Unilateral Implantation of Presbyopic Correcting IOLs – A Comparison of ReZoom, ReSTOR, Crystalens 5.0 , and

1. Unilateral Implantation of Presbyopic Correcting IOLs –A Comparison of ReZoom, ReSTOR, Crystalens 5.0, and Crystalens HD Frank A. Bucci, Jr, MD Bucci Laser Vision Institute Wilkes Barre, PA - USA No Financial Interest

2. Purpose:To evaluate pt. satisfaction & the visual outcome of 295 pts. having received either 1 ReZoom (RZ), 1 ReSTOR (RS), 1 Crystalens-5.0 (CR-5.0), or 1 Crystalens HD (CR-HD) for the correction of presbyopia Methods:

3. Results • Unilateral Presbyopic IOLs

4. June 05 -- December 05 46 ReSTOR implanted Subjective Response of Patients - High % of pts. Very Disappointed • poor inter. (no computer vision)• perceived near focal point too close • generalized waxy vision at all focal points • SUBTLE, but distinct loss of UDVA & BCDVA dist. acuity Poor Patient Satisfaction - Vaseline Vision Dysphotopsia •3/46 Eyes (6.52%) • 3 emmetropic lensectomy pts. • mean age = 50 years • 3 explantations (exchanged for 3 ReZoom) Overall Outcomes • Consistent objective data • Very poor subjective responses Final Outcome • Use of ReSTOR 4.0 as unilateral IOL Abandoned

5. January 06– January 08138 ReZoom Implanted Subjective Response of Patients • High % of patients very satisfied • pleased with distance vision (esp. during the day) • pleased with enhanced intermediate vision • gained substantial amounts of reading • non haloed image in opposite eye at night with CL or emmetropia Pearls for Success • Careful Pre op Counseling • avoided disappointments re: need for reading glasses for fine print • avoided disappointments re: need of neuroadaptation for halos at night • Less halos and more rapid neuroadaptation observed with ReZoom vs. Array

6. Discussion Success is dependent upon 3 key factors as observed with bilateralpresbyopic IOLs • Knowledge of and efficient placement of PC IOL • Strong Dr. Communication skills to facilitate ▪ proper pt. selection ▪ effective pre op counseling ▪ management of post op expectations • Aggressive reduction in residual refractive errors

7. Discussion • ReZoom ReZoom was successful as a unilateral • Broad range of vision ▪ distance ▪ intermediate ▪ near • Pre op counseling was provided on the need for patience with neuroadaptation for halos • Unilaterally, need for neuroadaptation much less because of the non-haloed image in opposite eye • Conversion to bilateral with TMF diffractive has been shown to be very successful, if necessary

8. Discussion • TECNIS Multifocal TMF may be successful as a unilateral diffractive multifocal IOL, even though the ReSTOR failed • European data 1,2,3 has shown superior intermediate vision for TMF vs. RS • Outstanding near vision in both moderate and bright light • Wider near focal range vs. RS • No waxy vision 1Scheider A., et al, European Society of Cataract and Refractive Surgery, 2006 2Toto, L., et al, Journal of Cataract and Refractive Surgery, 2007 3Hutz, W., et al, Journal of Cataract and Refractive Surgery, March 2008

9. Discussion • Crystalens • Excellent distance with no halos at night • the only lens with entirely no light phenomenon at night • Excellent intermediate in high percentage • note that the mean J intermediate for CR-HD is better than RZ but it has a higher variance and some patients may lack minimal intermediate • Improved near • note that the CR-HD has one half J line improved near vision compared to the CR-5.0 without influencing quality of distance

10. Discussion • Crystalens • Unfortunately, even with the improved near (J2.7 vs. 3.2) and intermediate (J2.8 vs. 3.0) vision of the CR-HD compared to the CR-5.0 • A significant % of patients would still be less than satisfied at near unless some degree of monovision was pursued with sacrificing of distance vision • There is also significantly less predictability with all Crystalens for both distance and near targets which would be more accentuated when used unilaterally • Conversion to bilateral with TMF would likely be very successful

11. Discussion • ReSTOR One would expect the ReSTOR 3.0 with improved intermediate and a more comfortable focal point to function better than the ReSTOR 4.0. However, the ReSTOR 3.0 still reads poorly in dim light. Thus if a surgeon is considering a diffractive IOL, the TECNIS multifocal with excellent near vision at all levels of light (and pupil size) should be the lens of choice.

12. Conclusions / Final Comments 1. With proper preop counseling and surgical planning all of the current presbyopic IOLs (except the ReSTOR 4.0) can work well for reducing the patients dependency on glasses or contact lenses. 2. Strengths and weaknesses of each IOL are obviously similar to what is observed in bilateral circumstances. The RZ has the broadest range of vision which is an important “unilateral” characteristic, but less halos would be ideal. Conversion to RZ/TMF is synergistic, and powerful. 3. On average, unilateral results for the CR-HD are encouraging with no halos being a plus. Conversion to bilateral with TMF is very synergistic and a solution to the 30% that are ≤J4 at near because of a wide variance in results. 4. Even though RS 3.0 will be an improvement to RS 4.0, the TMF will be the diffractive lens of choice with excellent near vision in all lighting conditions. TMF could likely become the unilateral presbyopic lens of choice.

13. Thank You