Purpose: Report the outcomes of the implantable collamer lens (ICL) in myopic astigmatism using very high-frequency (VHF) digital ultrasound sizing. Methods: Analysis of 42 consecutive ICL procedures using EVO and EVO+ (Visian V4c) lenses (STAAR Surgical) was done. ICL size was chosen using the ultrasound-based Kojima Formula with Insight 100 VHF digital ultrasound (VHFDU). Standard visual outcomes analysis was performed using 3-month data, also including contrast sensitivity, refractive and corneal vector analysis, and ECC. Postoperative lens position was evaluated using VHF digital ultrasound. Results: Attempted SEQ was − 10.83± 3.39D (− 4.40 to − 16.98D). Cylinder was − 1.46± 1.15D (0.00 to − 4.25D). One-year follow-up was available in 86% of the eyes and 3 months in 96%. Postoperative UDVA was 20/20 or better in 89% of the eyes, relative to 71% preoperatively. Postoperative SEQ refraction was ± 0.50 D in 74% and ± 1.00 D in 98% of the eyes. There was a gain of one line of CDVA in 43% of the eyes, 2 or more lines in 10% of the eyes, while there was a one line loss in 7% and no eyes lost 2 or more lines. The vector mean for the corneal SIA was 0.24 D Ax 100. Contrast sensitivity showed a statistically significant increase with a mean of 0.14 log units at 6, 12, and 18 cycles per degree (P< 0.01). The mean change in ECC was − 153± 353 cells/mm2. Lens vault was 506± 233 μm (114– 924 μm). Footplate insertion was in zonular position in 48.3%, ciliary body in 49.2%, and sulcus in 2.5% of locations. Conclusion: ICL implantation resulted in high safety and efficacy but with an implantation vault range that ideally would be improved upon. VHF digital ultrasound of the lens footplate and posterior anatomical relations may provide essential information for evaluating postoperative vault outliers.