Beyond 20/20: The Transformative Power of EVO ICL
“Don’t read the chart yet.”
That’s what I tell my EVO ICL patients at their same-day post-op visit. I’m only checking their intraocular pressure—not their acuity—but they can’t help themselves.
By the next day, when I do check vision, many patients—such as the -3.00 D software engineer or the -15.00 D myope—are already seeing 20/20 or better and wondering why they waited so long.
As myopia rates continue to rise and more patients seek freedom from glasses and contact lenses, I am increasingly recommending EVO ICL as a first-line refractive surgery option, not just a backup for “edge cases.”
For many, the fear of adverse events from surgery is a significant concern, while others are hesitant about permanent surgical solutions. What if patients are clearly informed about the anticipated adverse events and the reversibility of the procedure?
This guide will walk through why—covering the lens design, clinical outcomes, and safety data—through the lens of real-world experience in a high-volume refractive practice.
Myopia on the Rise: An Opportunity to Make a Difference
By 2050, ~50% of the world's population is expected to be myopic, including around 9.8% who will be highly myopic. This increase represents a nearly sevenfold increase since 2000, leading to an estimated 5 billion people with myopia, of whom 1 billion will have high myopia (<-5.00 D), as shown in Figure 1.1
Figure 1. Population growth of Myopia from 2000 to 20501
The US has a reported prevalence of ~42% among patients aged 11-54 years.2 In my experience, these patients are seeking refractive surgery as an alternative to optical correction and have expectations for excellent outcomes, especially highly myopic patients.
In March 2022, the FDA approved the EVO ICL with a central port (Figure 2), a significant milestone that expanded non-optical correction options for patients.3 The EVO ICL is implanted in the posterior chamber of the eye, directly behind the iris and in front of the natural crystalline lens. It offers correction of myopia with spherical equivalent ranging from -3.00 D to ≤ -15.00 D with less than or equal to 2.50 D of astigmatism at the spectacle plane. It is also indicated for the reduction of myopia with spherical equivalent ranging from greater than 15.00 D to -20.00 D with less than or equal to 2.50 D of astigmatism at the spectacle plane with cylinder 1.00 D to 4.00 D.4
In Canada, EVO/EVO+ ICL was approved in 2016 for the correction and reduction of myopia in phakic patients with an anterior chamber depth (ACD) of 2.8 mm or greater. It is available in spherical powers ranging from -3.0 D to -18.0 D, with or without astigmatism correction, and cylinder powers ranging from 1.0 D to 6.0 D.5
Figure 2. EVO ICL with Central Port
EVO ICL Insights: Design, Outcomes, and Safety
The new EVO ICL design eliminates the need for preoperative iridotomies, and safety data suggest reduced rates of anterior subcapsular cataract (ASC) and pupillary block relative to earlier models. EVO ICL has an ASC rate of 0.16%, which was observed in only one study eye.6
Many optometrists mistakenly believe that EVO ICL increases the risk of angle closure glaucoma (ACG) and ASC. Although the central port design is generally considered not to alter the vault features of the ICL, it can help reduce the risk of associated adverse events.6
There are a few advantages of the EVO ICL, which center on preserving the tear film7 and the cornea8:
- No tissue removal
- No risk of ectasia
- Rapid recovery
- Straightforward calculations for future IOL implants when the patient may need surgery for age-related cataracts
The placement of the ICL between the anterior chamber and crystalline lens results in placement proximity to a patient’s nodal point, as shown in Figure 3.4,9-10 It also provides UV protection4 and, most importantly, is reversible.
Figure 3. Placement of EVO ICL results in placement proximity to the patient’s nodal point.
How EVO ICL Design Enhances Optical Quality and Safety
The lens design features a single-piece, posterior chamber phakic intraocular lens (IOL). This lens is made from a proprietary material called Collamer®, which combines collagen and copolymer properties, providing UV-blocking and hydrophilic benefits. This biocompatible material provides UV protection by incorporating a UV-absorbing chromophore within a poly-HEMA-based copolymer.4 With over 30 years of proven history, this unique material is exclusive to the EVO ICL. Collamer® effectively minimizes inflammation, glare, and cellular reactions.11-12
The Central port design (“KS-AquaPORTTM”), shown in the video below, eliminates the need for preoperative iridotomy and ensures physiologic aqueous flow. Available safety data support lower rates of anterior subcapsular cataract and pupillary block when compared with earlier-generation models.4,9
Aspheric optics reduces spherical aberration, and the Ganesh et al. (2017) study showed a significant reduction in higher-order aberrations compared to SMILE and fs-LASIK, which may have been due to reduced intraocular scatter.7 For patients with larger pupils, the EVO+ ICL has an expanded optic.13
The Patient Journey: Procedure and Post-Op Follow-ups
Patients often comment that the procedure is quick. The video below shows the procedure, including inserting and centering the ICL.
Why EVO ICL Delivers: A Look at Its Proven Clinical Efficacy
The EVO ICL shows outcomes comparable to those of LASIK and SMILE in patients with moderate to high myopia.14 In the three-year EVO ICL FDA clinical trial, 90.7% of eyes were within +0.50D of the target, and 99% were within +1.00D of the target. Additionally, 48.9% of patients gained one or more lines of CDVA.6
In studies evaluating the visual efficacy of the EVO ICL, 56% of patients with > 6.00 D of myopia achieved a gain of 1 or more lines in corrected distance visual acuity (CDVA),10 compared with 42% in those with < 6.00 D of myopia.15
For patients with > 6.00 D of myopia, 98% achieved an uncorrected distance visual acuity (UDVA) of 20/20 or better, and 98% had a manifest refraction spherical equivalent within +0.50 D at the six-month follow-up.15
For patients with < 6.00 D of myopia, 97% also achieved a UDVA of 20/20 or better, with 90% having a manifest refraction spherical equivalent within +0.50 D at the six-month post-operative follow-up.15
Safety Profile of EVO ICL: Evidence from Clinical Trials
The FDA clinical trials did not report any pupillary block.6,8 Although a temporary increase in IOP was reported 1 to 6 hours post-op, these increases were caused by retained OVD. There were no reports of elevated IOP due to blockage of aqueous flow through the central port, narrowing of the anterior chamber angle, pigment dispersion, or intraocular inflammation.6
Regarding halos and glare, only one eye was explanted, and the symptoms resolved. Of those with a vault less than 250 µm, only one eye (0.16%) developed a visually significant ASC, and vision improved after cataract surgery. Endothelial cell density was preserved, and the mean endothelial cell loss was 6.7% between pre-op and 3 years.6
How I Identify the Ideal EVO ICL Candidate
Patients frequently come to our practice for LASIK consultations, often encouraged by friends or family members who have had the procedure. As clinicians, it is our responsibility to ensure that they are aware of all their options and to help them make informed decisions that align with their lifestyles, needs, and preferences. Based on my experience, a patient’s lifestyle and personality do not impact my recommendation. I believe that the EVO ICL may be the better choice for many patients, as it offers quick visual recovery and sharp, clear vision from morning to night,6 and is ideal for those seeking a reversible option for vision correction.
For certain patients with thin corneas, high myopia, inferior steepening on topography, posterior elevation, or if the prescription is within range but there's dry eye with contact lenses, they are on dry-eye therapy, an EVO ICL may be the better option. Dry eye patients can prevent exacerbation as seen in other refractive surgery procedures.
Since the indications for EVO ICL differ between the US and Canada, the ideal candidates for the procedure also vary.
Ideal US Candidates
The ideal candidates for the EVO ICL lens are individuals aged 21 to 60. This lens effectively corrects myopia with a spherical equivalent ranging from -3.00 D to -15.00 D and allows for up to 2.50 D of astigmatism at the spectacle plane. Additionally, it is suitable for reducing myopia with a spherical equivalent between -15.00 D and -20.00 D, up to 2.50 D of astigmatism at the spectacle plane, and for those with a cylinder between 1.00 D and 4.00 D. In addition, the patient's eye must be healthy, with no history of glaucoma or cataract, and have an open angle, an anterior chamber depth of 3.00 mm or greater, and a healthy endothelium.4
Ideal Canada Candidates
The ideal candidates for this procedure are patients aged 21 to 60 who have myopia ranging from -0.50 D to -20.00 D, with astigmatism of 6.0 D or less at the spectacle plane. In Canada, EVO ICL lenses are available with a spherical power ranging from -3.0 D to -18.0 D, with cylinder power ranging from 1.0 D to 6.0 D. Additionally, candidates must be in good health, with no history of glaucoma or cataracts, an open-angle diagnosis, an anterior chamber depth of 2.80 mm or greater, and a healthy endothelium.5
These patients may be contact lens intolerant, have challenging contact lens fits, experience dry eye with contact lenses, and have corneas unsuitable for laser vision correction.
My pre-operative assessment includes the following:
- Autorefractor: obtain an estimate of the patient’s prescription and keratometry values.
- Refraction: perform both a manifest and cycloplegic refraction.4 It is important not to over minus the patient.
- Topography: evaluate the patient's cornea and check for risk of keratoconus.
- Pentacam: use this to double-check any suspicious findings in the topography.
- In our office, when a patient shows inferior steepening on their topography, I confirm the findings with a Pentacam to assess for posterior elevation. If their prescription falls within an acceptable range and they have dry eye issues related to contact lens use or are currently being treated for dry eye, I discuss the EVO procedure as a preferable option compared to LASIK, PRK, and SMILE.
- Biometry (IOL Master or Lenstar): evaluate anterior chamber depth (ACD)/anterior chamber angle, and axial length. White-to-white (WTW) measurement is also needed to determine the lens diameter.
- Ultrasonic biomicroscopy (UBM): confirms WTW measurement.4 Some doctors may find that ICL AI-powered tools assist in determining ICL sizing; however, for optimal results and per the EVO ICL Directions for Use, the STAAR® ICL calculation software4 should be used.
- IOP: check to make sure IOP is within range and establish the patient’s baseline.
- Dilated fundus exam: evaluate the health of the eye. Ensure the patient dilates to 8 mm; if the patient is borderline, it is at the surgeon's discretion whether to proceed with the surgery.
Overview of Refractive Surgery Options
Patients often arrive with an idea of what refractive procedure they are interested in. When discussing the various options, my goal is to ensure each patient is matched to the procedure that best suits their needs. Factors such as the severity of the refractive error, corneal characteristics, eye health, and the patient's preferences play a vital role in the decision-making process.14
Table 1 compares the EVO ICL, LASIK, SMILE, and PRK. Indications for each procedure vary based on the machine/laser available.
Table 1. Comparison of Refractive Surgery Options4,14,16-19
How to Talk About EVO ICL With Your Patients and Staff
Many patients have probably heard of LASIK and may visit the practice with the intention of getting it, only to find they are poor candidates. Patient education is paramount in helping patients determine which option works best for them. For people in high-risk professions or those who participate in high-contact sports like mixed martial arts, I tell them that ICL may be a better choice than LASIK, which has a flap that may dislodge. ICL implantation also provides a viable alternative for individuals with higher refractive errors or corneal irregularities.14
It’s important to explain the procedure in terms that the patient will understand. I use eye diagrams to illustrate that the EVO ICL is essentially like a built-in implantable lens. I assess the patient’s personality while explaining the procedure and adjust my explanations accordingly, tailoring my conversations to be more technical or simpler as needed.
I also drive home the reversibility of the procedure. If a patient experiences regret, wants to upgrade their lens, convert to monovision, or have cataract surgery, the process is straightforward, unlike that of other refractive surgeries.
Some patients may fall slightly out of range for the EVO ICL if they have high astigmatism. The first step is to rule out corneal ectasia. In my practice, our surgeon implants an EVO ICL and, if necessary, performs LASIK or limbal relaxing incisions to correct residual astigmatism as part of the package.
Sometimes, patients question why they would need a LASIK touch-up if they are told they aren’t a good candidate. I reiterate that the EVO will correct the majority of their prescription, and that a touch-up is only necessary if they absolutely need it. Glasses and contact lenses correcting the residual astigmatism are also options if they want to go that route.
Lastly, I emphasize the importance of training staff about the EVO ICL. It requires frequent staff education, similar to the points that involve patient communication. It’s a long process, and having some staff members who elected to have the EVO ICL has helped them understand the procedure. The practice has also sent staff to STAAR headquarters to learn more about the procedure and has participated in a training course that provided an overview of the entire process.
STAAR offers an Eyecare Professional Education Portal, a global hub for clinical learning and team support. The portal provides role-specific, customized resources to support the entire practice, from surgeons to staff. Access a broader range of impactful content, including surgeon certification modules, surgical videos, real-world case studies, and role-specific learning tools designed for surgeons, optometrists, and clinical support teams.
Comfort and Clarity: The EVO ICL Patient Experience
Patient satisfaction with EVO ICL is high, with STAAR survey results reporting 99.4% would elect to have the EVO procedure again.20 There are several common themes I often hear during post-operative visits, including:
- Painless, easy experience: Patients are frequently surprised by how comfortable the procedure is, especially when conducted under twilight anesthesia
- Immediate improvement: Many patients can see 20/20 or even 20/15 on the very first day, sometimes while still partially dilated
- Minimal dryness or irritation: Unlike LASIK and PRK patients, those who undergo the EVO procedure rarely report a foreign-body sensation or significant discomfort on the same day post-op visit
EVO ICL in Practice: Lessons From Routine and Complex Cases
Clinical Pearls
- We use a combination of Moxifloxacin/Prednisolone QID OU for 2 weeks after EVO ICL and dispense 2x 500 mg Diamox extended-release tabs to be used q12 hours for 24 hours after surgery.
- If any residual astigmatism is found at any post-op visit, I recommend dilating to confirm that the ICL has not rotated. The ICL can be rotated back to the correct position and may need to be sized up to prevent further rotation.
- The lens vault (the distance between the anterior surface of the crystalline lens and the posterior surface of the EVO/EVO+ ICL/TICL lens) should be assessed 24 hours postoperatively at a slit lamp and in the follow-up visits. Although the postoperative vault of the EVO/EVO+ ICL/TICL lens is intended to be approximately equal to the central corneal thickness, we believe that the optimal vault should be between 50% and 150% of central corneal thickness. However, in the absence of signs and symptoms, lens vault outside of this range may not necessarily require exchange or removal of the ICL. It is recommended that the EVO/EVO+ ICL/TICL lens be removed in cases where the patient also shows signs and symptoms (narrowing of the anterior chamber angle, thus decreasing aqueous flow, or other reasons on an individual basis).
- If IOP is high on the same day or 1 day post-op, consider corneal burping (using closed forceps to gently touch near paracentesis to open the wound to lower IOP) and/or giving the patient Diamox to lower IOP. High IOP in early post-op with an open angle is typically due to retained viscoelastic, which will naturally absorb over the next few days. You can burp it, though, to lower the IOP sooner, as mentioned before.
- If residual refractive error is present at 1-3 months post-op, indicating it is more stable now and the patient is symptomatic, consider LASIK/PRK enhancement for a small correction. Always confirm with the trial frame that the residual MR improves vision. If the difference is negligible, then it is not worth performing another surgery to correct a small residual MR.
EVO ICL Isn’t Just Another Procedure—It’s a Modern Refractive Approach
EVO ICL addresses the needs of both patients and clinicians by offering rapid recovery, excellent visual quality, and a reversible solution that preserves the cornea, enabling flexibility as patient needs change. The design improvements from the Visian ICL reduce the risk of complications such as ACG and ASC. For patients with high myopia and astigmatism, optometrists should consider this option to ensure optimal vision and a smooth recovery post-surgery. In my practice, it has become the primary option for eligible myopic patients.
The data are compelling—high rates of 20/20 or better UCVA, low complication rates, stable endothelial cell counts—and the real-world experience is equally strong: minimal dryness, quick return to normal activities, and patients who consistently report that the procedure was easier and more comfortable than expected.
For eyecare professionals, the take-home message is straightforward:
- Consider EVO ICL earlier in the refractive decision tree, especially for patients with high myopia, thin corneas, or dry eye.
- It is an excellent option for moderate myopes with astigmatism, with high patient satisfaction.21
- Invest in education—for yourself, your staff, and your patients—so EVO is presented as a strong evidence-based option rather than an unfamiliar “last resort”.
When you put the numbers, design innovations, and lived patient experiences together, EVO ICL is not simply another refractive procedure—it is a modern refractive strategy for a world where myopia is only becoming more common.
Visit the STAAR website for more information at: www.staar.com
Important Safety Information for the EVO/EVO+ ICL (US Only)
The EVO Visian ICL is indicated for phakic patients 21-60 years of age to correct/reduce myopia with up to 4.00 D of astigmatism with a spherical equivalent ranging from -3.00 to -20.0 D and with an anterior chamber depth (ACD) of 3.0 mm or greater.
The EVO Visian ICL is indicated for phakic patients 21-60 years of age to correct/reduce myopia with up to 4.00 D of astigmatism with a spherical equivalent ranging from -3.00 to -20.0 D and with an anterior chamber depth (ACD) of 3.0 mm or greater.
The EVO Visian ICL is contraindicated in patients with a true ACD of <3.00mm; with anterior chamber angle less than Grade III; who have moderate to severe glaucoma, who are pregnant or nursing; less than 21 years of age; and who do not meet the minimum endothelial cell density (ECD) listed in the Directions For Use (DFU).
A summary of the relevant warnings, precautions and side effects: Endothelial cell loss, corneal edema, cataract, narrowing of the anterior chamber angle, pupillary block, increased intraocular pressure, glaucoma, secondary surgery to reposition, replace or remove the ICL, loss of BSCVA, increase in refractive astigmatism, glare and/or halos, pigment dispersion, iris transillumination defects, endophthalmitis, hypopyon, corneal endothelial damage, ICL dislocation, cystoid macular edema, iritis, retinal detachment, vitritis, and iris prolapse.
Please review the DFU available at https://edfu.staar.com/edfu/ for complete safety and other information before performing the clinical procedure.
Please review the DFU available at https://edfu.staar.com/edfu/ for complete safety and other information before performing the clinical procedure.
Important Safety Information for the EVO/EVO+ ICL (Canada only)
The EVO/EVO+ ICL is indicated for phakic patients 21-60 years of age with an anterior chamber depth (ACD) 2.8 mm or greater and are available in spherical powers ranging from -3.0 D to -18.0 D for the correction/reduction of myopia with or without a cylinder power range from 1.0 D to 6.0 D. 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.
The EVO/EVO+ ICL is indicated for phakic patients 21-60 years of age with an anterior chamber depth (ACD) 2.8 mm or greater and are available in spherical powers ranging from -3.0 D to -18.0 D for the correction/reduction of myopia with or without a cylinder power range from 1.0 D to 6.0 D. 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.
US-EVO ICL-25-0143
