Mean 6 SD Range
Age (y) 31.4 6 8.3 19-50
Sex (% female) 64.0 -
Laterality (% right eye) 50.0 -
ICL power (diopters) 14.4 6 6.4 7.0 to 24.0
ICL size (mm) 12.1 6 0.4 11.5-13.0
ICL vault (mm) 619.0 6 215.4 252.5-1152.0
Toric ICL (%) 38 -
ICL ¼ implantable collamer lens.
corneal incision in order to reduce astigmatism. Foot plates
were tucked under the iris and on the ciliary sulcus using
a modified intraocular spatula. Any remaining viscoelastic
was irrigated out of the anterior chamber with a balanced
salt solution. The corneal wound was self-sealed without
any suturing. All of the surgeries were uneventful. Postop-
erative medication included topical antibiotics (Cravit;
Santen, Japan) and steroids (Fluorometholone; Osaka,
Santen) taken 4 times a day for up to 1 month.
The incidence and severity of night vision disturbances
were evaluated using a questionnaire administered
6 months after surgery. Implantable collamer lens recipi-
ents were asked to evaluate their current night vision
disturbances (glare and halo) using a 5-point scale
(0 ¼ no symptoms, 1 ¼ minimal, 2 ¼ mild, 3 ¼ moderate,
4 ¼ severe), which was adopted from a prior study.18 At the
time of questionnaire administration, patients underwent
postoperative ophthalmologic examinations as described
above.
The possible risk factors for night vision disturbances
that were evaluated included keratometric value, anterior
chamber depth, postoperative residual refractive error,
higher-order aberrations, preoperative and postoperative
mesopic pupil size, the difference between preoperative
and postoperative mesopic pupil size, the difference
between mesopic pupil size and implantable collamer lens
optic zone diameter, white-to-white (WTW) diameter,
STS diameter, and postoperative implantable collamer
lens vaulting. The power, size, optic zone diameter, and
toricity of the implantable collamer lens were also assessed
as possible risk factors.
Statistical analyses were performed using PASW 18.0
software (SPSS Inc, Chicago, Illinois, USA). A paired
t test was used for the statistical comparison of preoperative
and postoperative manifest refraction, aberrations, and
pupil size. Univariate simple logistic regression analysis
was used to examine the association between night vision
disturbances and the aforementioned variables. Factors
with a P value less than .1 were considered to be associated
with night vision disturbances and included as candi-
dates for multivariate analysis. Stepwise multiple logistic
JANUARY 2014
 TABLE 2. Preoperative and Postoperative Outcomes in Eyes That Underwent Implantable Collamer Lens Implantation
Parameters Preoperative
Spherical equivalent (diopters) 11.05 6 4.56
Aberrations (mm)
Total RMS 9.63 6 4.70
Higher-order RMS 0.38 6 0.16
Coma 0.23 6 0.16
Trefoil 0.16 6 0.10
Spherical aberration 0.06 6 0.17
Mesopic pupil size (mm) 5.97 6 0.93
RMS ¼ root mean square.
regression analysis was performed to evaluate meaningful
risk factors affecting postoperative night vision distur-
bances. P values less than .05 were considered statistically
significant.
RESULTS
PATIENT BASELINE CHARACTERISTICS ARE LISTED IN
Table 1. The mean patient age was 31.4 6 8.3 years (range:
19-50 years). Nine patients (36.0%) were men and 16
(64.0%) were women. The mean implanted implantable
collamer lens power and size was -14.4 6 6.4 D
(range: 7.0 to 24.0 D) and 12.1 6 0.4 mm (range:
11.5-13.0 mm), respectively. The mean implantable
collamer lens vaulting was 619.0 6 215.4 mm (range:
252.5-1152.0 mm). A spherical equivalent (SE) of
60.5 D was noted in 94% (47/50) of eyes and 74% (37/
50) of eyes achieved UCVA > _20/20. The mean SE
improved significantly from 11.05 6 4.56 D to 0.25
6 0.66 D postoperatively (P ¼ .00). Among higher-order
aberrations, trefoil increased significantly after surgery
(P ¼ <.01) (Table 2).
Pupil size was evaluated under mesopic conditions
(50 lux) using WaveScan. The mean preoperative pupil
size was 5.97 6 0.93 mm (range: 3.25-7.0 mm), and the
mean postoperative pupil size was 5.69 6 0.68 mm (range:
3.0-6.75 mm). Pupil size decreased in 64% of eyes (32/50),
increased in 20% (10/50), and was unchanged in 16%
(8/50). Overall, mesopic pupil size was significantly
decreased after surgery (P ¼ .01) (Table 2).
Night vision disturbances were assessed by a question-
naire for each eye. Of all subjects, 34% (17/50) reported
halos and 26% (13/50) reported glare. Of all questionnaire
responses (2 per patient), 6% (3/50) reported more than
a moderate degree of halos that caused difficulties in their
lives.
We analyzed multiple preoperative and postoperative
variables to determine if any were associated with postop-
erative night vision disturbances using univariate simple
VOL. 157, NO. 1 HALOS AND GLARE AFTER PHAKIC INTRAOCULAR LENS IMPLANTATION
Mean 6 SD
Postoperative P Value (Paired t Test)
0.25 6 0.66 <.01
1.42 6 0.71 <.01
0.43 6 0.17 .11
0.26 6 0.23 .44
0.31 6 0.24 <.01
0.00 6 0.25 .15
5.69 6 0.68 .01
logistic regression. The possible determinants with a signif-
icance value P < .1 in univariate analysis were entered in
the multiple logistic regression analysis. WTW and STS
diameter, residual cylindrical power, postoperative spher-
ical aberrations, size and optic zone diameter of implant-
able collamer lens, the difference between mesopic pupil
size and implantable collamer lens optic zone diameter,
and postoperative implantable collamer lens vaulting
were summarized as potential risk factors for halos with P
values less than .1 (Table 3). Multicollinearity was found
among implantable collamer lens size and WTW and
STS diameter. Implantable collamer lens size and STS
diameter were removed in the multivariable analysis.
Table 4 shows the results of multiple logistic regression
analysis. Halos were found to be significantly related to
the difference between mesopic pupil size and implantable
collamer lens optic zone diameter (P ¼ .013), as well as
WTW (P ¼ .028) and implantable collamer lens optic
zone diameter (P ¼ .030).
In the same way, postoperative mesopic pupil size, a toric
implantable collamer lens, the amount of cylindrical power
of the toric implantable collamer lens, the difference
between mesopic pupil size and implantable collamer lens
optic zone diameter, and postoperative implantable
collamer lens vaulting were selected as possible risk factors
associated with glare (Table 3). For glare, the toricity of the
implantable collamer lens was revealed as a significant risk
factor (P ¼ .047) through multiple logistic regression
(Table 5).
DISCUSSION
THE STUDIES ON PHAKIC IOLS WERE MOSTLY FOCUSED ON
objective outcomes, including safety and refractive accu-
racy. Various studies have demonstrated the excellent
refractive accuracy, preservation of accommodation, and
reversibility of implantable collamer lenses without alter-
ation of the normal corneal aspheric contour.19–22 The
current issue with regard to implantable collamer lenses
137
 associates,23 WFG LASIK showed significantly better night
TABLE 3. Potential Risk Factors for Postoperative Night visual performance compared to conventional LASIK.
Vision Disturbances After Implantable Collamer Lens Night vision symptoms have been reported to be more
Implantationa
common with higher corrections after LASIK, because
Halos Glare
LASIK requires more laser ablation in highly myopic
eyes. Therefore, the shape of the cornea becomes more
Exp(B) Sig Exp(B) Sig
oblate, resulting in more surgically induced higher-order
Age 1.054 .156 0.985 .705 aberrations. WFG LASIK, which was developed to rectify
Keratometric value such disadvantages of conventional LASIK, has been
Flat K 0.906 .614 0.915 .673 reported to reduce the induction of higher-order aberra-
Steep K 0.855 .385 1.088 .670
tions. Implantable collamer lens implantation has an
Mean K 0.868 .470 1.004 .986
advantage over even current-day WFG LASIK in an aspect
Sim K 0.798 .500 1.658 .147
of visual quality, maintaining the prolate shape of the
Anterior chamber depth (mm) 2.680 .278 3.144 .232
Sulcus-to-sulcus diameter (mm) 3.373 .087 0.891 .871
cornea to induce fewer higher-order aberrations regardless
White-to-white diameter (mm) 6.613 .034 0.421 .342 of the amount of myopic correction.
Residual refractive errors (diopters) Ieong and associates24 evaluated patients’ satisfaction by
Spherical 0.819 .695 0.796 .668 using a quality-of-life impact of refractive correction
Cylindrical 0.282 .026 0.428 .113 (QIRC) score. Half of the patients reported worsening of
Spherical equivalent 0.512 .184 0.610 .278 nighttime driving even though their general quality of
Pupil size (mm) life had significantly improved after implantable collamer
Preoperative 1.424 .339 0.807 .518 lens implantation. However, research on visual quality
Postoperative 0.871 .751 0.411 .082
after implantable collamer lens implantation has not
Postoperative – preoperative 2.125 .124 1.609 .336
been carried out as actively as it has been for laser refractive
Preoperative aberrations (mm)
surgery. To our knowledge, this is the first report evaluating
Total RMS 0.957 .504 1.037 .618
Higher-order RMS 0.839 .635 0.876 .681
the incidence and multiple risk factors of night vision
Coma 0.711 .860 4.307 .450 disturbances after implantable collamer lens implantation.
Trefoil 25.873 .313 3.838 .699 In this study, around 30% of patients reported night
Spherical aberration 10.442 .317 0.242 .631 vision disturbances (34% for halos and 26% for glare) after
Postoperative aberrations (mm) implantable collamer lens implantation, including 6.0%
Total RMS 1.258 .587 1.309 .548 who had more than a moderate degree of discomfort.
Higher-order RMS 0.880 .942 0.102 .304 This is not low when compared to the incidence of night
Coma 0.497 .630 0.720 .829 vision disturbances reported from other procedures, which
Trefoil 0.087 .165 2.612 .451
are 11.8%-56.9% for LASIK and 44.1% for Artisan
Spherical aberration 0.003 .098 1.393 .834
lens implantation.6,7,25 This study determined factors
ICL power (diopters) 0.983 .729 0.973 .647
associated with night vision disturbances including halos
ICL size (mm) 13.795 .010 0.955 .958
ICL optic zone diameter (mm) 0.058 .008 0.906 .919
and glare after implantable collamer lens implantation.
Toric ICL 1.778 .346 0.214 .065 These factors included the difference between mesopic
Toricity of the ICL 1.089 .621 0.357 .072 pupil size and implantable collamer lens optic zone
Pupil – ICL optic zone 2.999 .053 0.311 .092 diameter (P ¼ .013), as well as WTW (P ¼ .028) and
diameter (mm) implantable collamer lens optic zone diameter (P ¼ .030)
Postoperative ICL vaulting (mm) 1.003 .043 0.997 .087 for halos, and the toricity of the implantable collamer
lens (P ¼ .047) for glare.
Exp(B) ¼ odds; ICL ¼ implantable collamer lens; K ¼ kerato-
Previous reports on laser refractive surgery revealed that
metric value; RMS ¼ root mean square; Sig ¼ significance
night vision disturbances were related to pupil size and
(P value).
a
Univariate simple logistic regression analysis.
scotopic and/or mesopic pupil–optical zone disparity.26–28
When light enters through the eye, it is interrupted by
the pupil– implantable collamer lens optic zone disparity.
has shifted to subjective outcomes such as visual quality This is similar to the ablation zone border in laser
after surgery. Igarashi and associates12 and Kamiya and refractive surgery. If pupil dilation induced by dark
associates13 reported that visual performance after implant- illumination exceeds the implantable collamer lens optic
able collamer lens implantation was superior to wavefront- zone diameter, central and peripheral light rays generate
guided (WFG) LASIK in terms of contrast sensitivity and 2 different images. This creates an out-of-focus image on
higher-order aberrations for high myopia, as well as for the retina, causing night vision disturbances. In our study,
low to moderate myopia. In the previous study comparing the difference between mesopic pupil size and implantable
night visual performance after WFG LASIK and conven- collamer lens optic zone diameter showed a significantly
tional LASIK for moderate myopia by Schallhorn and positive correlation with secondary visual alterations such

138 AMERICAN JOURNAL OF OPHTHALMOLOGY JANUARY 2014

 TABLE 4. Results of Multiple Logistic Regression Analysis for Halos After Implantable Collamer Lens Implantation

B SE Wald Df Sig Exp(B) 95% CI

Res cyl .820 .726 1.275 1 .259 .440 .106 1.828

ICL OZD 4.005 1.846 4.708 1 .030 .018 .000 .679
Post SA 6.853 6.017 1.297 1 .255 .001 .000 139.784
ICL vaulting .001 .002 .195 1 .658 .999 .995 1.003
Pupil_OZD 1.984 .797 6.204 1 .013 7.274 1.526 34.668
WTW 3.689 1.677 4.840 1 .028 40.014 1.496 1070.532
Constant 24.207 16.159 2.244 1 .134 .000

B ¼ log odds; CI ¼ confidence interval; Df ¼ degrees of freedom; Exp(B) ¼ odds; ICL ¼ implantable collamer lens; OZD ¼ optic zone
diameter; Post SA ¼ postoperative spherical aberration; Pupil_OZD ¼ the difference between mesopic pupil size and implantable collamer
lens optic zone diameter; Res cyl ¼ residual cylindrical power; SE ¼ standard error; Sig ¼ significance (P value); Wald ¼ Wald statistic;
WTW ¼ white-to-white diameter.

TABLE 5. Results of Multiple Logistic Regression Analysis for Glare After Implantable Collamer Lens Implantation

B SE Wald Df Sig Exp(B) 95% CI

ICL toricity 1.289 .648 3.954 1 .047 .276 .077 .982

ICL vaulting .005 .002 3.779 1 .052 .995 .991 1.000
Post pupil .032 1.253 .001 1 .980 1.033 .089 12.045
Pupil_OZD .833 1.527 .297 1 .586 .435 .022 8.678
Constant 2.267 1.431 2.512 1 .113 9.653

B ¼ log odds; CI ¼ confidence interval; Df ¼ degrees of freedom; Exp(B) ¼ odds; ICL ¼ implantable collamer lens; ICL toricity ¼ cylindrical
power of toric implantable collamer lens; Post pupil ¼ postoperative mesopic pupil size; Pupil_OZD ¼ the difference between mesopic pupil
size and implantable collamer lens optic zone diameter; SE ¼ standard error; Sig ¼ significance (P value); Wald ¼ Wald statistic.

as halos. As the disparity increased, the risk of halos
increased (odds ratio ¼ 7.274, P ¼ .013).
Pupil size under mesopic conditions of 50 lux was 5.97 6
0.93 mm (range: 3.25-7.0 mm) preoperatively and 5.69 6
0.68 mm (range: 3.0-6.75 mm) postoperatively, which
was a significant decrease (P ¼ .01). According to previous
reports that examined the effects of implantable collamer
lens implantation on pupil reaction, the mean postopera-
tive pupil diameter was smaller than the preoperative diam-
eter.29 Kamiya and associates30 reported that the entrance
diameter of the pupil decreased transiently at 1 day after
implantable collamer lens implantation, which soon
increased to preoperative levels 1 week after implantation
and stabilized thereafter.
The postoperative reduction in pupil size may be bene-
ficial in view of night vision disturbances, since halos
produced by a pupil diameter exceeding the boundaries
of the optical zone are less frequent. On the other
hand, the contact and rubbing between the optic of the
implantable collamer lens and the posterior iris surface
may cause mechanical irritation and play a role in postop-
erative pupil reaction. In this study, postoperative
mesopic pupil size was significantly reduced after surgery.
However, implantable collamer lens vaulting was within
a normal range (619.0 6 215.4 mm) and no abnormal
signs of inflammation in the anterior chamber were
observed.
Secondary visual disturbances can also occur from a small
optic zone. In the field of phakic intraocular lenses, the
Food and Drug Administration cohort of implantable
collamer lenses showed a negative trend between optic
zone diameter and subjective visual symptoms (available
at: www.accessdata.fda.gov/cdrh_docs/pdf3/P030016c.pdf;
accessed February 11, 2010). Even though these data
were not analyzed statistically, they support our results. In
our study, implantable collamer lens optic zone diameter
turned out to be a statistically significant risk factor associ-
ated with halos (odds ratio ¼ 0.018, P ¼ .030). Optic zone
diameter is inversely related to night halos by increasing
the effective optic zone.
While optic zone diameter of implantable collamer lens
affects the development of halos, it is a favorable condition
that the effective optical zone of the implantable collamer
lens at the corneal plane is approximately 1.25 times its
actual optic diameter. Because such visual disturbances
have been attributed to small treatment zones and post-
surgical irregular astigmatism in corneal refractive
surgery,31–33 large optical zone and WFG LASIK was
developed. Therefore, with its position behind the cornea
and close to the nodal point, the effective optical zone of

VOL. 157, NO. 1 HALOS AND GLARE AFTER PHAKIC INTRAOCULAR LENS IMPLANTATION 139
the implantable collamer lens magnified at the corneal
plane may cause less night halos.
Lastly, WTW diameter showed a strong positive correla-
tion with halos (odds ratio ¼ 40.014, P ¼ .028). The WTW
diameter mean value was 11.51 6 0.38 mm (range: 10.80-
12.30 mm). Because the possibility exists that the STS
diameter or implantable collamer lens diameter, which is
affinitive to WTW, might affect the selection of candidates
for night vision disturbances, we performed a post hoc
comparison. WTW was confirmed as a determinant that
had the strongest correlation with the development of
halos among the aforementioned variables. We assumed
that a larger WTW diameter reflected a larger corneal
diameter. This could disturb the integrity of the refracting
surface of the cornea and make a variable angle of inci-
dence more than a small cornea. However, keratometric
values or spherical aberrations were not revealed as possible
risk factors for halos by multivariable analysis. At present,
we have no other clear explanations for this result.
The potential risk factors for glare are quite different
from those of halos. The toricity of an implantable collamer
lens significantly affects the development of glare (odds
ratio ¼ 0.276, P ¼ .047). Interestingly, the number of
patients who were complaining of glare decreased as
implantable collamer lens toricity increased. The results
suggested that patients with high-diopter eyeglasses or
contact lenses preoperatively, particularly those with
high astigmatism, might have experienced significant
visual distortions that could lead to image degradation asso-
ciated with night vision disturbance. The postoperative
correction of higher astigmatism contributed to the satis-
faction of those patients more than patients with mild
astigmatism who had been preoperatively less affected by
secondary visual distortion. Meanwhile, implantable
collamer lens vaulting, which is considered a strong suspect
of night disturbances, did not show statistical significance
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
and none were reported. The authors indicate no funding support, and they have no financial or proprietary disclosures regarding any materials or methods
described herein. Involved in conception and design (E.C., T.C.) and conduct of the study (D.L., I.L., S.C.); collection, management and interpretation of
data (D.L., I.L. S.C., E.C, T.C.); data analysis (D.L. I.L., S.C.); writing the article (D.L., I.L.); and preparation, review, and approval of the manuscript
(D.L., I.L. S.C., E.C, T.C.).
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140 AMERICAN JOURNAL OF OPHTHALMOLOGY
(P ¼ .052) in multiple logistic regression analysis. This
result supports Seo and associates34 by demonstrating
that there was no statistically significant association
between implantable collamer lens vaulting and night
vision disturbances.
There are several limitations to our study, including its
retrospective design and small sample size. The variables
such as spherical aberrations, which were assumed as
possible risk factors and revealed as potential candidates
with P values <.1 in univariate analysis, could be underval-
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contribute to the development of night vision disturbances.
We could not suggest a more plausible explanation
regarding the WTW diameter as a risk factor for halos.
This study was unable to compare the incidence or severity
of night disturbances preoperatively and postoperatively
because we did not administer questionnaires preopera-
tively and then administered them only 6 months after
implantable collamer lens implantation surgery.
Despite these limitations, our results addressed impor-
tant issues concerning night vision disturbances after
implantable collamer lens implantation. Halos after
implantable collamer lens implantation are correlated
with the difference between mesopic pupil size and
implantable collamer lens optic zone diameter, as well as
WTW and implantable collamer lens optic zone diameter,
and glare is related to the toricity of the implantable
collamer lens. These issues emphasize the importance of
preoperative communication with the patient about the
possibility of night vision disturbances. Moreover, the
preoperative assessment of predictive factors would make
it possible to identify patients at high risk of experiencing
night vision disturbances. Further prospective evaluations
with larger sample sizes are required for clarification of defi-
nite risk factors for night vision disturbance after implant-
able collamer lens implantation.
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pupil diameter after posterior chamber phakic intraocular
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31. Seo KY, Lee JB, Kang JJ, Kim EK. Comparison of higher-order
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33. Nepomuceno RL, Boxer Wachler BS, Scruggs R. Functional
optical zone after myopic LASIK as a function of ablation
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 Biosketch
Dong Hui Lim, MD, is a clinical instructor of the Department of Ophthalmology at Samsung Medical Center,
Sungkyunkwan University School of medicine, Seoul, South Korea. She graduated from Sungkyunkwan University
School of medicine in 2007, where she completed her ophthalmology residency in 2012. Her special interests are visual
quality and refractive error, including keratoplasty, cataract and refractive surgery.

141.e1 AMERICAN JOURNAL OF OPHTHALMOLOGY JANUARY 2014