diffractive multifocal lenses after corneal laser …...clarvista c 5. ellex l 6. excellens c, o 7....

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Diffractive Multifocal Lenses after Corneal Laser Vision Correction SHERAZ DAYA MD FACP FACS FRCOphth FRCS(Ed) MARCELA ESPINOSA MD CRISTIA SUNGA BOptom

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Page 1: Diffractive Multifocal Lenses after Corneal Laser …...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

Diffractive Multifocal Lenses after Corneal Laser Vision Correction

SHERAZ DAYA MD FACP FACS FRCOphth FRCS(Ed)

MARCELA ESPINOSA MD

CRISTIA SUNGA BOptom

Page 2: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 3: Diffractive Multifocal Lenses after Corneal Laser …...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

Can Multifocals be used following LVC ?

Considerations following LVC

– Demanding patients

– Induced aberrations

– ? Reduced contrast – visual quality

– Dry eye

– Predictabililty - Accurate lens calculations

Page 4: Diffractive Multifocal Lenses after Corneal Laser …...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

Post Laser vision Correction

Induced aberrations• Spherical aberrations – oblate cornea / small zones

– Myopia - POSITIVE SA

– Hyperopia NEGATIVE SA

• Coma – decentered treatments

Page 5: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 6: Diffractive Multifocal Lenses after Corneal Laser …...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

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 ?

Page 7: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 8: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 9: Diffractive Multifocal Lenses after Corneal Laser …...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

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)

Page 10: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 11: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 12: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 13: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 14: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 15: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 16: Diffractive Multifocal Lenses after Corneal Laser …...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

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)

Page 17: Diffractive Multifocal Lenses after Corneal Laser …...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

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”

Page 18: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 19: Diffractive Multifocal Lenses after Corneal Laser …...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

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)

Page 20: Diffractive Multifocal Lenses after Corneal Laser …...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

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)

Page 21: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 22: Diffractive Multifocal Lenses after Corneal Laser …...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

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)

Page 23: Diffractive Multifocal Lenses after Corneal Laser …...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

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)

Page 24: Diffractive Multifocal Lenses after Corneal Laser …...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

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)

Page 25: Diffractive Multifocal Lenses after Corneal Laser …...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

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)

Page 26: Diffractive Multifocal Lenses after Corneal Laser …...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

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]

Page 27: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 28: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 29: Diffractive Multifocal Lenses after Corneal Laser …...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

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

Page 30: Diffractive Multifocal Lenses after Corneal Laser …...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

Thank you …