KHOZAM I, TANGUY C, COCHENER B Multifocal implantation 4 years later : stability of results according to the IOL model KHOZAM I, TANGUY C, COCHENER B (CHU BREST) The authors do not benefit of any financial interest concerning this study.

INTRODUCTION: Independence of spectacles use has become a postoperative target after cataract surgery, and can greatly enhance patients’ quality of life. The global experience around the world concerning the latest generation of multifocal IOLs is very promising. This technology offers surgeons a feaseble way of meeting patients’expectations of an improved lifestyle as the result of reduced spectacles dependence. STUDY: -Purpose: To compare visual results and quality of vision of five types of multifocal intraocular lenses and evaluate these results during 4 years of follow up. -Patients: 148 patients (278 eyes) -Mean age: 58.38 years +/-7.85 (from 41 to 80 years) -Surgery (Phacoemulsification): June 2006 to November 2009

POPULATION: Groupe I: 77 ReStor (Alcon) AD3 (addition +4) Groupe II: 21 ReStor (Alcon) AD1 (addition+3) Groupe III: 69 Tecnis (AMO) ZM 900 Groupe IV: 20 ReZoom (AMO) NGX1 Groupe V: 92 AcriLisa (Zeiss)

EVALUATION: 1) Visual acuity (distance, near and intermediate VA, pre and postoperative) 2) refraction (pre et postoperative) 3) quality of vision (objective/subjective) Symptoms (glare, halos, problems with night vision) PC platform « EyeVis Pro » for the quality of vision study and visual performance score Defocus curve 4) Slit lamp examination (IOLs centration/ posterior capsule opacification) 5) Nd:YAG capsulotomy for PCO 6) PRK for residual ametropia 7) Questionnaires (patient satisfaction/independence of spectacles use)

RESULTS: Preoperative refraction: Postoperative refraction: ReStor AD3 Tecnis ZM 900 ReZoom NGX1 AcriLisa Sphere 0.93(+/-3.3) (-8.50 to 9.75) 0.94(+/-2.05) (-2.75 to 4.50) 0.86(+/-3.72) (-10 to 9) 0.71(+/-1.8) (-3.75 to3.25) -3.46(+/-5.4) (-15 to 8.5) Cylinder 1.66(+/-1.08) (0 to 5) 0.29(+/-0.54) (0 to 0.75) 0.03(+/-0.76) (0 to 1.75) 0.28(+/-0.61) (0 to 2) 0.25(+/-1.2) (0 to 4) Preoperative refraction: ReStor AD3 ReStor AD1 Tecnis ZM 900 ReZoom NGX1 AcriLisa Sphere -0.03(+/-0.74) (2.50 to1.75) 0.61(+/-0.62) (0.50 to1.75) 0.15(+/-0.77) (-2 to 2) -0.54(+/-0.9) (-2.50 to 1) 0.02(+/-0.53) (-2 to 1.25) Cylinder 0.12(+/-0.76) (0 to 1.75) 0.29(+/-0.66) (0 to 0.75) 0.35(+/-0.84) 0.44(+/-1.04) (0 to1.50) 0.16(+/-0.61) (0 to 2) Postoperative refraction:

RESULTS: Uncorrected Visual Acuity (UCVA) ReStor AD3 ReStor AD1 Tecnis ZM 900 ReZoom NGX1 AcriLisa Distance VA (4m) 0.7(+/-0.21) (0.1to1) 0.69(+/-0.18) (0.6 to 1) 0.64(+/-0.24) (0.5 to 1) 0.69(+/-0.22) (0.4 to 1) 0.65(+/-0.23) % > 0.8 75% 74% 62% 67% 58% Intermediate VA (50cm) P4.7(+/-1.9) (P2 to P8) P4.9(+/-1.18) (P2 to P6) P3.9(+/-1.4) (P2 to P10) P4.5(+/-1.2) (P2 to P12) P4.69(+/2.13) (P3 to P12) Near VA (33cm) P2.44(+/-0.92) (P2 to P5) P2.29(+/-0.46) P2.29(+/-0.24) P2.61(+/-1.5) P2.51(+/-1.32) (P2 to P14) % P2 78% 73% 80% 82% 77%

Postoperative interval RESULTS: Treatment with complementary PRK (for residual ametropia): % treatment with PRK Postoperative interval Mean VA %>0.8 ReStor AD3 23% 5.5 months(+/-2.2) 0.83(+/-0.12) (0.6 to 1) 80% ReStor AD1 14% 5.8 months(+/1.8) 0.93(+/-0.05) (0.9 to 1) 100% Tecnis ZM900 39% 6 months(+/-2) 0.86(+/-0.15) 75% ReZoom NGX1 11% 5.8 months(+/-1) 0.9 (0.8 to 1) AcriLisa 20% 6 months(+/-1) 0.9(+/-0.05) 95%

RESULTS: Nd:YAG capsulotomy for PCO: % % Intervention by Nd:Yag (between 6 to 36 months ) Early intervention by Nd:Yag (between 6 and 12 months)

RESULTS: ReStor AD3 ReStor AD1 Tecnis ZM900 ReZoom NGX1 AcriLisa VA post Nd:YAG: Mean VA %>0.8 ReStor AD3 0.91(+/-0.07) (0.8 to 1) 100% ReStor AD1 0.93(+/-0.05) Tecnis ZM900 0.93(+/-0.07) (0.7 to 1) 97% ReZoom NGX1 0.9(+/-0.08) (0.6 to 1) AcriLisa 0.89(+/-0.09) 95%

RESULTS: QUALITY OF VISION Questionnaires: % Reading test: fluence and comprehension

DISCUSSION: Patients satisfied with their IOL performance/ most would have multifocal IOLs implanted again. 15% of overall population: PRK for residual ametropia (esp.astigmatism) Not before 3 months posoperatively (neuroadaptation). Excellent intermediate vision with Restor AD1++(then by order of performance come: AcriLisa, Restor AD3, ReZoom, Tecnis) Mild PCO significantly influences visual performance/ Earlier intervention was noticed with AcriLisa group; but at 2 years comparable YAG rate in all groups Safety issue: No retinal complications at the term of 4 years (even after early Nd:Yag laser treatment in Prelex )

CONCLUSION: Modern cataract surgery refractive cataract surgery. (The new technologies in the design of multifocal IOLs has greatly improved the quality of life in active patients who wish to reduce their dependence on glasses) Optimisation of results by: - preoperative patient selection - excellent IOL calculation management and surgical technique - advent of toric multifocal IOLs shoud decrease the rate of secondary procedure Surgical pearls: Good peroperative cleaning of anterior capsule/ large capsulorrhexis (6mm)/ perfect centralisation of the IOL + prevent early PCO Larger series and longer follow up (one decade) must be needed to reinforce the proof of the safety issue of this procedure.