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i s t a n b u l c e r r a h i h a s t a n e s i. Accomodative and Multifocal IOL implantations. DR. FAİK ORUCOV İSTANBUL SURGERY HOSPİTAL DEPARTMANT OF CATARACT AND REFRACTİVE SURGERY. Crystalens AT-45. Accomodative,monofocal IOL,pupil independent

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accomodative and multifocal iol implantations

i s t a n b u l c e r r a h i h a s t a n e s i

Accomodative and Multifocal IOL implantations

DR.FAİK ORUCOV

İSTANBUL SURGERY HOSPİTAL

DEPARTMANT OF CATARACT AND REFRACTİVE SURGERY

crystalens at 45
Crystalens AT-45

Accomodative,monofocal IOL,pupil independent

4.5 mm silicon optic (now also available as 5 mm)

Plate haptic

1.5 mm thickness

Lens responds to the natural accommodative

response(with the ciliary muscle contraction vitreus pressure increases pushes the IOL optic forward)

11.5 mm diameter

i s t a n b u l c e r r a h i h a s t a n e s i

slide3

i s t a n b u l c e r r a h i h a s t a n e s i

Crystalens

  • 56 eyes of 30 patients
  • Cataract surgery between december 2002- september 2005 with facoemulsification
  • AT-45 Crystalens implantation
  • 14 male 16 female
  • 4 years follow up
review multifocal iols

i s t a n b u l c e r r a h i h a s t a n e s i

Review: multifocal IOLs
  • Retrospective analysis of 124 patients(223 eyes)
  • Surgeries from October 05 –May 07
  • Postop expected bcva 20/40 or over (can be measured by potential acuity meter)with No anterior segment or retinal pathology
  • Small incision facoemulsification
  • Monoculer,binoculer implantation
  • Mix-match
demographics

i s t a n b u l c e r r a h i h a s t a n e s i

Demographics:
  • Female: 62 % Male: 38 %
  • Age: 7-82 (Mean=60.7)
  • Preop refraction Seq -14.25 to +9.25

78 myopic

26 emetropic

119 hypermetropic eyes

  • 6 months to 2 years follow up time
  • Average one year
  • 28 % ≤ 6 months
  • 72 % ≥ 6months
slide6

Optical Principles of IOLs

Refractive monofocal

far focus

Diffractive

near focus

far focus

1st generation zonal refractive

near focus

far focus

amo rezoom refractive multifocal iol

i s t a n b u l c e r r a h i h a s t a n e s i

AMO Rezoom-Refractive multifocal IOL
  • Large distant dominant central zone in bright light conditions and

four periferal zones that provide near,intermediate and distance focus

  • Pupil dependent
  • +3.5 D near add
  • acrylic hydrophobic
  • OptiEdge (less capsule opasification)
  • Biconvex ModC, Angle 5°
  • Haptics PMMA
  • Optic 6.0, length 13.0mm
  • Power +6.0 +30.0 D (steps

0.5D)

  • A-constant 118.4
tecnis iol

i s t a n b u l c e r r a h i h a s t a n e s i

Tecnis IOL
  • Diffractive posterior surface with 32 concentric rings
  • Light distribution of 50 % for distance vision, 50% for near vision
  • add +4:0 D
  • Tecnis:distribution of focus is independent

of pupil size

  • 5-34 D
  • Silicon
  • A-constant 119
slide11

+ ACE Cornea

near focus

far focus

Diffractive TECNIS ZM001

acri lisa iol

i s t a n b u l c e r r a h i h a s t a n e s i

Acri.lisa IOL
  • Distance –dominant -diffractive multifocal IOL
  • Independent of pupil size
  • Smooth steps in the refractive diffractive structure
  • Light distribution is not equal for far and near vision

(Asymmetrical light distribution) 65/35%

  • Acrylic
  • A-constant 118
  • 10-30 dpt
restor multifocal iol

i s t a n b u l c e r r a h i h a s t a n e s i

ReSTOR multifocal IOL
  • Appodized(gradually decreasing steps) diffractive optic at the center of the anterior surface ,refractive optical zones towards periphery
  • 10-3o dpt
  • A-constant 118.2
  • +4.0 Add
  • Reduced photic phenomena like glare,halos,low contrast sensitivity
pre op examinations
Pre-op examinations

i s t a n b u l c e r r a h i h a s t a n e s i

  • Preop full examinations:
  • Bcva
  • Dominant –nondominant eye selection
  • Oculer Tension
  • Retina and anterior segment examination
  • Topography
  • Oculyzer –Pentacam
  • Contrast sensitivity
  • Potential acuity meter
  • Pupillometry
  • Biometry
  • Pachymeter
  • Tear film quality (punctum plugs if required)
iol selection
IOL selection

i s t a n b u l c e r r a h i h a s t a n e s i

Expectations should be well discussed in detailbefore the operation

Driving,computer usage,reading,working distance

  • Distance vision may be affected by glare at low light conditions
  • Neuro-adaptation (takes time)
  • Possibility of another procedure(lasik) for better vision
  • May need reading glasses in dim light
biometry
Biometry

i s t a n b u l c e r r a h i h a s t a n e s i

  • Repeated measurements
  • Check keratometer measurements
  • Srk-t for emetropics,myopics
  • Haigis for high hyperopias
  • Check first eye’s refraction at least one week after the operation and then plan the second eye
  • For crystalens binoculer implantations postop -0.5 D myopia planning for the first eye , emmetropia for the second eye
surgery
Surgery

i s t a n b u l c e r r a h i h a s t a n e s i

  • Facoemulsification
  • Topical anesteshia
  • Corneal tunnel incision in the steepest axis (don’t consider astigmatism due to crystalline lens)
  • Capsulorexis smaller than optic diameter
  • Posterior capsule polishing
  • Care to the optic of the IOL
  • Intracapsuler ring may be implanted if necessary!
post op t esting
Post-op testing

i s t a n b u l c e r r a h i h a s t a n e s i

  • Ucva at distant, intermediate and near
  • Bcva at distant, distant corrected intermediate and near
  • Contrast sensitivity and glare was checked by Ophtec 6500 sine wave gratings of 5 different spatial frequencies: 1.5, 3, 6, 12, cycle per degree
  • Patient satisfaction questionarie
crystalens four year results
Crystalens – Four Year Results

i s t a n b u l c e r r a h i h a s t a n e s i

  • First week after the surgery with the back and front movement of the IOL -0.5 and -2.0D transient myopia was found but disappeared in one week
  • Post op mean refractive error Seq was :±0.75
  • Bcva for distant is between 20/32-20/20
  • Distance corrected near vision (40 cm) is between J 7 –J9
  • Distance corrected intermediate vision (80 cm) is between J5 - J7
  • Mean addition required for reading was

1.5 ± 0.35 D 6 months after the operation

2.25±0.25 D 4 years after operation, increased in time

crystalens results
Crystalens results

i s t a n b u l c e r r a h i h a s t a n e s i

  • According to the two years follow up, accomodative IOLs are satisfactory for the daily activities but 85 % patients need glasses for near reading
  • Near vision reading capacity decreased in time
  • Overall patient satisfaction mean score was 2 over 4
  • Patient satisfaction depends on occupation and daily activities
  • High patient satisfaction for distance
multifocal iol results
Multifocal IOL - Results

i s t a n b u l c e r r a h i h a s t a n e s i

  • Capsuler ring was placed in two eyes because of zonnuler defect
  • 3 implantations to sulcus (posterior capsula perforation)
  • Three eyes had inflammation 2 weeks after Tecnis IOL implantation
  • Two of them undergone seconder IOL exchange operation
  • Yag capsulotomy was needed in 7 patients
  • Postop secondary excimer lazer treatment was performed in 12 patients (5 %)
  • Mean monoculer post operative refractive error Seq after secondary treatment was ±0.50
contrast sensitivity results
Contrast Sensitivity-Results

i s t a n b u l c e r r a h i h a s t a n e s i

  • Contrast sensitivity functions of all multifocal and accomodating IOLs were within the reference rate of normal limits, but lower than monofocal group
  • At the middle and high spatial frequencies contrast sensitivity in the diffractive groupwas lower than refractive group
3 main groups
3 Main groups

i s t a n b u l c e r r a h i h a s t a n e s i

  • Mix-match:

Rezoom-Tecnis 26 patients

Rezoom-Acri.Lisa 21 patients

  • Bilateral -multifocal same IOL:

Rezoom-Rezoom 21 patients

Acri.Lisa-Acri.Lisa 12 patients

  • Monoculer- multifocal implantation(other eye not operated):

Rezoom one eye 22 patients

Acri.Lisa one eye 13 patients

Tecnis 9 patients

mix match
MIX-MATCH

i s t a n b u l c e r r a h i h a s t a n e s i

binoculer same iol
BINOCULER SAME IOL

i s t a n b u l c e r r a h i h a s t a n e s i

monoculer distance corrected visual acuities
MONOCULER DISTANCECORRECTED VISUAL ACUITIES

i s t a n b u l c e r r a h i h a s t a n e s i

questionnaries

i s t a n b u l c e r r a h i h a s t a n e s i

Questionnaries
  • Halo,glare(subjective experience)
  • Near,intermediate, distant vision
  • Driving (day,night)
  • Reading (newspaper,maps,prescriptions)
  • Activities(sports, shopping)
  • Patient satisfaction

1-bad

2-fair

3-good

4-very good

patient satisfaction
PATIENT SATISFACTION

i s t a n b u l c e r r a h i h a s t a n e s i

overall glare
Overall glare

i s t a n b u l c e r r a h i h a s t a n e s i

Room light

None

Always

At bright light

Night driving

Night

glare

i s t a n b u l c e r r a h i h a s t a n e s i

Glare
  • Rezoom 76 %
  • Tecnis 62 %
  • Acrilisa 58 %
  • ReStor 56 %
  • Crystalens 50%
multifocal iol patient satisfaction

i s t a n b u l c e r r a h i h a s t a n e s i

Multifocal IOL Patient Satisfaction
  • Overall satisfaction rate is 3.5
  • 92% of the patients would have the same implant again
  • 70% of the patients have some complaints while night driving
  • 79 % glasses free(computer, newspaper,outdoor activities)
  • 18 % wear glasses for reading smallprints
  • 3 % wear glasses for distant (driving)
conclusions

i s t a n b u l c e r r a h i h a s t a n e s i

Conclusions
  • Diffractive IOLs are pupil independent and for myopic patients who read alot
  • Reezoom more pupil-size dependet
    • Too small (pupils) poor reading ability ,
    • Too large - more halos
  • Refractive IOL’s (Rezoom) optical performance is better for intermediate vision
  • With monofocal-multifocal combination :satisfactory binoculer near vision (%70)
  • Best near vision with acri.Lisa is from 30-35 cm

with ReZoom 45 cm