DR. FAİK ORUCOV İSTANBUL SURGERY HOSPİTAL DEPARTMANT OF CATARACT AND REFRACTİVE SURGERY Accomodative and Multifocal IOL implantations i s t a n b u l c

DR.FAİK ORUCOV

İSTANBUL SURGERY HOSPİTALDEPARTMANT OF CATARACT AND REFRACTİVE

SURGERY

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

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


56 eyes of 30 patientsCataract surgery

between december 2002- september 2005 with facoemulsification

AT-45 Crystalens implantation

14 male 16 female 4 years follow up

Crystalens 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 implantationMix-match


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 eyes6 months to 2 years follow up timeAverage one year28 % ≤ 6 months72 % ≥ 6months


Diffractive

1st generation zonal refractive

far focusnear focus

Refractive monofocal

far focus

Optical Principles of IOLs

near focus far focus

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


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


1st generation zonal refractive principle

Tecnis IOL

Diffractive posterior surface with 32 concentric rings

Light distribution of 50 % for distance vision, 50% for near vision

add +4:0 DTecnis:distribution of focus is independent of pupil size5-34 DSiliconA-constant 119


Diffractive TECNIS ZM001

+ ACE Cornea


Acri.lisa IOL

Distance –dominant -diffractive multifocal IOLIndependent of pupil sizeSmooth steps in the refractive diffractive

structureLight distribution is not equal for far and near

vision (Asymmetrical light distribution) 65/35% AcrylicA-constant 11810-30 dpt


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

Preop full examinations:BcvaDominant –nondominant eye selectionOculer TensionRetina and anterior segment examinationTopographyOculyzer –PentacamContrast sensitivityPotential acuity meterPupillometryBiometryPachymeter Tear film quality (punctum plugs if required)


IOL selection

Expectations should be well discussed in detail

before the operation Driving,computer usage,reading,working

distanceDistance vision may be affected by glare at low

light conditionsNeuro-adaptation (takes time)Possibility of another procedure(lasik) for better

visionMay need reading glasses in dim light


Biometry

Repeated measurementsCheck keratometer measurementsSrk-t for emetropics,myopicsHaigis for high hyperopiasCheck first eye’s refraction at least one week

after the operation and then plan the second eyeFor crystalens binoculer implantations postop -

0.5 D myopia planning for the first eye , emmetropia for the second eye


Surgery

FacoemulsificationTopical anesteshiaCorneal tunnel incision in the steepest axis

(don’t consider astigmatism due to crystalline lens)

Capsulorexis smaller than optic diameter Posterior capsule polishingCare to the optic of the IOLIntracapsuler ring may be implanted if

necessary!


Post-op testing

Ucva at distant, intermediate and nearBcva at distant, distant corrected

intermediate and nearContrast 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

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 :±0.75Bcva for distant is between 20/32-20/20Distance corrected near vision (40 cm) is between J 7

–J9Distance 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

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 activitiesHigh patient satisfaction for distance


Multifocal IOL - Results

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

implantationTwo of them undergone seconder IOL exchange

operationYag capsulotomy was needed in 7 patientsPostop 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 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 group was lower than refractive group


3 Main groups

Mix-match:Rezoom-Tecnis 26 patientsRezoom-Acri.Lisa 21 patients Bilateral -multifocal same IOL:Rezoom-Rezoom 21 patientsAcri.Lisa-Acri.Lisa 12 patients Monoculer- multifocal implantation(other eye not

operated):Rezoom one eye 22 patientsAcri.Lisa one eye 13 patientsTecnis 9 patients


MIX-MATCH

PATIENT NO

FREE OF GLASSE

S

HALOGLARE

NEAR

INTERMEDIATE FAR

RezoomTecnis

26 98% 75% J1.6 J2 20/20

Rezoom Acri.Lisa

21 75% 60% J 1.6 J2 20/25


BINOCULER SAME IOL

PATIENT NO

FREE OF GLASSES

HALOGLARE

NEAR INTERMEDIATE FAR

Acri.LisaAcri.Lisa

12 85% 70% J 1.5 J 2 20/20

Rezoom Rezoom

21 75% 60% J 2 J 2 20/25


MONOCULER DISTANCE CORRECTED VISUAL ACUITIES

NEAR INTERMEDIATE DISTANT

Tecnis J1.6 J2.1 20/20

Rezoom J2.2 J1.8 20/25

Acri.Lisa J1.5 J2 20/20

Restor J2 J2.2 20/20


Questionnaries

Halo,glare(subjective experience)Near,intermediate, distant visionDriving (day,night)Reading (newspaper,maps,prescriptions)Activities(sports, shopping)Patient satisfaction1-bad2-fair3-good4-very good


PATIENT SATISFACTION

HALO GLARE

NEAR INTERMADIATE DISTANT

Rezoom 2 3 4 3

Tecnis 3 4 2 4

Acri.Lisa 3 4 3 4

Restor 3 3 2 3


Overall glare

11%

2%

10%

5%

17%

55%

night driving

night

at bright light

always

none

room light


Night driving

Night

At bright light

Always

None

Room light

Glare

Rezoom 76 %Tecnis 62 %Acrilisa 58 %ReStor 56 %Crystalens 50%


Multifocal IOL Patient Satisfaction

Overall satisfaction rate is 3.592% of the patients would have the same

implant again70% of the patients have some complaints while

night driving79 % glasses free(computer, newspaper,outdoor

activities)18 % wear glasses for reading smallprints3 % wear glasses for distant (driving)


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


Documents

DR. FAİK ORUCOV İSTANBUL SURGERY HOSPİTAL DEPARTMANT OF CATARACT AND REFRACTİVE SURGERY Accomodative and Multifocal IOL implantations i s t a n b u l c