271 © Springer International Publishing AG 2018 J.L. Alio, D.T. Azar (eds.), Management of Complications in Refractive Surgery, https://doi.org/10.1007/978-3-319-60561-6_30 Complications of Anterior Chamber Angle-Supported Phakic Intraocular Lenses: Prevention and Treatment Antonio Renna and Jorge L. Alió Core Messages In this chapter, the complications of AS-PIOLs will be reviewed as follows: • Intraoperative and early postoperative complications. • Late postoperative complications and their management. • Complications that lead to explantation of the AS-PIOLs. • Explantation techniques of AS-PIOLs. • The ideal PIOL design. • Anterior segment OCT and aging. AS-PIOLs have been widely used for a long time. They were the irst PIOLs to be used and the irst to be aban- doned, according to long-term evaluations made by sev- eral authors [1–5]. The reason AS-PIOLs have remained popular is primarily due to the ease of implantation. The anterior chamber (AC), especially in myopic eyes, is the largest space in the anterior segment of the eye and its anatomy can be studied easily both preoperatively and postoperatively. Other reasons for PIOLs popularity are that they do not induce for glaucoma, if properly selected, and that they do not induce cataract formation because they are not in contact with the lens at any given moment [6–20]. Despite these features, all models of AS-PIOL, some in early stages and others in later stages, face the risk of central corneal endothelial loss [21–35]. Excluding the Kelman Duet lens, all the AS-PIOLs were phased out of the market because of unacceptable complication rates. Angle-supported lenses were developed initially with dif- ferent models. Charles Kelman and Jorge Alió in Alicante co-developed the Duet Lens (Fig. 30.1). Its design includes a tripod support of PMMA that can be implanted through a <2.75 mm incision that allows the implantation of the hap- tic and the injection of the silicon optic that later is attached to the haptic into the anterior chamber. This represents the best example of an AS-PIOL that adapts to the concept of minimal incision providing very good outcomes for the patients initially and in the long term, even if it is no lon- ger in use [36]. This lens was followed by a foldable model, the Alcon Cachet, that is injectable through a 2.6 mm incision and follows almost all the rules of small- incision surgery with the advantage of using the AcrySof material. All models of AS-PIOL have revealed to be either unsafe in the early postoperative, from 1 year to 3 years or in the long term. All of them are affected by the anatomy of the anterior segment and other issues related to the behavior of the patients, such as rubbing or the position 30 A. Renna, M.D. Vissum, Instituto Oftalmológico Alicante, Avda. De Denia s/n, 03016 Alicante, Spain Department of Medical and Biological Sciences—Ophthalmology, University of Udine, Udine, Italy J.L. Alió, M.D., Ph.D. (*) Vissum, Instituto Oftalmológico Alicante, Avda. De Denia s/n, 03016 Alicante, Spain Universidad Miguel Hernandez, Alicante, Spain e-mail: jlalio@vissum.com Fig. 30.1 Kelman Duet angle-supported phakic intraocular lens