Diffractive Multifocal Lenses after Corneal Laser Vision Correction

SHERAZ DAYA MD FACP FACS FRCOphth FRCS(Ed)

MARCELA ESPINOSA MD

CRISTIA SUNGA BOptom

Financial DisclosureCompany Code

1. Abbott Medical Optics Inc. S

2. Bausch + Lomb C,L

3. Carl Zeiss Meditec C

4. Clarvista C

5. Ellex L

6. Excellens C, O

7. LinCor Biosciences C

8. Medicem C

9. Nidek, Inc. C,L

10. Physiol L

11. PRN O

12. STAAR Surgical C

13. Strathspey Crown C

14. Scope Pharmaceuticals C

15. Rayner C

C = Consultant / Advisor

E = Employee

L = Lecture Fees

O = Equity Owner

P = Patents / Royalty

S = Grant Support

Can Multifocals be used following LVC ?

Considerations following LVC

– Demanding patients

– Induced aberrations

– ? Reduced contrast – visual quality

– Dry eye

– Predictabililty - Accurate lens calculations

Post Laser vision Correction

Induced aberrations• Spherical aberrations – oblate cornea / small zones

– Myopia - POSITIVE SA

– Hyperopia NEGATIVE SA

• Coma – decentered treatments

Issues following LVC

• Biometry Error– ? Measurement of effective corneal power

– Refractive surprises

• Myopic LVC - hyperopic

• Hyperopic LVC – myopic

– Why ?

• Instrument error (not designed for abnormal corneas)

• ACD error

• Refractive index change ?

• Calculation formulas

Diffractive Lenses following LVC

• Do Cornea optics combine with diffractive lenses ?

– Potential for reduced performance – intermediate / near

– Visual quality issues ?

• Is there a high enhancement rate ?

– Lens calculation error

• Are NEGATIVE SA lenses harmful post-Hyperopic LVC?

• Is visual quality adversely affected ?

Patients & Methods

• Retrospective study from Post LVC with Diffractive lenses 2007

• N= 57 eyes 33 patients

• Mean Age: 63 years (range 49 to 72)

• Male: Female 28:29 (eyes)

EYES BILATERALHyperopic LVC: 31 14

Myopic LVC: 26 10

Patients and Methods

• LENS CALCULATION– Pentacam Holladay Report K readings

– Holladay 2 Formula

• SURGERY– 1.8mm Microincisional cataract surgery

(Stellaris MICS)

– Diffractive lenses:

• Acrilisa (Bifocal) 4 eyes

• Finevision Trifocal 51 eyes

• AT Trifocal Toric 2 eyes

RESULTS – Refractive Outcomes

PREOP 1M 3M

Sph Equivalent 0.05 D ± 1.98 ( range -6.00 to 2.00)

0.62 D ± 0.48(range -2.25 to 0.00)

0.08 D ± 0.54 (range -0.75 to 1.50)

Cylinder 0.62 D ± 0.48 (range -2.25 to 0.00)

0.43 D ± 0.39(range -1.50 to 0.00)

0.41 D ± 0.44 (range -1.50 to 0.00)

y = 0.96xR² = 0.85

0

1

2

3

4

5

6

7

8

9

10

0 1 2 3 4 5 6 7 8 9 10

Shera

z D

aya, M

D

avg. deviation -0.09 D (from -1.48 to 1.24)

Ach

ieve

d c

ha

nge

in S

EQ

Refr

action [D

]

Attempted change in SEQ Refraction [D]

Scatter: Attempted vs. Achieved SEQ 'PREDICTABILITY' 58 eyes - 1 m postOP

overcorrected

undercorrected

PREDICTABILITY

y = 1.02xR² = 0.89

0

1

2

3

4

5

6

7

8

9

10

0 1 2 3 4 5 6 7 8 9 10

Shera

z D

aya, M

D

avg. deviation 0.02 D (from -0.96 to 1.50)

Ach

ieve

d c

ha

nge

in S

EQ

Refr

action [D

]Attempted change in SEQ Refraction [D]

Scatter: Attempted vs. Achieved SEQ 'PREDICTABILITY' 40 eyes - 3 m postOP

overcorrected

undercorrected

1 M 3 M

0%

5%

10%

15%

20%

25%

30%

35%

7%

14%

17%

26%

33%

2% 2%

20%

25%

13%

28%

10%

5%

SHER

AZ

DA

YA, M

D

± 0.50 D: 65%

± 1.00 D: 95%

Refractive outcome - Percentage within Attempted

1 m (58) 3 m (40)

month (eyes)

Refractive outcome

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

14%

45%

78%

93%97%

3%

15%

48%

75%

90%

98%

3%

Monocular1 m (58) 3 m (40)month

(eyes)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

31%

74%

100% 100% 100%

35%

84%

95%100% 100%

Binocular UDVA UDVA

UNVA 40cm

0%

20%

40%

60%

80%

100%

36%

57%

84%

97%

3%

23%

60%

78%

95%

5%

Monocular UNVA @40

1 m (58) 3 m (40)

mo

nth

0%

20%

40%

60%

80%

100%

46%

83%

98%100%

38%

81%

92%100%

Binocular UNVA

mo

nth

20/30 J3

20/25 J2

20/20 J1

UIVA 60cm

0%

20%

40%

60%

80%

100%

2%

22%

59%

91%97%

3%

30%

50%

83%

98%

3%

Cumulative UIVA @60

1 m (58) 3 m (40)

mont

h

0%

20%

40%

60%

80%

100%

35%

78%

98% 100%

3%

30%

81%

97% 100%

Binocular UIVA @60

mo

nth

UIVA 80cm

0%

20%

40%

60%

80%

100%

10%

45%

74%

93% 95%

5%

18%

48%

73%

95% 98%

3%

Monocular UIVA @80

1 m (58) 3 m (40)

mo

0%

20%

40%

60%

80%

100%

19%

65%

93%100%100%

14%

68%

86%95%

100%

Binocular UIVA @80 mo

nth

SAFETY

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2% 2%

16%

50%

19%

5%7%8%

20%

43%

18%

8%5%

Change in CDVA - Percentage 'SAFETY'

1 (58) 3 (40)month

(eyes)

Q values post LVC

• Hyperopic Myopic*

Q value Mean SD Range

Pentacam(n= 26)

+0.271 0.461 -0.20 to -1.11

OPD 3 (n=25) +0.322 0.547 -.17 to -2.02

Q value Mean SD Range

Pentacam(n=29)

-0.521 0.303 -0.06—1.50

OPD 3(n=29) -0.516 0.239 -0.17—1.129

* 1 eye “blended vision”

Corneal Aberrations• Hyperopic Myopic

OPD 3 4mm SA COMA TOTAL

Mean 0.074 0.237 0.392

SD 0.0717 0.188 0.284

Range 0.013 –0.242

0.078 -0.825

0.087 -1.296

PENTACAM SA HOA

Mean 0.148 0.601

SD 0.105 0.172

Range 0.066 to 0.312

0.512 -1.068

OPD 3 4mm SA COMA TOTAL

Mean 0.139 0.261 0.404

SD 0.133 0.346 0.456

Range 0.023 -0.513

0.037 -0.806

0.900 –1.027

PENTACAM SA HOA

Mean 0.788 1.215

SD 0.252 0.401

Range 0.591 -1.046

0.891 –1.821

Hyperopia (n=31) vs Myopia (n=26)

• Refractive outcomePREOP 1M 3M

SPH EQUIV

-1.01 D ± 2.07 ( range -6.00 to +1.50)

-0.16 D ± 0.68(range -1.50 to +1.13)

0.10 D ± 0.70 (range -0.75 to 1.50)

CYL -0.63 D ± 0.44 (range -1.50 to 0.00)

-0.34 D ± 0.40(range-0.34 to +0.40)

-0.33 D ± 0.39 (range -1.00 to 0.00)

PREOP 1M 3M

SPH EQUIV

0.71 D ± 1.56 (range-5.88 to +2.00)

-0.19 D ± 0.41(range -1.00 to +0.75)

-0.17 D ± 0.36 (range -0.75 to +0.63)

CYL 0.60 D ± 0.52 (range -2.25 to 0.00)

-0.05 D ± 0.41(range -1.00 to 1.00)

-0.07 D ± 0.44 (range -1.50 to 0.00)

Hyperopia vs Myopia

0%

5%

10%

15%

20%

25%

30%

35%

3%

13%

23%

29%

32%

22%

26%

13%

30%

9%

Sher

az D

aya,

MD

± 0.50 D: 70%

± 1.00 D: 100%

Refractive outcome Hyperopic LVC

1 m (31) 3 m (23)

mont

0%

5%

10%

15%

20%

25%

30%

35%

12%12%12%

23%

35%

4% 4%

13%

25%

13%

25%

13%13%

± 0.50 D: 63%

± 1.00 D: 88%

Refractive outcome – Myopic LVC

1 m (26) 3 m (16)

Hyperopic vs Myopic LVC - Monocular

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

16%

55%

84%

100%100%

26%

57%

78%

91%96%

4%

UDVA – Hyperopic LVC

1 m (31) 3 m (23)

mon

th

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12%

35%

73%

85%92%

8%

38%

69%

88%

100%

Sher

az

UDVA – Myopic LVC

1 m (26) 3 m (16)

mont

h

Hyperopic vs Myopic LVC -Binocular

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

41%

79%

100%100%100%

48%

86%

100%100%100%

Binocular UDVA Hyperopic LVC

1 m (29) 3 m (21)

mont

h

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

21%

67%

100%100%100%

13%

80%87%

100%100%

Binocular UDVA –Myopic LVC

1 m (24) 3 m (15)

Hyperopic vs Myopic LVC – UNVA Binocular

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

38%

83%

96%100%

27%

53%

80%

100%

Binocular UNVA - Percentage

1 m (24) 3 m (15)

mont

h

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

55%

86%

100% 100%

48%

100% 100% 100%

Binocular UNVA - Hyperopic LVC

1 m (29) 3 m (21)

month

(eyes)

Hyperopic vs Myopic LVC Binocular 80cm

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

72%

100% 100% 100%

10%

71%

90%

100% 100%

Sher

az

Day

a, M

D

Binocular UIVA @80 – Hyperopic LVC

1 m (29) 3 m (21)

mont

h

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

42%

54%

83%

100% 100%

20%

60%

80%87%

100%

Binocular UIVA @80 – Myopic LVC

1 m (24) 3 m (15)

Hyperopic vs Myopic LVC - Safety

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

4% 4%

12%

42%

19%

4%

15%

19%

6%

38%

13% 13% 13%

Change in CDVA - Percentage 'SAFETY'

1 (26) 3 (16)

0%

10%

20%

30%

40%

50%

60%

19%

55%

19%

6%

30%

43%

22%

4%

Change in CDVA – Hyperopic LVC'

1 (31) 3 (23)

Hyperopic vs Myopic LVC - Contrast

3.51

1.73 1.81

3.90

9.70

3.98

1.78 2.19

6.15

16.78

3.24

1.15 1.51

3.67

8.81

0.00

5.00

10.00

15.00

20.00

1,5cpd 3cpd 6cpd 12cpd 18cpd

Contrast Sensitivity Hyperopic LVC

pre op (6) 1 m (15) 3 m (9)

month

Spatial Frequency [cycles/degree]

6.28

3.23 3.80

6.16

11.77

3.53

1.91 2.32

9.04

22.24

3.98

2.05 1.92

5.42

14.28

0.00

5.00

10.00

15.00

20.00

25.00

1,5cpd 3cpd 6cpd 12cpd 18cpd

Contrast Sensitivity Myopic LVC

pre op (15) 1 m (19) 3 m (9)

month

Spatial Frequency [cycles/degree]

Interventions• Enhancements 4 eyes (7%)

– 3 Lasik (2 prev Hyperopia , 1 myopia)

– 1 PRK (prev myopia)

• Decentered Trifocal 1 eye– Required re-centration

• Explantations 0 eyes

• YAG Capsulotomies 6 eyes

Diffractive Lenses following LVC• Did Corneal optics combine with diffractive lenses ?

– YES – good performance – better in Hyperopic LVC

• Was there a high enhancement rate ?– 7% in this study

• Were NEGATIVE SA lenses harmful in post Hyperopic LVC ?– no impact – Hyperopic LVC did better than myopes !

• Was visual quality adversely affected ?– Contrast sensitivity good at 3 months in both groups- Hyperopic LVC

did better

– No patient complaints – all spectacle free

Conclusions

• Diffractive lenses can be used in patients following Corneal Ablative Refractive Surgery

• Consider aberrations at 4.0mm rather than 6.0mm

• Holladay Report / Holladay 2 – accurate IOL calculation

• Careful patient selection and counselling – recommended

Thank you …