Trusting UBM AI + ICLguru Versus Other Methods: AS-OCT

Background

A 31-year-old female patient is of child-bearing age, with relatively thin corneas, slightly shallow ACDs, and struggles with dryness and habitually rubs her eyes. The pre-op anterior chamber measurements and refraction were as follows:

               OD         2.99 mm ACD       33.3° angle       0.1 (-3.75/-0.50x180) = 1.3

               OS          2.91 mm ACD       29.4° angle       0.1 (-4.25/-0.50x160) = 1.3

Initial Approach

Due to thin corneas, the patient was considered a prospective candidate for ICL. Our practice had not yet adopted Sonomed Escalon UBM AI + ICLguru for sizing when the patient was first seen in June 2024. Therefore, calculation using the AS-OCT-based nomogram was utilized, which recommended sizing of 12.6 mm for OD and 13.2 mm for OS. A recommendation was also obtained from OCOS, which suggested 12.6 mm in both eyes. Due to the slightly narrower angle in the OS, I was particularly concerned to ensure the correct ICL size was selected. The decision was made to proceed with 12.6 mm for OD and 13.2 mm for OS, primarily based upon the results of AS-OCT.

Note, implementation based on: Russo, Andrea, et al “Predictability of the vault after implantable Collamer lens implantation using OCT and artificial intelligence in White patient eyes.” Journal of Cataract and Refractive Surgery 49.7 (2023)

Modified Approach

Just prior to surgery, our practice obtained a Sonomed Escalon system with UBM AI and subscribed to ICLguru. The patient was advised that new cutting-edge technology was now available, and they agreed to undergo a UBM examination to confirm whether ICLguru based on UBM AI would yield the same size recommendations as AS-OCT. Suffice it to say, it did not – based on the ICLguru calculation results, the ideal sizes would be 12.1 mm for OD and 12.1 mm for OS. Further, the 13.2 mm size for OS recommended by AS-OCT would result in hyper vault. Therefore, surgery was postponed and rescheduled for when the new 12.1 mm lens sizes for both eyes would be available.

Results

The post-op vaults and angles were within reasonable range of the predicted values of ICLguru and all at safe levels (measured at day-1, as shown below):

               OD              0.493 mm vault           28° angle

               OS               0.511 mm vault           34° angle

Conclusion

Sonomed Escalon UBM AI + ICLguru made a significant difference in our practice’s very first case utilizing the technology. The 12.1 mm size ICLs were definitely the correct choice, and it is likely that the OS lens would have required explant and exchange had the AS-OCT recommendation of 13.2 mm been heeded. The patient and practice avoided two additional trips to the OR. Further, the predictive angle information provided by ICLguru led to a more informed decision regarding lens size. It is also worthwhile noting that this case was performed in June 2024 using a prior generation of ICLguru, and that due to its deep-learning AI model, the accuracy of ICLguru has increased significantly since that time, along with now providing predictive rotational stability information. This continual improvement provides even further confidence that Sonomed Escalon UBM AI + ICLguru is, in my opinion, the best method to use for determining optimal ICL sizing.