Toric implantable collamer lens and bioptics show comparable results for high myopia with astigmatism

Patients with high myopia and astigmatism who are not suitable for laser vision correction alone now have fresh evidence comparing two surgical strategies: implanting a toric implantable collamer lens (TICL) in a single procedure, or performing bioptics, a staged approach that combines a spherical implantable collamer lens (ICL) with later corneal laser correction of residual astigmatism. A prospective interventional case series conducted at private centers in Menoufia and Cairo, Egypt, between May 2022 and September 2025, followed 36 eyes for a mean of 12 months, with follow-up extending to 18 months, and found that both techniques delivered comparable refractive and visual outcomes and similarly high patient satisfaction.

The study enrolled 18 eyes of 11 patients in the TICL group, seven of whom had bilateral surgery and four unilateral surgery, and 18 eyes of 10 patients in the bioptics group, eight with bilateral and two with unilateral surgery. All participants were older than 20 years with an anterior chamber depth greater than 3 mm. Exclusions included corneal opacity producing irregular astigmatism, cataract, a history of glaucoma, pigment dispersion syndrome, low endothelial cell count, uncontrolled systemic disease, and pregnancy or nursing. The mean age was 21.44 ± 1.79 years in the TICL group versus 22.67 ± 2.22 years in the bioptics group, and the cohorts were predominantly female, at 77.8% and 88.9% respectively.

Surgical technique differed fundamentally between the groups. Both spherical ICL and TICL implantations were performed through a 3 mm temporal clear corneal incision under local subtenon anesthesia, with the lens positioned behind the iris and centered on the pupil. For toric lenses, the required axis was marked at the limbus with the patient sitting upright to avoid cyclotorsion, and the lens was aligned intraoperatively with a measuring ring and a modified intraocular spatula. In the bioptics group, Femto-LASIK, PRK, or transepithelial PRK was performed two to four months after ICL implantation, once refraction and topography had stabilized. Femto-LASIK flaps were created with a VisuMax femtosecond laser before ICL surgery, taking advantage of the eye’s untouched corneal biomechanics, with the flap lifted and excimer laser applied two months later. PRK cases used alcohol-assisted epithelial removal, static cyclotorsion compensation, mitomycin C to reduce corneal haze, and a contact lens removed five days postoperatively. Femto-LASIK was performed in eight eyes, PRK in two, and transepithelial PRK in eight, with ablation optical zones ranging from 6.3 to 7 mm.

The refractive results showed substantial and statistically significant improvement within each group. Median spherical error fell from −12 diopters (range −15 to −8) preoperatively to −0.5 D postoperatively in the TICL group, and from −10.87 D (range −15 to −8) to 0 D in the bioptics group, both with p = 0.001, and with no statistically significant difference between groups postoperatively (p = 0.179). Median astigmatism, which was −3 D in both groups before surgery, improved to −1 D with TICL and −0.875 D with bioptics (p = 0.001 within each group), again with no significant between-group difference afterward (p = 0.974). Median spherical equivalent changed from −14 D to −1 D in the TICL group and from −12.12 D to −0.75 D in the bioptics group, with no significant postoperative difference (p = 0.353).

Visual acuity outcomes revealed one of the more nuanced findings. Mean preoperative best corrected visual acuity (BCVA) was 0.62 ± 0.20 in the TICL group versus 0.7 ± 0.15 in the bioptics group, a non-significant baseline difference. Postoperative uncorrected visual acuity (UCVA) reached 0.667 ± 0.20 in the TICL group, which the authors reported as a non-significant change (p = 0.832), while the bioptics group improved significantly from 0.7 ± 0.15 BCVA to 0.794 ± 0.143 UCVA (p = 0.014), and the between-group difference in postoperative UCVA was statistically significant (p = 0.034). The authors suggested that the elimination of the minification effect of thick preoperative glasses may have helped many patients read more lines on the chart after surgery.

Composite indices of safety, efficacy, and predictability were statistically comparable between the procedures. The safety index, calculated as postoperative BCVA divided by preoperative BCVA, averaged 1.20 ± 0.24 for TICL versus 1.11 ± 0.16 for bioptics. The efficacy index, postoperative UCVA divided by preoperative BCVA, was 1.18 ± 0.23 versus 1.07 ± 0.15. Predictability, the proportion of eyes achieving postoperative spherical equivalent within ±0.50 D and ±1.00 D of target, averaged 0.875 ± 0.46 versus 0.764 ± 0.488. Mean satisfaction scores were nearly identical at 8.33 ± 1.02 for TICL and 8.39 ± 0.85 for bioptics, with no statistically significant difference on any of these measures.

Corneal measurements documented the expected anatomical footprint of the laser step.

Safety findings were broadly reassuring but not identical. No significant intraoperative or postoperative complications occurred in either group, no crystalline lens opacity was observed during follow-up, and no cases of incision dehiscence, lens dislocation, or decentration followed the laser step in the bioptics group. One eye in the TICL group required retreatment to correct postoperative lens rotation, which was performed successfully. The clearest difference was dry eye, reported in 7 cases, all in the bioptics group, representing 38.9% of that group and particularly those who underwent Femto-LASIK, versus no cases in the TICL group, a statistically significant difference assessed with the Ocular Surface Disease Index questionnaire. Rates of transient uveitis, corneal haze, elevated intraocular pressure, ICL rotation, and corneal edema did not differ significantly between groups, and one case of transient IOP elevation was controlled with antiglaucoma drops.

The authors place their results in the context of earlier work, noting consistency with Zaldivar and colleagues’ original bioptics reports, Sanders and colleagues’ FDA toric ICL trial in which most patients achieved postoperative UCVA equal to or better than preoperative BCVA, and Choi and colleagues’ earlier direct comparison of TICL and bioptics, which likewise found no significant differences in safety and efficacy. They also acknowledge that cataract formation and pupillary block have been reported as common ICL-related complications in other series, and that early cataract formation can occur in young patients, making continued monitoring advisable, even though no such cases appeared in this cohort.

The study’s limitations temper the conclusions. The sample of 36 eyes is small, which may limit statistical power and generalizability, and the follow-up period, though extending to 18 months with a mean of 12, is relatively short for assessing long-term refractive stability, endothelial cell changes, cataract formation, and late complications. The authors recommend larger samples, longer follow-up, and further randomized prospective studies to define the relative advantages of the two approaches. For now, the practical takeaway is that both TICL and bioptics proved effective and safe for correcting high myopia with astigmatism, with the toric lens offering a single procedure, faster recovery, and no effect on the corneal surface, while bioptics allows finer adjustment of astigmatism and is less costly for the patient.

Subject of Research: Comparison of toric implantable collamer lens implantation and bioptics for correcting high myopia with astigmatism

Article Title: Comparison of toric implantable collamer lens and bioptics for correction of high myopia with astigmatism

Article References: Sarhan, A. E. E., Khairy, H. A., Elqattan, M. M., & Basiony, A. I. (2026). Comparison of toric implantable collamer lens and bioptics for correction of high myopia with astigmatism. BMC Ophthalmology, 26(1), Article 683. https://doi.org/10.1186/s12886-026-05071-6

Image Credits: AI Generated

DOI: 10.1186/s12886-026-05071-6

Keywords: high myopia, astigmatism, toric implantable collamer lens, bioptics, phakic intraocular lens, refractive surgery, LASIK, PRK, visual acuity, dry eye, patient satisfaction, ophthalmology