Multi focal IOL

Intraocular Surgery for Presbyopia Multifocal IOL Diffractive Restor IOL (Alcon,USA) A splitting of the image Some light for near Some light for distance Tecnis IOL (AMO,USA) Aspheric optic improves contrast sensitivity Multifocal IOL Refractive Rezoom (AMO, USA) Halo from refractive rings at night Visual abberations Monovision Anisometropia Decline in binocular function Some cannot tolerate this. Accommodative IOL CrystaLens Accommodative 1CU

Human Crystaline Lens A. Distance Observation Near Power Forms In-Focus Image on Retina C. Near Observation A. Distance Observation Distance Power Forms an In-Focus Image On Retina. B. Intermediate Observation Intermediate Power Forms Human Crystaline Lens

Monofocal IOLs Distance image Forms an In-Focus Image On Retina. Intermediate image Forms Out-of-focus image on Retina; A. Distance Observation Distance image Forms an In-Focus Image On Retina. B. Intermediate Observation C. Near Observation Near image Forms Only one focus point usually for distance Only distance is clear Manual Camera with only one focus point Relies on Spectacles for near Alternative choice: Multifocal

Multifocal Refractive IOLs 38 cm (15”) from Spectacle Plane (not to scale) Intermediate Power Forms Image on Retina; Distance and Near Powers form slightly out-of-focus Images on Retina Add (range of foci) A. Emmetropia: Distance Observation average add = +2.62 D Distance Power Forms an In-Focus Image On Retina. Near Power Forms a Weak, Out-of-Focus Image Of Distant Object On Retina. 66 cm (26”) B. Emmetropia: Intermediate Observation Intermediate distance object (~66 cm = 26”) C. Emmetropia: Near Observation Near Distance (+2.62 D add) = 38 cm (15”) In-Focus Image on Retina Multiple focus point for distance, near and intermediate Two or more images formed at once One clear, others blur Brain works to ignore out-of-focus image, only accepts clear image Takes time for adapting Less reliant on spectacles, compromise on quality of image Distance Power Forms a Weak Out-of-Focus Image of Near Object on Retina

Optical Principles of IOLs monofocal far focus diffractive near focus far focus refractive

Multifocal IOL : evolution Many studies have been shown to restore near vision higher than J3 in between 92-99% Things to overcome.. Degradation of image quality by multifocal vision 2. Distribution of incoming light through several foci  Generate out-of-focus images overlapping the image of distant focus  Induces blur (particulary, in low contrast level) 3. Previous spherical design of IOL  Increases spherical aberration : glare & halo (photopic)

Accommodating IOL Crystalens - actually a monofocal lens that has the ability to move forward inside the eye to change focus from distance to near to some degree (pseudoaccommodation). Flexible haptics that allow the lens optic movement back and forth with contraction of ciliary muscle :  1.5 D of accommodation theoretically 2008 curr opin ophth 그대로 읽기

still requires target of mild myopia in non-dominant eye

HD-100 Lens Design Proprietary optic design modification Single retinal image Increase effective focal range Monocular uncorrected distance/ near visual acuity were superior to AT-45 and Five-O Fourth Generation Crystalens HD-100 provides very acceptable distance, intermediate, and near visual acuity

New-Generation Multifocal IOL OPTIC PLATFORM COMMENT ResTor (ALCON) Dif./Ref. (Apodized) 1 piece Hydrophobic Acryl Square edge Good distant and near vision. Distance dominant(-) High capsular biocompatibility Rezoom (AMO) Refractive 3 pieces PMMA haptic Good distant and intermediate Distance dominant(+) Tecnis-MF (AMO) Diffractive Silicon / PVDF haptic Aspheric Pupil –independent AcriLisa 366D (AcriTec) Acrylate Square edge / Aspheric Plate configuration. MICS 가능 M-Flex (Rayner) Hydrophilic Acryl Optic size : 6.25mm Good distance vision. PCO rate ↓

Multifocal Refractive IOLs Rezoom IOL(AMO) five different zones with each zone designed for different light and focal distances in a range of light conditions Allows the formation of intermediate images on the retina, even if distance and near powers form slightly out-of-focus images on the retina 그대로 읽기

Pros Cons Rezoom IOL “ Balanced View Optics” ** Light distribution ** The mean uncorrected intermediate visual acuity (UCIVA) was significantly better in refractive (ReZoom) mulitifocal IOL than monofocal and diffractive (Tecnis) multifocal IOL. Rezoom IOL “ Balanced View Optics” Aspheric transitions between the zones provide balanced intermediate zone. ** Light distribution ** Far 50% Near 37% Intermediate 13% In 2.8mm pupil However, such a faint focused image arising from intermediate distance objects mixed with confused images from far and near annular zone The actual is often contradictory to the ideal ! Ophthalmology 2008;115:1508-16 Cons

Strengths and Limitations of ReZoom™ IOL Very good distance vision; similar to monofocal lens at small pupil size Good intermediate vision Good spectacle independence Limitations Spectacles sometimes needed for prolonged reading or small prints

Apodized Diffractive IOLs Acrysof Restor ™ (Alcon) apodized diffractive technology: controls both image quality and energy balance Diffract steps cover the central 3.6mm diameter of the IOL, while optic peripheral to the 3.6mm diameter out to the 6.0 mm edge is refractive surface dedicated to distance vision Step heights decrease peripherally from 1.3 – 0.2 microns A +4.0 add at lens plane equaling +3.2 at spectacle plane Central 3.6 mm apodized diffractive structure Provides a full range of vision 그대로 읽기

Key limitation of ReSTOR Apodized Diffractive IOLs In mesopic condition, (pupil dilation) Near & intermediate vision would reduce significantly Acrysof Restor ™ (Alcon) 2mm pupil : near 40% distance 40% lost 20% (to higher diffraction order) 5mm pupil : near 10% distance 84% lost 6% Key limitation of ReSTOR intermediate vision in the 50 to 70 cm range (drop in VA to 20/40 at intermediate range) Blaylock et al, J cataract Refract Surg 2006 Werner et al , J cataract Refract Surg 2008

CeeOn® 811E IOL diffractive surface TECNIS® Multifocal IOL Multifocal diffractive IOLs Tecnis™ IOL (AMO) Full diffractive posterior surface Modified prolate anterior surface Aspheric Pupil – independent Light Far : 41% Near: 41% Lost: 18% + = TECNIS® IOL modified prolate anterior surface CeeOn® 811E IOL diffractive surface TECNIS® Multifocal IOL

Strengths and Limitations of TECNIS® Multifocal IOL Very good distance vision Low contrast loss Excellent near vision, even under low light conditions Spectacle independence in 95% of patients† Limitations Spectacles sometimes needed for intermediate vision (e.g. computer work)

Restor vs Tecnis Multifocal IOL N=28 eyes of 28 patients (14 eyes each) High and low contrast UCVA and BSCVA for distance Restor = Tecnis Multifocal Wavefront analysis - RMS HOA, Coma, Spherical Aberration Restor > Tecnis Multifocal Near VA - Restor > Tecnis Multifocal Intermediate VA - Restor < Tecnis Multifocal Toto et al, J Cataract Refract Surg, 2007

TECNIS ZM900 Multifocal IOL Test Using the US Air force Target Targets developed by the US Air Force Used for vision tests for pilots and to evaluate lenses A measure of contrast sensitivity at 1 spatial frequency Approved for distribution outside the US 18 Feb, 2005. Revised 01 Mar, 2005.

TECNIS ZM900 Multifocal IOL USAF Target Projection This test shows an image of the US Air Force target projected through the ACE model eye. The purpose is to obtain a subjective impression of the optical performance of the system. Approved for distribution outside the US 18 Feb, 2005. Revised 01 Mar, 2005.

Average Cornea Eye Model 3mm pupil Tecnis™ multifocal lens near Tecnis™ multifocal lens far ReSTOR® multifocal lens near ReSTOR® multifocal lens far

Average Cornea Eye Model 4mm pupil Tecnis™ multifocal lens near Tecnis™ multifocal lens far ReSTOR® multifocal lens near ReSTOR® multifocal lens far

Average Cornea Eye Model 5mm pupil Tecnis™ multifocal lens near Tecnis™ multifocal lens far . ReSTOR® multifocal lens near ReSTOR® multifocal lens far

Average Cornea Eye Model 5mm pupil Model Eye: All lens powers range from 20.0 to 21.5D.

Multifocal Progressive Diffractive Lens (OII) COMBINES CHARACTERISTICS OF ReSTOR, ReZOOM AND ASPHERIC IOLs Patented Technology Diffractive-refractive posterior surface design Progressive Refractive Distance-Intermediate within central 1.6 Ø to provide depth of focus for distant Diffractive single focus for Near within 1.6-2.0 Ø Apodized diffractive multifocal for Distant through Near within 2.0-3.8 Ø of surface to reduce Halos Aspheric Refractive design for Distance outside 3.8 Ø to improve image contrast Apodized zone Distance Near 0.75 1.0 1.5 1.75 100% Relative energy 0.0% Distance from lens center (mm) 2.75 D Effective Add power Aspheric Distance Periphery Diffractive Multifocal within 3.8 Ø Near diffractive within 2.0 Ø Progressive distance-intermediate within 1.6 Ø

Limitation of multifocal IOL Bilateral Crystalens : excellent distant and intermediate VA, but patients often use glasses for near tasks. Bilateral Restor IOL : excellent distant and near VA, but dissatisfied with intermediate VA, particularly in dim lighting. Bilateral Rezoom IOL : excellent distant and intermediate VA, but dissatisfied with near VA particularly in bright lighting. By Kerry D.SOLOMON, MD

Bilateral implantation ? Crystalens IOL : better best-spectacle corrected distance, uncorrected and distance-corrected intermediate, and best-corrected near vision. ReSTOR multifocal IOL : better uncorrected near vision, required the lowest reading add, and had the lowest uncorrected and distance-corrected intermediate vision. Monocular mesopic contrast sensitivity with and without glare was better with the Crystalens IOL

Combination implantation ? Any combination of Crystalens : better for intermediate vision. Any combination of ReSTOR : better for near vision.  Crystalens and ReSTOR combination : better mean intermediate and near vision overall Multifocal IOL in one or both eyes  lower contrast sensitivity and more subjective reports of photic phenomena Accommodating and multifocal IOL combinations : less night glare symptoms than bilateral multifocal IOL Visual performance of Patients with Bilateral vd Combination Crystalens, ReZoom,and ReSTOR IOL implnats American J Ophthalmology 2007 ;144:347-357

Visual Results Following Implantation of a Refractive Multifocal IOL in One Eye and a Diffractive Multifocal IOL in the Contralateral Eye -This prospective study enrolled 40 eyes of 20 patients Dominant eye-ReZoom Nondominant eye-Tecnis - Near, intermediate, and distance vision were assessed at 2 months following implantation Frank Joseph Goes, MD [J Refract Surg. 2008;24:300-305.]

Case M/65 VA distance : OD 0.125 (0.8 x +2.00Ds) OS 0.2 (0.8 X +1.75Ds) VA near : OD 0.05 (0.65 add +1.50Ds) OS 0.05 (0.2 add +2.00Ds) Dominant eye : OD (by hole-in card, alternative, pointing-a-finger method) Lens NO2NC2C2P1 (OU) Occupation : businessman Lifestyle : computer work, mah-jong

2008.6.15 phaco+PCL (OD)  ReZoom +19.5D Progress note POD # 1M (OD) Refractive error : +0.25Ds = -0.5Dc Ax102 VA distance : 1.0 VA near : 0.5 (1.0 , add +2.50Ds) He satisfied with intermediate vision but complained with near vision and night glare & halo. POD # 1M (OS) Refractive error : -0.25Dc Ax53 VA distance : 0.8 VA near : 0.8 2008.6.15 phaco+PCL (OD)  ReZoom +19.5D 2008.7.3 phaco +PCL (OS)  Tecnis +20.5D

Contrast sensitivity (log) Contrast sensitivity (log) Visual performance Binocular VA Monocular contrast sensitivity No glare / halo Satisfied with his binocular vision 2 months was required to adapt his new vision Distance uncorrected 1.0 Distance best corrected Intermediate uncorrected 0.8 Intermediate best corrected Near uncorrected Near best corrected Contrast sensitivity (log) Contrast sensitivity (log) 3 cd/m² (night time) 80 cd/m² (daytime) Spatial frequency (cpd) Spatial frequency (cpd)

Pros of Mix & Match Mix & Match Non of the new-generation multifocal IOL is perfect by oneself The needs of the patients to provide a full range of vision – near, intermediate & far Mix & Match Mix & Match with refractive & diffractive multifocal IOL The concept was started in 2000.(Gunenc et al, Array & 811CeeOn) A number of studies reported in ASCRS 2006

: preferred near point of fixation, Combination of ReZoom & ReSTOR showed better intermediate VA than bilateral ReSTOR Bucci et al in ASCRS 2006 Combining Tecnis & ReZoom showed best intermediate VA Tecnis & ReZoom mix &match group showed better results than bilateral ReSTOR group Mere mix & matching is not enough! Customized vision required : preferred near point of fixation, pupil dynamics, glare, contrast condition

Cons of Mix & Match In view of the discrete power of diffractive multifocal IOL, it is recommended to plan the IOL power bilaterally (even though the second eye may not yet be scheduled for surgery). This way, the IOL powers for both eyes can be conveniently planned to be closest to emmetropia.

Target refraction For the first eye, it is advisable to aim for emmetropia, i.e. between +0.30D to -0.20D. To improve intermediate vision, the second eye may be targeted to be slightly hyperopic A postoperative myopic outcome may render the reading distance uncomfortably near, and intermediate vision will be compromised.

Example 1 The choice for the right eye 2nd choice d/t pts needs & symptom 1st choice is closest to emmetropia The choice for the right eye 1) Reducing haloes, less tolerant of night visual disturbances : +19.0D 2) Improve range of near vision, pt prefer near vision : +19.5D

Example 2 The choice of Left eye 1) For least defocus: +26.0D 1st choice is closest to hyperopic emmetropia 2nd choice d/t pts needs & symptom The choice of Left eye 1) For least defocus: +26.0D 2) More intermediate vision & reduce post-operative night vision disturbances:+25.5D

Customized vision : Lifestyle For Kim who makes his living driving a taxi  Distant, no photic sx (monofocal IOL) For Lee ,a heavy readers, but no night drive  Near fixation, pupil-dependent For Park who use computer, drive and strongly desire to be spectacle-free  intermediate & distance (mix& match : refractive& diffractive) For Chung, an X-ray technologist who works in a darkened room  Intermediate and near, pupil-independent

Multifocal IOL selection for 1st eye Personality/lifestyle Lens type Laid back nature lovers, sporty Bookworm, sewing, fine near work ReZoom Tecnis ZM900, Restor 43

Multifocal IOL selection for 2nd eye satisfication Lens type more intermediate visual demand more near visual demand All satisfied distance ReZoom Tecnis ZM900, Restor Use the same lens 44

Customized vision : Pupil dynamics Patients who underwent ReSTOR IOL implantation were divided according to their photopic pupil diameter : 2.0-3.5mm, 4.0-5.5mm, and 6.0-6.5mm Larger pupil : correlated with better distance VA and worse near VA J cataract Refract Surg 2007;33:430-8. Consider the patient’s photopic pupil size! When performing near visual task under photopic condition, it’s OK. However, under mesopic conditions, near VA may be compromised. ” It’s very difficult to read a menu in a restaurant ! “

Effect of Astigmatism on Multifocal IOL Multifocal IOL group Monofocal IOL group Influence of astigmatism on multifocal and monofocal intraocular lenses Am J Ophthalmol. 2000 Oct;130(4):477-82

Both distance and intermediate VA deterioration caused by astigmatism was greater with a multifocal IOL than with a monofocal intraocular lens, whereas near visual acuity was better with the multifocal IOL. When astigmatism was within 1.0 D, eyes with a multifocal IOL achieved good VA at both distance and near.

Conclusion To maximize the benefits of multifocal IOLs, Patient selection Accurate preoperative evaluation Astigmatism control are important !!! The surgeon must weigh the specific advantages and disadvantages of each lens in selecting either bilateral implantation or mixing different IOL in an effort to customize the treatment plan for each patient.

Counseling Considerations Document in the clinical chart what you tell the patient Counsel the patient about visual disturbances Counsel the patient about the reading distance Tell them it takes time for full adaptation Don’t promise “you’ll never wear glasses again” Remember, out of pocket expenses may result in higher patient expectations Provide patients with the Surgical Patient Information Booklet 3 to 6 months or more is required for brain adaptation