Supplement to EyeWorld February 2015

Premium care for your monofocalpatients: Achieving optimal ELPwith the AcrySof platform

Sponsored by Alcon

The AcrySof platform’s exceptional design provides excellent vision across all AcrySof IOLs

The AcrySof platform (Alcon,Fort Worth, Texas) includesa family of IOLs that sharethe key components neces-sary to provide excellent

IOL stability, IOL performance, andpostoperative refractive outcomes.These components include highlybioadhesive hydrophobic acrylic material, a single-piece lens design,STABLEFORCE haptics, a yellow chromophore with blue light filteringproperties, and a remarkably highindex of refraction—all of which play arole in effective lens positioning (ELP)and better patient outcomes.

Treating your monofocal patientsOur first and foremost goal withcataract surgery is to provide our patients with the best possible visionafter surgery. Our second goal with acataract refractive procedure is to leaveour patients with as little need for anoptical device as possible. Today’smonofocal patient may accept theneed for spectacle correction, but he orshe is understandably unwilling to relyupon them for every visual chore. Inmy practice, it is important for ourmonofocal patients to be just aspleased with their outcomes as our

the lens slightly out of position via tiltor decentration. The STABLEFORCEhaptics are designed to hold the lens inplace; they’re constructed of the same material as the lens itself. These haptics hold the center of the lens well and do not “let go” until the lens is actually fixated in place in the bag.

Biocompatibility and fibronectinEarly in my career, I was heavily involved in helping to design lensesthat would be biocompatible—we usedfluorocarbon coating on the lens or experimented with other substanceswe thought would work well. We evaluated explanted lenses (throughcadaver donations or implanted/explanted from rabbits) and created a solution that was fairly close to thecomponents of the protein compo-nents inside the eye. We measuredwhat kind of materials bound to thelens implant. We found a whole seriesof proteins, including fibronectin.

Fibronectin is present in humanserum. It’s also present in the bloodaqueous barrier around the eye andcan bind to the lens implant. Becauseof its natural properties, fibronectinhelps stabilize the lens in the bag. AcrySof is incredibly well tolerated be-cause it has the same protein that thebody manufactures naturally, and has ahigh level of fibronectin bioadhesion.

The AcrySof platform provides premium outcomes to satisfy the demands of our increasingly savvy patients—for every visual goal.

Dr. Maxwell is a partner with Fogg, Maxwell,Lanier & Remington Eye Care in Fresno, Calif. He can be contacted at 559-449-5010 oramaxwellmd@gmail.com. Dr. Maxwell is a paid consultant and investigator for Alcon.

Clinical update on blue lightfiltering and aspheric technologies

This supplement was produced by EyeWorld and sponsored by Alcon. The doctors featured in this supplementreceived compensation from Alcon for their contributions to this supplement.

Copyright 2015 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarilyreflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS.

www.eyeworld.org

by Andrew Maxwell, MD, PhD

premium lens patients. I think we can do that because of the design of the AcrySof lenses we implant.

As surgeons, we have technologythat helps us measure the length of the eye, the curvature of the eye,everything needed to calculate whatthe lens power implant should be. Avery significant component in that iswhere does the lens fit inside the eye?If the lens shifts forward a little bitafter implantation, the patient is a bitmyopic. If the lens shifts backward abit, the patient is a bit hyperopic.

Effective lens positioning simplymeans the lens stays where we want it to be. All of our IOL calculation for-mulas presume that if we place a lensin the capsular bag, it will stay whereplaced and correct the refractive errorwe thought it was going to correct.

With the AcrySof line, the bioad-hesive hydrophobic acrylic materialhas a little tackiness to it so the bag basically seals to it. In my hands, itmeans the lens sits where we predictit’s going to sit, and I’ve rarely had anysignificant surprises.

Those benefits work across theplatform—so whether I’m using a toric lens or a monofocal or I’m using a femtosecond laser to create my capsulorhexis, these lenses end up where I expect them to be. Becausethe capsule shrinks around the lens soquickly, the lens doesn’t have a lot ofvariability whether it’s going to shiftbackward or forward.

The role of the hapticsThe STABLEFORCE haptics have a specific amount of compression forcethat helps fixate the lens in the bagand do not lose that compressionforce. Before this technology was available, we had lenses with hapticsthat would lose that compression forcewithin 24 hours, essentially shifting

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Understanding how the light spectrum functions is necessaryto understand how vision works in older patients

As a neuroscientist but a vision scientist as well,understanding vision andhow the brain perceivesimages is the basis for my

research. It is common to regard visionstrictly in terms of glasses, or refractiveerrors. Yet for the vast majority ofhuman history, refractive conditionslike astigmatism and myopia were very rare. The eye evolved to deal with the challenges posed by the naturalenvironment such as bright light andseeing at a distance through veilinghaze. This is why so many species havedeveloped internal ocular filters to aidvision under ecological conditions.

Clinical update on blue light filtering and aspheric technologies 2

Given the preponderance of blue light in our atmosphere (via Rayleighscatter), those filters are inevitablyblue-absorbing and appear yellow in color. In humans, this filtering is done by the yellow macular pigments(chromophores accumulated from the dietary intake of green leafy vegetables) and the natural yellowingthat occurs with the crystalline lens.1

What the pigments doVision researchers have intensivelystudied the effect of the macular pigments on daily vision. It has beendocumented that these pigments improve visual function by reducingthe deleterious effects of intense light.2

The pigments reduce disability and the discomfort caused by bright light that is largely driven by the blue portion of the visible spectrum. By absorbing very intense light, they reduce the amount of time it takes to recover from short intense light exposures (photostress recovery). They may also aide object detection by improving chromatic contrast (accentuating a colored border by absorbing one side more than theother). By similar mechanisms ofstrategic filtering, they improve visualrange (how far one can see). This isdone by absorbing the biggest limiter

Blue light filtration: What is the evidence today?

continued on page 3

by Billy Hammond, PhD

of distance vision, which is veiling dueto blue haze.

When Alcon (Fort Worth, Texas)developed its AcrySof IQ lens, it created an IOL that mimics the spectral absorbance characteristics of the othermajor yellow chromophore in thehuman eye, the natural crystalline lens.This was originally done to reduce actinic damage sometimes referred toas the “blue light hazard.” Light is, ofcourse, necessary for life and optimalfunction—for instance, to synthesizevitamin D. However, some vision scientists also believe light has the potential of damaging biologic tissue.3

Light can convert oxygen to a more reactive form that can, in turn, peroxi-dize fats (a big problem for fatty tissueslike the retina, which are exposed to alot of light and oxygen).4 It’s believedthe energy in light is inversely relatedto wavelength so shorter wavelengthsare more damaging than longer wave-lengths; for example, ultraviolet light is a lot more damaging than infrared.5

Real world applicationsAlthough protection from actinic lightmay be a strong advantage of blue-absorbing filters, it is likely that naturalchromophores like the macular pigments have effects that manifest

Less is better

Photostress recovery time

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early in life while an individual is stillfecund. Hence our interest in whetherblue-absorbing filters, like the macularpigments, affect visual functions that would influence daily life. We recently analyzed the effect of addedblue light filtration among pseudopha-kic eyes implanted with UV filteringIOLs.6 In this study, we measured visual performance as quantified by photo-stress recovery time and glare disabilitythresholds. Using a crossover design,154 pseudophakes with best correctedvisual acuity of 20/40 or better wererandomized to be tested with an addedblue-absorbing or placebo filter. All patients had to be at least 12 monthspast implantation with a UV filteringIOL. In our study, the addition of the blue-absorbing filter improved photostress recovery by 28%. Glare disability thresholds were improved by 8% (subjects could tolerate morelight before losing sight of a centralgrating target) when subjects werewearing the blue light filtering clip-onglasses compared to the placebo glasses.

Improving vision under duresslikely has many real world benefits.

For example, filtering blue light hasbeen shown to reduce photostress byreducing the intensity of the exposure(and hence the amount of photopig-ment that is bleached and must be regenerated). So if one were driving 60 mph and was blinded for 10 secondsby oncoming headlights, that translatesto about 880 feet. Improving recoveryspeed by 28% would mean that onewas only blinded for about 7 seconds,which translates to about 634 feet(meaning you shaved off about 246 feetor two-thirds the length of a footballfield). To put this into perspective, only .35 seconds of additional breaking response time was a key rationale supporting the National Highway Traffic Safety Administration mandate that all cars incorporate a third break light.7

References1. Hammond BR, Renzi LM, Sachak S, Brint SF. Contralateral comparison of blue-filtering and non-blue-filtering intraocular lenses: glare disability, heterochromatic contrast, and photostress recovery. Clin Ophthalmol. 2010;4:1465–1473.

2. Hammond, BR and Fletcher LM. Influence of the dietarycarotenoids lutein and zeaxanthin on visual performance:application to baseball. Am J Clin Nutrition. 2012;96:1207S–1213S.3. Greenstein V, et al. Scotopic sensitivity and color visionwith a blue-light-absorbing intraocular lens. J Cataract Refract Surg. 2007; 33(4):667–672. 4. Hammond BR, Bernstein B, Dong J. The effect of theAcrySof Natural lens on glare disability and photostress. Am J Ophthalmol 2009;148:272–276.5. Hammond BR, Johnson BA, and George ER. Oxidative photodegradation of ocular tissues: beneficial effects of filtering and exogenous antioxidants.Experimental eye research. 2014; 129:135–150.6. Fisher B, Hammond B, et al. Visual effects of additional short-wave filtering in patients with clear intraocular lenses. Poster presented at ASCRS 2014. 7. McKnight JA, Shinar D. Brake reaction time to centerhigh-mounted stop lamps on vans and trucks. Human Factors: The Journal of the Human Factors and Ergonomics Society. 1992;34(2):205–213.

Dr. Hammond is the graduate coordinator professor of the Behavioral and Brain SciencesProgram at the University of Georgia. He can be contacted at 706-542-4812 or bhammond@uga.edu. Dr. Hammond is a paidconsultant and investigator for Alcon.

Please refer to page 6 for important product information about the Alcon products described in this supplement.

More is better

Glare disability threshold

Clinical update on blue light filtering and aspheric technologies

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Aspheric profiles: What is the real impact?

To understand the value of asphericity for an in-traocular lens, we mustfirst appreciate the factthat the human visual

system is, in essence, a contrast sensitivity detection system. For most optical systems, image quality is measured by an ability to faithfullytransmit contrast from the objectbeing viewed to the image beingformed, and maintaining contrast is afundamental aspect of image quality.One need look no further than theimage quality differences between tele-vision technology from 20 years agoand what is readily available today forthe importance of maintaining con-trast to become immediately apparent.

More than 60 years ago, a Dutchphysicist name Fritz Zernike describeda method for quantifying how imagecontrast may be influenced in thepresence of different types of aberra-tions, referred to as the Zernike poly-nomials. The spherical and astigmaticcorrections in a typical pair of glasses,referred to as defocus and regular astig-matism, are known as second orderaberrations. A significant increase inany aberration results in a decrease inimage contrast. When we describesomething as being “in focus” what isactually meant is that it has high con-trast at high spatial frequencies. In thevisual world in which we live, main-taining contrast plays an importantrole and the presence of aberrationswork against this.

For traditional spherical IOLs, theimage quality degrades toward theoptic’s periphery.1 This is because themarginal rays are brought into focus in front of the central rays. It’s wellknown that the human cornea is alsoan imperfect lens and shares this prop-erty resulting in an elevated fourthorder aberration known as positive

positive spherical aberration of thecornea with a slightly lower negativespherical aberration value such thatthe final residual amount of sphericalaberration approximates that of theyouthful eye.

Including an additional correctionfor any regular corneal astigmatismfurther increases contrast and improvesvisual quality. This is one reason whyour AcrySof toric IOL patients withcorneal astigmatism are often veryhappy with the quality of their vision.Here, three separate aberrations arebeing addressed: defocus, regular astigmatism, and spherical aberration.

The AcrySof IQ adds a physiologicamount of negative spherical aberra-tion to help offset the naturally occurring amount of positive sphericalaberration of the cornea. Such a strat-egy has been developed to maintaincontrast and is less likely to result in anover correction. Maintaining contrastto maintain visual quality is the nameof the game.

References 1. Kohnen T, Kiaproth OK, Buren J. Effect of intraocular lens asphericity on quality of vision after cataract removal: an intraindividual comparison. Ophthalmology. 2009; 116:1697–1706.2. Wang L, Santaella RM, Booth M, Koch DD. Higher-order aberrations from the internal optics of the eye. J Cataract Refract Surg. 2005;31(8):1512–9.3. He JC, Gwiazda J, Thorn F, Held R. Wave-front aberrations inthe anterior corneal surface and the whole eye. J Opt Soc Am AOpt Image Sci Vis. 2003;20(7):1155–63.4. He JC, Burns SA, Marcos S. Monochromatic aberrations inthe accommodated human eye. Vision Res. 2000;40(1):41–8.5. Artal P. Optics of the eye and its impact in vision: a tutorial.Advances in Optics and Photonics. 2014;6(3):340.6. Beiko GH. Personalized correction of spherical aberration incataract surgery. J Cataract Refract Surg. 2007;33(8):1455–60.7. Wang L, Koch DD. Ocular higher-order aberrations in individuals screened for refractive surgery. J Cataract Refract Surg. 2003;29(10):1896–903.8. Awwad ST, Warmerdam D, Bowman RW, et al. Contrast sensitivity and higher order aberrations in eyes implanted with AcrySof IQ SN60WF and AcrySof SN60AT intraocularlenses. J Refract Surg. 2008;24(6):619–25.9. Tzelikis PF, Akaishi L, Trindade FC, Boteon JE. Ocular aberrations and contrast sensitivity after cataract surgery withAcrySof IQ intraocular lens implantation clinical comparativestudy. J Cataract Refract Surg. 2007;33(11):1918–24.10. Pandita D, Raj SM, Vasavada VA, et al. Contrast sensitivity and glare disability after implantation of AcrySof IQ Natural aspherical intraocular lens: prospective randomized maskedclinical trial. J Cataract Refract Surg. 2007;33(4):603–10.11. Legras R, Chateau N, Charman WN. Assessment of just-no-ticeable differences for refractive errors and spherical aberra-tion using visual simulation. Optom Vis Sci. 2004;81(9):718–28.

Dr. Hill is in private practice at East Valley Ophthalmology in Mesa, Ariz. He can be contacted at 480-981-6130 or hill@doctor-hill.com. Dr. Hill is a paid consultant and investigator for Alcon.

by Warren E. Hill, MD

spherical aberration. In the pseudopha-kic state, combining a traditionalspherical IOL with the naturally occur-ring positive spherical aberration of thecornea will result in a significant in-crease in the total amount of sphericalaberration. Above a certain level, thisleads to an increasing loss of contrastwith increasing pupil size. One of sev-eral important goals of cataract surgeryshould be to maintain image quality—said another way, to maintain contrast.

The crystalline lens in the youthfuleye, without a cataract, has somewherebetween –0.138 µm and –0.24 µm ofnegative spherical aberration, whichmeans it typically has more power inthe center than it does toward the periphery.2–5 The mean value for positive spherical aberration in thehuman cornea is about 0.274 µm.6

The net result is that, on average, asmall amount of naturally occurringpositive spherical aberration is com-monly present for those at the peak ofvisual function in early adulthood. It isinteresting to note that this amount isoften symmetrical.7

The AcrySof differenceIn the presence of a small pupil, theAcrySof IQ (Alcon, Fort Worth, Texas),Tecnis (Abbott Medical Optics, AbbottPark, Ill.), and any aberration neutralIOL, such as the SofPort AO (Bausch +Lomb, Bridgewater, N.J.), performabout the same in terms of contrastsensitivity. With a pupil size of 4 mmor larger, however, helping to neutral-ize the naturally occurring positivespherical aberration of the cornea begins to make a difference in terms of both image quality and visual performance as shown by contrast sensitivity testing.8–10

Beiko found that targeting a residual positive spherical aberration of 0.10 µm following cataract surgeryresulted in superior visual performanceat a 6-mm pupil size.6 And Legras et alfound that for a 6-mm pupil the opti-mal value for spherical aberration wasnot 0.0 µm but actually 0.08 µm.11 It’sthis research that led Alcon to target avalue for spherical aberration with theAcrySof IQ lens of about 0.10 µm forthe average pseudophakic eye.

The strategy behind the AcrySof IQlens is to offset this naturally occurring

Clinical update on blue light filtering and aspheric technologies

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Clinical update on blue light filtering and aspheric technologies

My surgical goal: improved functional vision

Monofocal patients can be wellserved with the AcrySof IQ

According to the 2014ASCRS Clinical Survey,while the average ASCRSmember performs 490cataract surgeries per year,

414 of these are monofocal implants.We owe it to these patients to givethem excellent functional vision with a monofocal lens. I believe theAcrySof IQ (Alcon, Fort Worth, Texas)provides that.

continued on page 6

by Lawrence Woodard, MD

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For most patients, the amount ofinformation available about their op-tions can be a bit overwhelming. Somefeel the monofocal option is a “bargainbasement quality lens.” I dispel thatmyth as quickly as possible—one lensis not better than the other, it is justthat these lenses do different things.So, for instance, if reading withoutglasses is not important to the patient,then I tell them a monofocal lens is byfar the best lens because it delivers thebest possible distance quality vision.We discuss blue light filters and howthat affects vision, how asphericity affects vision, and how these two concepts together can provide the high quality functional vision today’stechnology can deliver.

Spherical aberrations can reducethe image quality of a lens, especiallyin low-contrast situations. Positivespherical aberrations occur when lightrays are over refracted at the peripheryof a spherical IOL. An aspheric lensaligns the light rays to adjust for posi-tive corneal spherical aberrations. TheAcrySof IQ, however, features negativespherical aberration to compensate forthe positive aberration of an averagecornea. When I discuss this with patients, they immediately “get” how this type of technology improvescontrast sensitivity and that the IOLhas been designed to replicate theyouthful human crystalline lens.

Blue light filtering I only use the aspheric blue light filtering AcrySof IQ platform lenses.The biggest benefit I see for my patients with these lenses is how theyperform in low light conditions, as wellas how improved the overall contrast sensitivity is. Once patients grasp theconcept that the lens itself does nothave a yellow tint but a chromophorethat does not affect color perception,they “get it.”

At least half my cataract patientscomplain about glare and and inabilityto see in low light conditions. Cataractsurgery has significantly changed.Today’s patients are not waiting untiltheir vision is extremely poor to correcttheir cataracts. Today’s cataract pa-tients are coming in early for optionsto improve their functional vision. AcrySof IQ IOLs can help reduce the impact of glare disability.

Please refer to page 6 for important product information about the Alcon products described in this supplement.

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A persuasive study found theAcrySof IQ produced significantlygreater reduction in glare and in-creased the ability of drivers to executeturns more safely in low light condi-tions.1 Simulator studies have alsoshown patients are able to recognizetargets faster with an aspheric IOLcompared to a standard or sphericalIOL.2 Being able to recognize objectsbetter under photostress conditions(such as a significant amount of glareor a setting sun) is also improved with the AcrySof IQ.3

That makes a big difference to patients—even when the patient isonly interested in a monofocal lens,glare and imperfect lighting conditionsare common complaints this lens canimprove.

Benefits of longevityI personally have years of experienceimplanting this particular lens, andthat also eases patient concerns. I canpoint to studies that confirm how welltolerated the lens is and how long it’sbeen commercialized in the U.S., andthey find great comfort in that.

From a surgical standpoint, thislens is incredibly stable in the eye, andmost surgeons are familiar with theplatform.

I am happy to provide my monofocal cataract patients with an option that is anything but “bargain basement.” The benefits of this lens have consistently beengreatly appreciated by my patients—and knowing I can give them backtheir driving confidence in lower light-ing situations is yet another bonus.

References1. Gray R, Hill W, Neuman B, et al. Effects of ablue light-filtering intraocular lens on drivingsafety in glare conditions. J Cataract Refract Surg.2012;38(5):816–22.2. AcrySof IQ IOL Directions for Use3. Hammond B, et al. Contralateral comparison ofblue-filtering and non-blue-filtering intraocularlenses: glare disability, heterochromatic contrast,and photostress recovery. Clin Ophthalmol. 2010;4:1465–1473.

Dr. Woodard is in private practice at Omni Eye Atlanta. He can be contacted at 404-257-0814 or lwoodard@omnieyeatlanta.com. Dr. Woodard isa paid consultant for Alcon.

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AcrySof IQ Intraocular LensesCaution: Federal (USA) law restricts this deviceto the sale by or on the order of a physician.Indications: The AcrySof IQ posterior chamber intraocular lens is intended for the replacement of the human lens to achievevisual correction of aphakia in adult patientsfollowing cataract surgery. This lens is in-tended for placement in the capsular bag.Warning/precaution: Careful preoperativeevaluation and sound clinical judgmentshould be used by the surgeon to decide therisk/benefit ratio before implanting a lens in a patient with any of the conditions describedin the Directions for Use labeling. Cautionshould be used prior to lens encapsulation toavoid lens decentrations or dislocations.

Studies have shown that color vision discrimination is not adversely affected in individuals with the AcrySof Natural IOL andnormal color vision. The effect on vision ofthe AcrySof Natural IOL in subjects withhereditary color vision defects and acquiredcolor vision defects secondary to ocular disease(e.g., glaucoma, diabetic retinopathy, chronicuveitis, and other retinal or optic nerve dis-eases) has not been studied. Do not resterilize;do not store over 45 degrees C; use only sterileirrigating solutions such as BSS or BSS PLUSSterile Intraocular Irrigating Solutions.

Attention: Reference the Directions for Use labeling for a complete listing of indications,warnings, and precautions.

AcrySof IQ Toric Intraocular Lenses Caution: Federal (USA) law restricts this device to the sale by or on the order of a physician.Indications: The AcrySof IQ Toric posteriorchamber intraocular lenses are intended for primary implantation in the capsular bag of the eye for visual correction of aphakia andpre-existing corneal astigmatism secondary toremoval of a cataractous lens in adult patientswith or without presbyopia, who desire im-proved uncorrected distance vision, reductionof residual refractive cylinder, and increasedspectacle independence for distance vision.Warning/precaution: Careful preoperativeevaluation and sound clinical judgment shouldbe used by the surgeon to decide the risk/bene-fit ratio before implanting a lens in a patientwith any of the conditions described in the Directions for Use labeling. Toric IOLs shouldnot be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if aprimary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; ifnecessary lens repositioning should occur asearly as possible prior to lens encapsulation. All

viscoelastics should be removed from both theanterior and posterior sides of the lens; residualviscoelastics may allow the lens to rotate. Optical theory suggests that high astigmaticpatients (i.e.>2.5 D) may experience spatial dis-tortions. Possible toric IOL related factors mayinclude residual cylindrical error or axis mis-alignments. Prior to surgery, physicians shouldprovide prospective patients with a copy of thePatient Information Brochure available fromAlcon for this product informing them of possible risks and benefits associated with the AcrySof IQ Toric Cylinder Power IOLs. Studies have shown that color vision discrimi-nation is not adversely affected in individualswith the AcrySof Natural IOL and normal colorvision. The effect on vision of the AcrySof Natural IOL in subjects with hereditary colorvision defects and acquired color vision defectssecondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and otherretinal or optic nerve diseases) has not beenstudied. Do not resterilize; do not store over 45degrees C; use only sterile irrigating solutionssuch as BSS or BSS PLUS Sterile Intraocular Irrigating Solutions. Attention: Reference the Directions for Use labeling for a complete listing of indications,warnings and precautions.

Important product information

© 2014 Novartis 1/15 ACR14046JS

Clinical update on blue light filtering and aspheric technologies

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