CAKE 31 Supplement by Media MICE

SUPPLEMENT September 2026 MediaMICE.com

FROM THE PANEL TO PRACTICE

EVO ICL GLOBAL EXPERT CONSENSUS, EVOLIVE 2026 Faculty Guidance and Live Poll Insights from 280 EMEA Refractive Surgeons This supplement accompanies the EVOlive™ Webinar (9 March 2026). It is intended as a durable clinical reference for practicing refractive surgeons—attendees and non-attendees alike. Poll data

were collected live from 280 EMEA surgeons during the session. Faculty statements are attributed to individual panelists and represent their personal clinical experience and opinion. Published references are cited where faculty positions are supported by peer-reviewed evidence. This supplement was sponsored by STAAR Surgical™ .

Faculty Panel SCOTT D. BARNES, MD Chief Medical Officer STAAR Surgical (USA)

AMIR-MOBAREZ PARASTA, MD Medical Director & Founder, Munich Eye (Germany)

BARBARA LEYSSENS, MD Ophthalmologist & Refractive Surgeon FYEO (Netherlands)

Postoperative vault management was presented as a clinical rather than isolated numeric thresholds, particularly in the era of the central-port EVO™ design. Low vault in clinically stable eyes was approached with observation, supported by long-term published data.1-3 High vault without IOP elevation, pigment dispersion or patient symptoms was similarly managed with structured monitoring. Early IOP elevation was addressed through mechanism-specific treatment, with viscoelastic selection identified as a preventive variable. [STAAR Surgical recommends a low molecular weight 2% hydroxypropyl methylcellulose (HPMC) or dispersive, low viscosity ophthalmic viscosurgical device.]

EVOlive at a Glance

GÖRAN HELGASON, MD Consultant Ophthalmic Surgeon EuroEyes (Sweden & Denmark)

EFEKAN COŞKUNSEVEN, MD Professor of Ophthalmology Medicana Health Group (Türkiye)

Executive Summary The EVOlive Webinar, held on 9 March 2026, brought together four experienced refractive surgeons to discuss practical decisionmaking around EVO ICL™ (STAAR Surgical, Lake Forest, CA, USA) across six clinical domains: patient selection, lens size selection, postoperative vault assessment, intraocular pressure (IOP) management, surgical technique and patient experience. Live poll responses from 280 Europe, the Middle East and Africa (EMEA) surgeons supplemented the faculty discussion and provided a contemporaneous snapshot of current practice patterns across the region. Patient selection was framed as a multifactorial clinical judgment rather than a threshold-based decision. Corneal topography was the dominant preoperative factor, with dry eye and ocular surface status identified as secondary considerations. When both laser vision correction (LVC) and EVO ICL were clinically appropriate, faculty discussion focused on tissue preservation, reversibility, expected quality of vision and the preservation of future surgical options.

4 million ICLs sold in more than 85 countries Milestone announced at the opening of the EVOlive Webinar, 9 March 2026

The webinar opened with a milestone noted by Dr. Scott D. Barnes: STAAR Surgical has reached 4 million ICLs sold in more than 85 countries.

1. Patient Selection: Beyond the Refraction Preoperative factors

Patient selection for EVO ICL involves clinical judgment across multiple anterior segment parameters, not refraction alone. When asked which preoperative findings most influence their decision to proceed with EVO ICL, 75.5% of poll respondents selected corneal topography, with dry eye assessment (38.2%) and ocular surface status (28.2%) as secondary considerations (Poll 1).

Patient selection for EVO ICL should not be limited to the prescription. Surgeons need to consider the whole eye.

Lens size selection in routine practice centered on white-to-white (WTW) measurement and anterior chamber depth (ACD), each calibrated to the individual surgeon’s imaging platform. Angle anatomy was consistently characterized as a candidacy and safety screen rather than a primary sizing variable.

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Poll 1. Preoperative factors most influencing the decision to proceed with EVO ICL

Prof. Parasta identified the presbyopia corridor as an increasingly relevant component of this discussion: patients who undergo corneal laser surgery may face limitations on subsequent lensbased procedures due to the altered corneal profile, a constraint that does not apply following EVO ICL implantation. Dr. Leyssens highlighted reversibility and biocompatibility as the most effective patient-facing arguments. Dr. Helgason described reversibility as the most comprehensible advantage for most patients. Prof. Coşkunseven emphasized the absence of corneal tissue removal as particularly relevant for higher myopes, where the optical consequences of ablation are most pronounced.

Faculty responses reflected the same hierarchy. Topography was treated as essential for excluding ectasia risk. Prof. Coşkunseven linked topography to anticipated optical quality, noting that beyond approximately -6.00 D of myopia, post-laser corneal shape changes may limit visual outcomes sufficiently to favor EVO ICL over laser procedures, including small-incision lenticule extraction (SMILE). Prof. Parasta emphasized corneal biomechanics as a determinant of long-term refractive stability, noting that biomechanical compromise may not manifest until several years postoperatively. Dr. Leyssens framed candidacy evaluation as requiring assessment of the whole eye, not the refractive error in isolation.

The best point to make is reversibility.

Published data support EVO ICL for myopic correction across a range of dioptric values, including lower corrections where LVC is also a viable option, with documented predictability, safety and optical quality outcomes.4-6

EVO ICL vs. LVC: The clinical argument above -3.00 D When an audience member asked which procedure the faculty would prefer in a patient with myopia greater than -3.00 D — where both LVC and EVO ICL are clinically viable — the panel’s responses were consistent. Prof. Parasta stated that he would choose EVO ICL for his own eye, even at relatively low levels of myopia. Dr. Helgason noted that he underwent EVO ICL surgery himself and applies no strict lower dioptric cutoff when the patient is a suitable candidate.

Counseling the 55-year-old myopic patient with a clear crystalline lens An audience question addressed the 55-year-old myopic patient with a clear crystalline lens, a scenario where the choice between EVO ICL and refractive lens exchange (RLE) is not straightforward. Faculty responses were individualized rather than uniform. Dr. Leyssens prioritized retinal detachment risk stratification, incorporating axial length and posterior vitreous detachment (PVD) status into the decision. In high-risk eyes without PVD, she favored deferring lens extraction. Dr. Helgason expressed greater willingness to proceed with RLE in this age group and saw a limited role for EVO ICL in patients with clear lenses at age 55. The faculty divergence reflects the influence of axial length, PVD status, retinal risk profile and patient expectations on a decision that does not yield to a single protocol. Decision framework: 55-year-old myopic patient with a clear crystalline lens

For patients with myopia above -3.00 D where both procedures are clinically appropriate, the panel consistently emphasized EVO ICL’s optical quality profile: EVO induces low coma-like, sphericallike and total higher-order aberrations (HOA).7 At higher corrections, post-ablation corneal shape changes can introduce optical aberrations and limit the range of future interventions available, including lens-based presbyopia correction.6,8 EVO ICL avoids these sequelae by preserving the natural corneal profile. The procedure also does not cause or worsen dry eye syndrome9 — a relevant consideration in a refractive surgery population where pre-existing ocular surface disease is common.

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2. Lens Size Selection

The role of angle anatomy

Core parameters

Poll 2 asked respondents how much weight they assign to angle anatomy when selecting ICL size. Approximately two-thirds weighted it heavily or moderately (Poll 2).

Across all four panelists, Pentacam-derived WTW measurement and ACD were the primary inputs for routine lens selection. Each panelist also described applying a surgeon-specific correction factor developed from their own outcomes of data, reflecting the role of device familiarity and individual calibration in achieving consistent results.

Poll 2. Weight given to angle anatomy in ICL size selection

Prof. Parasta described a sizing approach based on Pentacam measurements and an in-house correction factor adjusted to the behavior of his specific imaging device. Prof. Coşkunseven described a high-volume workflow centered on WTW and ACD, with sulcus-to-sulcus, angle-to-angle and crystalline lens rise acknowledged as theoretically relevant but not routinely driving the lens selection decision. Dr. Leyssens and Dr. Helgason described equivalent workflows. Dr. Barnes summarized the panel’s position: experienced surgeons consistently achieve low exchange rates using well-calibrated WTW and ACD-based sizing, despite debate in the field about whether these parameters have been superseded by more advanced imaging modalities. This was reinforced during the Q&A, where Dr. Leyssens reported a vault-related exchange rate below 1% in her clinic using current methods, and Dr. Helgason referenced sustained low exchange rates using the STAAR nomogram since the 1990s. Less than 1% vault-related exchange rate reported in Dr. Leyssens’s clinic using current WTW/ACDbased sizing methods.

Faculty discussion distinguished between angle anatomy as a candidacy variable and as a sizing variable. Dr. Leyssens described angle assessment as part of the preoperative safety evaluation used to confirm candidacy, not as a primary input for selecting lens dimensions. Prof. Parasta identified preoperative IOP elevation as a more clinically decisive concern than angle anatomy per se, noting that he generally avoids EVO ICL implantation in eyes with preoperative IOP above 21 mmHg. Prof. Coşkunseven noted closer attention to angle anatomy when ordering a 13.7 mm lens, where the risk of high vault is proportionally greater. Dr. Helgason agreed that angle anatomy functions primarily as a screening variable rather than a sizing determinant in routine myopic cases.

I do not use angle anatomy for sizing itself. I use it before surgery to confirm that the eye is a safe candidate. That is a candidacy question, not really a sizing question.

When asked about their approach to low vault without accompanying symptoms, approximately 60% of poll respondents indicated they would follow the patient more closely without intervening, approximately 35% would continue with routine follow-up unchanged, and a small minority reported they would proceed to exchange or explantation (Poll 3). Poll 3. Medical approach to low vault without accompanying symptoms

The poll results and faculty discussion are not contradictory. A surgeon who weighs angle anatomy heavily as a clinical factor may still rely on WTW and ACD as the primary sizing inputs in most routine cases, reserving detailed anatomical assessment for selected presentations.

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3. Postoperative Vault: Interpretation and Management Day 1 assessment Faculty agreed that the first postoperative day is a clinical safety check rather than a moment for definitive vault interpretation. Residual viscoelastic, pupil dilation and a still-settling anterior segment all limit the value of early numeric vault measurement. Dr. Leyssens described Day-1 assessment as centered on slit-lamp evaluation of the iris and anterior segment, along with IOP. Vault measurement was deferred to the one-month visit, at which point it was interpreted in the context of angle configuration, IOP and patient symptoms. Dr. Helgason made the same point, emphasizing that conclusions drawn from Day-1 vault measurements are often unreliable. Prof. Parasta described a same-day afternoon check focused on IOP and overall postoperative appearance, with vault as a secondary consideration at that stage. Prof. Coşkunseven described a more active early follow-up schedule, including vault, IOP and pupil status, attributing this to the demands of a highvolume practice.

He noted that the historical 250 µm threshold as a trigger for intervention does not apply to the central-port EVO design and cited his up to 7-year review of 1,490 patients demonstrating stable vault and clinical outcomes across the follow-up period.10 AlfonsoBartolozzi et al. reported stable visual and refractive outcomes, stable IOP, low endothelial cell loss, and no cases of ICL-induced anterior subcapsular opacity in eyes with vault below 250 µm over 10 years of follow-up with the central-port design.1,2

With the central port design, the old threshold of 250 µm does not mean what it used to mean. In my view, 50 to 250 µm is often a safe zone. - Prof. Efekan Coşkunseven

Dr. Leyssens reported eyes with a vault of 20 to 30 µm remaining clinically stable without cataract formation. Prof. Parasta specified two scenarios in which he would consider lens exchange: toric lens re-rotation following an initial repositioning attempt and a low vault or lens touch situation coupled with a myopic shift. In the absence of these findings, he favors observation. No cases of ICL-induced anterior subcapsular opacity in eyes with vault below 250 µm over 10 years of follow-up with the central-port design. Alfonso-Bartolozzi et al. J Cataract Refract Surg. 2024; Silva et al. J Cataract Refract Surg. 2026.1,2

High vault Excessive vault, in the absence of IOP elevation, pigment dispersion or patient-reported symptoms, was not treated as an automatic indication for exchange. Dr. Leyssens described assessment of the iris, angle, iris transillumination and patient symptoms as the key determinants. She noted that vault values around 1,300 µm can produce glare and halos even without pressure elevation and that lens exchange is appropriate when anatomical findings create genuine doubt about long-term safety, particularly in young and active patients.

Low vault Low vault was not treated as an automatic indication for lens exchange. In clinically stable eyes, observation was the preferred approach across all four panelists, a position consistent with published long-term follow-up data in the central-port design era.1-3 Prof. Coşkunseven provided context-specific thresholds: below 100 µm in myopic eyes and below 250 µm in hyperopic eyes as working definitions of low vault requiring closer attention.

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These are young patients. You want to give them visual freedom and not a yearly check-up for the rest of their lives.

Dr. Helgason favors observation when the patient is asymptomatic and IOP is normal, proceeding to exchange consideration when visual disturbance is reported. Prof. Parasta’s threshold for intervention is clinical rather than numeric: in the absence of dynamic changes, the lens is left in place. Prof. Coşkunseven described a case of declining vault from approximately 1,280 µm to 1,100 µm that prompted gonioscopy and specialist angle imaging, ultimately leading to exchange based on anatomical concern about future iris configuration rather than active symptoms.

management depends on identifying which mechanism is operative. Prof. Parasta noted that eyes with preoperative IOP in the 18 to 20 mmHg range may experience transient elevation in the first few days postoperatively, typically manageable with pressure-lowering drops. He identified preoperative IOP above 21 mmHg as a candidacy concern, not solely an IOP management consideration. Dr. Helgason raised the question of whether routine postoperative corticosteroids are necessary in all cases, citing the low inflammatory burden of EVO ICL implantation relative to other intraocular procedures and suggesting that non-steroidal anti-inflammatory drugs (NSAIDs) may be sufficient in selected patients. Elevated vault was also noted as a contributing factor to IOP elevation and should be included in the postoperative assessment.

Viscoelastic selection

Vault determinants Poll 4 asked respondents to identify the surgical factors with the greatest impact on postoperative vault. ICL compression, reflecting lens size selection, was the leading response (35.3%), followed by irido-corneal angle (29.3%), crystalline lens rise (21.6%) and pupil dynamics (13.8%). Poll 4. Surgical factors most impacting postoperative vault

Dr. Leyssens’s clinic performs hydroimplantation, eliminating retained viscoelastic as a source of early IOP elevation. For surgeons using viscoelastic, Dr. Barnes described the rationale for STAAR Surgical’s recommendation of dispersive hydroxypropyl methylcellulose (HPMC) over cohesive viscoelastic: material retained behind the lens must exit through the central port aperture, and cohesive viscoelastic is more likely to cause sustained outflow obstruction in this setting. When asked about their approach to high vault without accompanying symptoms, approximately two-thirds of poll respondents indicated they would follow the patient more closely, approximately one-third reported they would continue with routine observation, and fewer than 10% reported they would proceed to exchange or explant immediately (Poll 5). Poll 5. Medical approach to high vault without accompanying symptoms

Faculty responses were consistent with the poll data. Dr. Helgason identified lens compression as the dominant short-term factor and crystalline lens rise as progressively more influential over time as the natural lens thickens. Prof. Parasta added measurement quality and haptic position as variables, noting that footplate placement outside the sulcus can affect vault, particularly in low-power lenses.

4. IOP Management and Postoperative Safety Causes of early IOP elevation

Management pathway Prof. Coşkunseven outlined a sequential approach: identify the cause before initiating treatment. Retained viscoelastic may resolve with pressure-lowering drops and time. Fibrin obstructing the pre-existing central port aperture can be cleared with Nd:YAG laser without surgical return. Uncontrolled or unexplained IOP elevation warrants escalation to acetazolamide or surgical intervention.

Prof. Coşkunseven identified three primary causes of early postoperative IOP elevation: retained viscoelastic, steroid response and fibrin obstruction of the central port. The appropriate

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5. Surgical Technique

6. Patient Experience and Practice Growth

Explantation incision size Faculty responses on explantation incision size were contextdependent. Dr. Barnes recommended 3.0 mm as a standard, with slight enlargement to 3.1 to 3.2 mm for less experienced surgeons. Dr. Leyssens described a 2.4 mm superior incision as feasible when explanting without reimplantation and a 3.0 mm incision as preferable for lens exchange. Prof. Coşkunseven uses 2.8 mm routinely for explantation and enlarges to 3.0 mm when the lens has been in place for several years. Dr. Helgason uses approximately 2.4 to 2.5 mm when explanting before transitioning to cataract surgery through the same incision.

Intraoperative error management On identifying an upside-down lens during implantation, the panel reached unanimous agreement: remove and reload. Attempting to reorient the lens inside the eye carries unacceptable risk of endothelial damage and was not supported by any panelist. On lens extraction, Dr. Leyssens noted that the collamer material can be torn by a single sharp forceps and recommended guiding the lens through the incision using two forceps rather than applying traction with one.

Special populations

Referral patterns Poll 6 asked respondents which procedure generates more patient word-of-mouth referrals. Responses were closely distributed: 28.1% reported LVC generating more referrals, 26.3% reported both procedures as equal, 23.7% reported EVO ICL generating more referrals, and 21.9% observed no difference. The even distribution reflects a genuine gap between perception and measurement. Prof. Parasta has measured referral patterns in his practice using an ERP system and published the findings in The Ophthalmologist.11 ICL patients referred more often and for longer than laser patients, reducing advertising-driven acquisition costs per lead. Laser surgery has become common enough that it generates little follow-up curiosity, while ICL still prompts questions like how it works, what happens if the prescription changes and whether it can be removed. That sustained interest produces longer referral chains. Once ICL accounts for roughly 30% of a practice’s refractive volume, growth becomes self-reinforcing. In Prof. Parasta’s practice, approximately 70% of non-presbyopic patients are now treated with EVO ICL.11 Dr. Leyssens independently measured a referral uplift in her clinic from adding ICL to the refractive menu, and reported that patients now frequently arrive having already decided on ICL before the consultation. The emotional intensity of high myopia correction, which several faculty described as qualitatively different from low-correction laser outcomes, appears to be a consistent driver of this effect. ~70% of non-presbyopic refractive patients in Prof. Parasta’s practice are now treated with EVO ICL. Prof. Amir-Mobarez Parasta, EVOlive Webinar, 9 March 2026

Plateau iris and reverse iris configuration. The panel noted that EVO ICL implantation may normalize iris configuration in some plateau iris or reverse iris cases, and that these anatomical presentations are not necessarily absolute contraindications. The panel acknowledged limited data in this area.

Poll 6. Procedure generating more patient word-of-mouth referrals

Prior aqueous misdirection. The panel felt that earlier noncentral-port designs may have been a contributing factor in prior cases of post-ICL aqueous misdirection. With the EVO centralport design, aqueous misdirection had not generally recurred in their collective experience, though they acknowledged limited personal case numbers in this specific scenario. Keratoconus post-corneal cross-linking (CXL). Prof. Coşkunseven confirmed that standard Pentacam WTW measurement is appropriate in keratoconus patients who have undergone CXL and that the ectatic cornea does not require a modified measurement approach.

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ICL patients referred more often and kept referring for a longer period.

REFERENCES 1. Alfonso-Bartolozzi B, Fernández-Vega-Cueto L, Lisa C, et al. Ten-year follow-up of posterior chamber phakic intraocular lens with central port design in patients with low and normal vault. J

Conclusion

Cataract Refract Surg. 2024;50(5):441-7. 2. Silva R, Vaz Pereira M, Pinto C, et al. Long-term results of efficacy and safety of lens vault following implantation of posterior

The EVOlive Webinar produced a body of faculty guidance across six clinical areas that reflects both individual practice variation and consistent underlying principles. Patient selection extends beyond refractive error to include corneal topography, biomechanics, ocular surface health and long-term surgical planning, including the preservation of options for future presbyopia management. For myopia above -3.00 D where both LVC and EVO ICL are clinically viable, published comparative data support EVO ICL as a primary option in the informed consent discussion.4-6 Lens sizing remains anchored in WTW and ACD measurements calibrated to the individual surgeon’s platform, with angle anatomy serving a candidacy screening function rather than a primary sizing role. Vault interpretation in the central-port EVO era is supported by long-term data showing stable outcomes in eyes with low vault1-3, and management in both low- and high-vault scenarios is guided by clinical assessment rather than numeric thresholds alone. Early IOP elevation is addressed through mechanism-specific treatment, with viscoelastic selection and steroid protocols functioning as upstream preventive variables. Surgical technique guidance from the Q&A reinforces clear decision rules for intraoperative errors and context-specific approaches for explantation and special populations. At the practice level, faculty data suggest that EVO ICL patients generate durable referral activity that may compound as ICL volume increases.11

chamber implantable collamer lens. J Cataract Refract Surg. 2026;52(1):37-43. 3. Mechleb N, Gatinel D, Saad A. Nine years’ follow-up of bilateral extremely low vaulting of implantable collamer lens: case report. J Refract Surg Case Rep. 2023;3(1):e5–e9. 4. Alonso-Juárez E, Velázquez-Villoria D. Low diopter phakic implantable collamer lens: refractive and visual outcomes in low myopia and myopic astigmatism. Clin Ophthalmol. 2022; 16:2969-77. 5. Packer M. The EVO ICL for moderate myopia: results from the US FDA clinical trial. Clin Ophthalmol. 2022;16:3981-91. 6. Kamiya K, Shimizu K, Igarashi A, et al. Posterior chamber phakic intraocular lens implantation: comparative, multicentre study in 351 eyes with low-to-moderate or high myopia. Br J Ophthalmol. 2018;102(2):177-81. 7. Igarashi A. Posterior chamber phakic IOLs vs LASIK: benefits and complications. Expert Rev Ophthalmol. 2019;14(1):43-52. 8. Ganesh S, Brar S, Pawar A. Matched population comparison of visual outcomes and patient satisfaction between 3 modalities for the correction of low to moderate myopic astigmatism. Clin Ophthalmol. 2017;11:1253-63. 9. Zhang H, Deng Y, Ma K, et al. Analysis on the changes of objective indicators of dry eye after implantable collamer lens (ICL) implantation surgery. Graefes Arch Clin Exp Ophthalmol. 2024. ePub ahead of print. 10. Coşkunseven E, Kayhan B. Reasons for explantations of posterior chamber phakic intraocular lenses in 1,490 eyes. J Refract Surg.

Editor’s Note This supplement was published by Media MICE with support from STAAR Surgical. The views expressed are those of the individual faculty members and do not constitute medical advice. EVO ICL indications, contraindications and prescribing information vary by country. Physicians should consult current local labeling and regulatory guidance before clinical use.

2024;40(11):e797-803. 11. Parasta AM. The ripple effect: lens versus laser surgery. The Ophthalmologist. 2025 Sep 26. Available at: https:// theophthalmologist.com/issues/2025/articles/september/theripple-effect-lens-versus-laser-surgery/ Accessed on July 3, 2026.

EU-EVO ICL-26-0048

Important Safety Information for EVO/EVO+ ICL The EVO/EVO+ ICL is indicated for phakic patients 21-60 years of age and pseudophakic patients 21 years and older to correct/ reduce myopia up to -20.0 D with up to 6.0 D of astigmatism. Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/ benefit ratio before implanting a lens in a patient with any of the conditions described in the DFU. Prior to surgery, physicians should inform prospective patients of possible risks and benefits associated with the EVO/EVO+ ICL. Reference the EVO/EVO+ ICL DFU available at https://edfu.staar.com/edfu/ for a complete listing of indications, contraindications, warnings and precautions.

This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.

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