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Keratorefractive surgeries, such as photorefractive keratectomy and LASIK, have limitations when used for the correction of high refractive errors.1, 2, 3 Intraocular refractive procedures offer many potential advantages: a broader range of treatable ametropia, faster visual recovery, more stable refraction, and better visual quality.4, 5, 6 Two basic intraocular refractive procedures exist: phakic intraocular lens (pIOL) implantation, and clear lens extraction with lens implantation. Refractive lens exchange may increase the risk for retinal detachment,7 and is generally not considered in myopic pre-presbyopic patients who can still accommodate.
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The risks and benefits of pIOL implantation in appropriate patients may be more favorable than other refractive surgery techniques. The pIOL is removable surgically, with fast visual recovery, and preserved accommodation. However, it is important to realize that complications relating to pIOLs can be more disabling than those from keratorefractive surgery.3 Several generations of both anterior and posterior pIOLs have been introduced in the past few years.
Multiple studies from different parts of the world addressed the visual outcomes of both procedures, but only few studies were conducted in the Middle East. The purpose of this assessment was to review the safety and outcomes of two pIOLs, which are currently approved by the FDA in our hospital. The Verisyse phakic IOL marketed internationally as the Artisan lens by Ophtec (Boca Raton, FL, USA; FDA approval 2004), and the Visian ICL (ICL), manufactured by STAAR Surgical Company (Monrovia, CA, USA; FDA approval 2005).
For eyes undergoing implantation of anterior-chamber, iris-fixated pIOLs, the pupil was constricted with miotic drops, and the procedure was performed under peribulbar anesthesia. Two paracenteses were created, and the anterior chamber was filled with viscoelastic. A limbal incision was made, usually in the steepest corneal meridian, which is approximately equal to the lens optic diameter. The pIOL was inserted and rotated into a horizontal position. A fold of the peripheral iris was then captured by the pincher-like lens haptics in a process called enclavation. A peripheral surgical iridotomy was performed. The incision was closed with an appropriate suture and the viscoelastic was then removed. Generally, the procedure on the other eye follows in 1 or 2 weeks (Figure 1).
For eyes undergoing implantation of posterior-chamber pIOLs, the pupil was dilated with mydriatic drops, and the procedure was performed under peribulbar anesthesia. A 3.2-mm temporal clear corneal incision was created, as well as 1 or 2 paracenteses. The anterior chamber was filled with viscoelastic. The pIOLs was then injected into the anterior chamber, anterior and parallel to the iris plane, and allowed to unfold. Each corner of the footplates was gently tucked beneath the iris. Once the pIOL is well positioned, the viscoelastic was removed, a peripheral surgical iridotomy was performed, and the corneal wound was checked for integrity. Generally, the procedure on the other eye follows in 1 or 2 weeks (Figure 2).
Follow-up examinations are typically scheduled at 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year after surgery. Postoperative examinations included slit-lamp biomicroscopy, keratometry, applanation tonometry, subjective and objective refraction, and measurement of uncorrected distance visual acuity (UDVA), and CDVA. Within the first six-postoperative weeks, the sutures were cut or removed if it has created undesirable corneal astigmatism in cases implanted with Artisan lens. Each procedure safety index and efficacy index were calculated as follows: safety index=mean postoperative CDVA/mean preoperative CDVA, and efficacy index=mean postoperative UDVA/mean preoperative CDVA (using decimals for visual acuity).
Phakic IOL surgery is an efficacious technique for correcting refractive error in patients who would otherwise be poor candidates for corneal refractive surgery, and can provide immediate improvement in UDVA, an increase in CDVA, and preservation of accommodation.8
In this study, there was no statistically significant difference between the two groups as regards the postoperative CDVA and UDVA. Although most studies showed comparable outcomes between both lenses like ours, Boxer et al9 reported that binocular UDVA was better in the ICL group, and Menezo et al10 found slightly better visual results with the Artisan than with the Visian ICL.
In our study, there was one case of malignant glaucoma in the Artisan group that required anterior vitrectomy in the first postoperative day; there was also a case of angle closure glaucoma in the ICL group, which was related to oversizing of the IOL that required explantation and replacement of the IOL. There have been case reports of malignant glaucoma,11 and intractable elevation of IOP requiring filtration surgery after ICL implantation.12
We did not report any case of cataract after implantation of either Artisan or ICL, but this may be attributed to the relatively short follow-up period. Menezo et al10 found two basic cataract types: anterior subcapsular opacification (in cases of ICL), and nuclear cataract (in cases of Artisan). The mean time to nuclear cataract appearance after Artisan IOL implantation was 54.8322.12, and ICL implantation was 201 month.
In our study, pigment dispersion occurred in 12 eyes (28.6%) in the Artisan group and in two eyes (15.38%) in the ICL group. Increased flare has also been found after the implantation of a posterior chamber pIOL.13, 14 We did not report any case of retinal detachment or endophthalmitis after implantation of either Artisan or ICL. One report showed that the risk of retinal detachment in pIOL cases was lower than in clear lens extraction cases.15 Although there were no cases of retinal detachment or endophthalmitis, however, the number of subjects studied was too low to adequately detect a retinal detachment or endophthalmitis.
We did not find any clinical or statistical difference in the visual outcomes between Artisan and ICL after 1-year follow-up, and the short-term rates of complications and loss of CDVA are acceptable. However, a weakness of the study is the retrospective design, and that the ICL group is significantly smaller (26) than the Artisan group (42). Comprehensive preoperative evaluation and long-term postoperative follow-up examinations are needed to monitor for and prevent serious complications, and to establish long-term safety.
In 2016, Mackie portrayed Martin Luther King Jr. in the HBO TV drama All the Way.[22] In 2018, Mackie appeared as gang leader King in The Hate U Give, a film adaptation of the bestselling novel of the same name.[23] In 2019, Mackie had a role in the Netflix science-fiction film, IO.[24]
In July 2018, it was announced that Mackie was cast in the role of Takeshi Kovacs for the second season of Netflix's science-fiction series, Altered Carbon.[25] In March 2019, it was announced that Mackie was cast in the fifth season of Netflix's science-fiction anthology series, Black Mirror.[26] The following month, Disney confirmed a Marvel television series starring Mackie and Sebastian Stan, called The Falcon and the Winter Soldier, would be aired on their upcoming Disney+ streaming service, debuting on March 19, 2021.[27][28] Mackie starred in and produced the science fiction film Outside the Wire which was released by Netflix on January 15, 2021.[29] In August 2021, Mackie closed the deal to reprise the role in the fourth Captain America film,[30] Captain America: Brave New World.[31]
In January 2022, it was announced that Mackie will helm the drama film Spark, starring Saniyya Sidney, as his directorial debut project.[32] In February 2022, he was set to lead action film Ending Things along with Priyanka Chopra Jonas, directed by Kevin Sullivan[33] and star in a live-action series adaptation of the game Twisted Metal at Peacock.[34] In 2022, it was announced Mackie would be attached to a film based on the 1956 Sugar Bowl which feature's his brother's Alma mater Georgia Tech.[35][36]
In November 2013, Mackie was arrested for driving while intoxicated after he was initially stopped by police for having tinted windows, which is illegal in New York. He was pulled over at 1:22 a.m., officers noticed an odor of alcohol and observed that Mackie had bloodshot eyes. He was fined $300, ordered to complete a drunk driving program and banned from the road for 90 days in New York state for the violation.[41]
Until she meets Macky, she doesn't give much thought to the advantages she's had; they're simply what she would expect as a Roman. She has certainly never thought that the Romans were wrong to invade other peoples' land and try to get them to believe the same things that they do.
Portia's father is a senior Roman army commander, but he's far away with his troops, and she lives with her uncle Tiberius, who is the powerful Governor of Alexandria (the setting for Series One). Her uncle is no substitute for a caring father and Portia misses him - though she would never admit it. As a Roman, she's expected to be strong, and to cope with all that life has to throw at her.
There are enormous obstacles: class, religion, money (and the lack of it) - not to mention Macky's dangerous involvement in activities which he hopes will set his people free from Roman rule - activities which the Romans would punish severely if they ever found out. But Portia starts to see her fellow Romans through Macky's eyes, and that, combined with the wonderful stories he tells her, begins to change her. She starts to use her own strength of character to help others, and in the course of thirty-nine episodes, we'll see her change from spoiled child to gracious young adult. 152ee80cbc
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