implant lenses after cataract surgery: new · pdf fileno financialinterestin...
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No financial interest in any products mentioned !
Implant lenses after cataract surgery: new developments
Oliver Findl
Hanusch Hospital, Vienna
Moorfields Eye Hospital, London
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Cataract
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Incision
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Capsulorhexis
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Phacoemulsification
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Intraocular lens (IOL)
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New IOL Developments
• Toric IOL
• Aspheric IOL
• Multifocal IOL
• Accommodating IOLs
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Aberrations of the eye
• Astigmatism
• Higher Order Aberrations: spherical aberration
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Causes
> 1.0 D Asti. - 20-32%> 1.5 D - 15-20%
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Astigmatism - Orientation
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Toric IOL
Staar toric plate haptic IOL
– Rotationally instable – 20% of >25 degrees
rotation
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Toric IOL
Z-haptic (Dr. Schmidt)
– For high powered astigmatism
– Difficult to position
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Toric IOL
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Precision of alignment is key (Euler)
On meridian
1 deg off – 3% loss
10 deg off – about 1/3 loss = happy patient?
30 deg off – no correction + axis change
= unhappy patient
> 30 deg off – worse off with toric = very unhappy
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Seated – Supine Cyclotorsion
Author Year nmean °
> 5° max ° Excyclo.
Chermyak 2004 51 2.0 14% 9.5 79%
Ciccio 2005 1019 4.1 - 17.5 46%
Hori-Komai
2007 192 2.3 - 7.3 -
Hyojin 2008 27 2.6 13 10 54%
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Pre-Op Marking
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95.9°°°° 93.1°°°°
1 day postOP 6 month
postOP
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Rotation
Boxplot: Whiskers: minimum & maximum, box: middle 50%
n = 14
1st month 6 months
n = 33
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Astigmatism
preOP K‘s 1month 6 months
DA
sti
gm
ati
sm
n = 14
IOL-Master K‘s
Autorefractor Cylinder
n = 33
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Summary - Toric
• Modern toric IOLs
– Rotational stability
• Planning is key
– Measurement
– Alignment
• Good uncorrected distance acuity
• High patient satisfaction
KEEP moderate myopic ATR astigmatism !
– Good distance vision, good intermediate vision, moderate reading vision
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Spherical aberration
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Functional Vision
Visual acuity (high contrast and photopic) – relevant?
Low contrast Mesopic conditions
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Contrast Sensitivity Tests
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Prolate Optic to compensate spherical aberration of cornea
Mester et al, JCRS 2003; 29:652–660
Aspheric IOL
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ResultsResults
Contrast Sensitivity (Ginsburg box, FACT chart)
0
10
20
30
40
50
60
70
80
90
"1.5" "3,0" "6,0" "12,0" "18,0"
Spatial Frequency (c/deg)
Co
ntr
ast
Sen
sit
ivit
y S
co
re
CeeOn Edge
Tecnis
*
*
1.5 3.0 6.0 12.0 18.0
* p < 0.05
54 eyes of 27 patients (76 yrs)
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ResultsResults
High order aberrations
-1,0
-0,5
0,0
0,5
1,0
Z(3,-3) Z(3,-1) Z(3,1) Z(3,3) Z(4,-4) Z(4,-2) Z(4,0) Z(4,2) Z(4,4) Tot.
RMS
Hi.
Ord.
RMS
911A
Tecnis
*
* p < 0.05
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ResultsResults
High order aberrations (large pupil)
-1,0
-0,5
0,0
0,5
1,0
1,5
2,0
Z(3,-3) Z(3,-1) Z(3,1) Z(3,3) Z(4,-4) Z(4,-2) Z(4,0) Z(4,2) Z(4,4) Tot.
RMS
Hi.
Ord.
RMS
CeeOn Edge
Tecnis
*
* p < 0.05
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HOA – aspheric IOL
Pre-OP topography to find best aspheric IOL:
Pre-OP corneal
spherical Aberration
IOL
negative Standard spherical IOL
0 to 0.15µm Rayner; Akreos AO, B&L
0.16 to 0.33µm AcrySof IQ, Alcon
> 0.33µm Tecnis, AMO
Beiko G, Ontario
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Presbyopia Treatments
1. Multifocal IOL
2. Monovision
3. Accommodating IOLs– No evidence that current designs work
4. Corneal approaches– Inlays– Multifocal profile ablation
5. Scleral incisions– No evidence that they work
6. Lens Refilling – Phakoersatz– Still experimental – main problem after-cataract
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Multifocal IOL - Principle
Diffractive Refractive
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Multifocal IOLs - Principle
Distance
Near
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far focusnear focus
far focus
DDDDiffraiffraiffraiffracccctivtivtivtive MIOLe MIOLe MIOLe MIOL
RRRRefraefraefraefracccctivtivtivtive MIOLe MIOLe MIOLe MIOL
MMMMonofoonofoonofoonofoccccal IOLal IOLal IOLal IOL
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Bifocal diffractive IOL
Picture/ Movie 01
NEAR NEAR FAR FAR
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Multifocal IOL
Simultaneous vision
• 2 images superimposed – one blurred – retinal rivalry
• Brain selects the best image
Resulting disadvantages:
• Loss of image contrast
– ~ 20% of light lost to higher order diffraction
– < 50% of incoming light on each focus
• Halos in 100% - perceived by patient in ~ 20%
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Diffractive bifocal IOL
Tecnis Multifocal, AMO
Picture/ Movie 01
Tecnis Multifocal
• Light distribution 50:50
• Loss of 18% to higher order diffraction
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Bifocal IOL
AcriLisa, Zeiss / Acritec
AcriLisa
• Light distribution 65:35
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Bifocal IOL
ReSTOR, Alcon
ReSTOR
• Apodized optic
• Central 3.6mm with 12 concentric diffr. Zones
• Gradual reduction in step height
• Refractive region in periphery
• 2mm pupil 40:405mm pupil 84:10
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ReSTOR
Good Near VA
25% Halos / Glare
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Refractive Multifocal IOL
ReZoom, AMO
ReZoom
• Distance dominant
• 5 zones
• Aspheric transitions for intermediate vision
• Light distribution is pupil size dependent
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Want to have real fun on a Safari?
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Want to be a good golfer?
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Multifocal IOL Options
Diffractive
• Bifocal
• Good near acuity
• Less intermediate vision
Refractive
• Multifocal
• Moderate near acuity
• Good intermediate vision
Mix & match
• Idea: Good near and intermediate vision
• Concerns about asymmetry of halos
• Binocular function?
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Evidence
Cochrane review (Leyland M, 2006):
Metaanalysis of trials that were
• Randomised
• Controlled
• Masked (patient & examiner)
• 8 trials, n ≈ 700 patients
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Distance VA
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Distance VA – unaidedless than 6/6
multi mono
Refractive mIOL
Diffractive mIOL
All mIOL
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Distance VA – unaidedmean VA
Refractive mIOL
multi mono
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multi mono
Refractive mIOL
Diffractive mIOL
All mIOL
Distance VA – best correctedless than 6/6
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Contrast Vision
Fine spatial detail (visual acuity) is not everything
Low contrast Low illumination
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Contrast Vision
Different evaluation methods – monofocal slightly better CS
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Near VA - unaided
multi mono
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Refractive mIOL
Diffractive mIOL
All mIOL
multi mono
Spectacle Dependence
68% 95%
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Glare / Halo
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Glare / Halo
multi mono
Refractive mIOL
Diffractive mIOL
All mIOL
multi mono40% 18%
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Evidence multifocal IOLs
Cochrane review (Leyland M, 2006):
�No adverse effects on distance acuity (high contrast)
�Improvement in near vision
�Less spectacle dependence
o Trend for slightly lower contrast vision
oMore dysphotopsias (halos)
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Safety
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IOL Explantation
• ESCRS / ASCRS survey
• 10 year trend: increasing number of explanted mIOL
multi mono
Explantation 2007 24% 76%
Approx. marketshare < 10% > 90%
Main reasons Glare / Halo (70%)
Dislocation / Decentration
Incorrect power
N. Mamalis, ESCRS 2008 Berlin
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Patient selection is key !
Include:
• Wish to be spectacle independent (most of the time)
• Binocular implantation
Avoid:
• Night time drivers (truck driver, taxi driver)
• Overcritical patients
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Monovision - concept
� One eye for distance, one eye for near
� Brain selects image
� Suppresses one eye in case of conflicting images – binocular rivalry
� Integrates common features – binocular fusion
� Long track record with
� contact lens wearers
� cataract surgery
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Monovision - concept
Use of monofocal IOLs
� Preserve full contrast (100% light)
� Safe in cases of subsequent AMD
� No (less) halos, less glare
� Easily accessible – IOLs available
� Less dependent on centration / tilt
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Multifocal Monovision
Vision
Distance
Intermediate
Near (30cm)
+(+)
+
++
++
++
+
Contrast vision + ++
Binocular function ++ +
Halos + -
Glare + -
Price $$$ $
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Accommodating IOLs:
Do they work?
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Accommodating IOLs
No financial interest !
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Focus-Shift Principle
Far
Near
3 D
730 µm ~ 1 D
Radial
compression
Forward shift of apex
Vitreous pressure ??
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Focus-Shift Principle
Using 3D-UBM Data of presbyopic phakic subjects from:
O. Stachs et al. Graefe’s Arch Clin Exp Ophthalmol
(2002) 240:906–912
Disaccommodated
Pilocarpine
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Partial Coherence Interferometry
– measured eye fixates the laser
beam
– parallel to the optical axis
– high precision: 3 µm
– AC-Master (Zeiss)
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Acco-IOLs: pilocarpine movement
1 CUn=30
Crystalensn=30
.4.20.0-.2-.4-.6-.8mm
JCRS 2005: 1290-7
forward backward
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1d 1w
4w 6w
1CU – haptic infolding 1
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1CU – haptic infolding 2
1 month
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Crystalens - tilt
Cazal et al., ESCRS 2004, Poster
Pronounced IOL tilt – Z-phenomenon
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Crystalens - PCO
YAG-rate at 2 years: 35%
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Transition
Crystalens
AT-45 5-0 HDMultifocal IOL
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Future concepts - Dual optic
Synchrony, Visiogen
Graefes 2007:473-89
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Summary
• Toric IOL – effective
• Aspheric IOL – mesopic contrast better
• Presbyopia correcting IOL
– Multifocal IOL• Effective• Side effects
– Monovision• appears less appealing to most patients
– Accommodating IOLs• No evidence that current designs work