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

56 eyes of 30 patients Cataract surgery between december 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 implantation Mix-match i s t a n b u l c e r r a h i h a s t a n e s i

Demographics: Female: 62 % Male: 38 % Age: 7-82 (Mean=60.7) Preop refraction Seq to myopic 26 emetropic 119 hypermetropic eyes 6 months to 2 years follow up time Average one year 28 % ≤ 6 months 72 % ≥ 6months i s t a n b u l c e r r a h i h a s t a n e s i

Diffractive 1 st generation zonal refractive far focusnear focus Refractive monofocal far focus Optical Principles of IOLs near focusfar 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 D (steps 0.5D) A-constant i s t a n b u l c e r r a h i h a s t a n e s i

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

near focusfar focus 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 D Tecnis:distribution of focus is independent of pupil size 5-34 D Silicon A-constant 119 i s t a n b u l c e r r a h i h a s t a n e s i

Diffractive TECNIS ZM001 + ACE Cornea near focusfar focus

Acri.lisa IOL Distance –dominant -diffractive multifocal IOL Independent of pupil size Smooth steps in the refractive diffractive structure Light distribution is not equal for far and near vision (Asymmetrical light distribution) 65/35% Acrylic A-constant dpt i s t a n b u l c e r r a h i h a s t a n e s i

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 Add Reduced photic phenomena like glare,halos,low contrast sensitivity i s t a n b u l c e r r a h i h a s t a n e s i

Pre-op examinations Preop full examinations: Bcva Dominant –nondominant eye selection Oculer Tension Retina and anterior segment examination Topography Oculyzer –Pentacam Contrast sensitivity Potential acuity meter Pupillometry Biometry Pachymeter Tear film quality (punctum plugs if required) i s t a n b u l c e r r a h i h a s t a n e s i

IOL selection Expectations should be well discussed in detail before the operation Driving,computer usage,reading,working distance Distance vision may be affected by glare at low light conditions Neuro-adaptation (takes time) Possibility of another procedure(lasik) for better vision May need reading glasses in dim light i s t a n b u l c e r r a h i h a s t a n e s i

Biometry Repeated measurements Check keratometer measurements Srk-t for emetropics,myopics Haigis for high hyperopias Check first eye’s refraction at least one week after the operation and then plan the second eye For crystalens binoculer implantations postop -0.5 D myopia planning for the first eye, emmetropia for the second eye i s t a n b u l c e r r a h i h a s t a n e s i

Surgery Facoemulsification Topical anesteshia Corneal tunnel incision in the steepest axis (don’t consider astigmatism due to crystalline lens) Capsulorexis smaller than optic diameter Posterior capsule polishing Care to the optic of the IOL Intracapsuler ring may be implanted if necessary! i s t a n b u l c e r r a h i h a s t a n e s i

Post-op testing Ucva at distant, intermediate and near Bcva at distant, distant corrected intermediate and near Contrast sensitivity and glare was checked by O phtec 6500 sine wave gratings of 5 different spatial frequencies: 1.5, 3, 6, 12, cycle per degree Patient satisfaction questionarie 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 – 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 :±0.75 Bcva for distant is between 20/32-20/20 Distance corrected near vision (40 cm) is between J 7 –J9 Distance 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 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 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 activities High patient satisfaction for distance i s t a n b u l c e r r a h i h a s t a n e s i

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 implantation Two of them undergone seconder IOL exchange operation Yag capsulotomy was needed in 7 patients Postop secondary excimer lazer treatment was performed in 12 patients (5 %) Mean monoculer post operative refractive error Seq after secondary treatment was ±0.50 i s t a n b u l c e r r a h i h a s t a n e s i

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

3 Main groups Mix-match: Rezoom-Tecnis 26 patients Rezoom-Acri.Lisa 21 patients Bilateral -multifocal same IOL: Rezoom-Rezoom 21 patients Acri.Lisa-Acri.Lisa 12 patients Monoculer- multifocal implantation(other eye not operated): Rezoom one eye 22 patients Acri.Lisa one eye 13 patients Tecnis 9 patients i s t a n b u l c e r r a h i h a s t a n e s i

MIX-MATCH PATIENT NO FREE OF GLASSES HALO GLARE NEARINTERMEDIATEFAR Rezoom Tecnis 26 98% 75%J1.6 J2 20/20 Rezoom Acri.Lisa 21 75% 60% J 1.6 J2 20/25 i s t a n b u l c e r r a h i h a s t a n e s i

BINOCULER SAME IOL PATIENT NOFREE OF GLASSES HALO GLARE NEARINTERMEDIATEFAR Acri.Lisa 12 85%70%J 1.5 J 2 20/20 Rezoom 21 75%60% J 2 20/25 i s t a n b u l c e r r a h i h a s t a n e s i

MONOCULER DISTANCE CORRECTED VISUAL ACUITIES NEARINTERMEDIATEDISTANT TecnisJ1.6J2.120/20 RezoomJ2.2J1.820/25 Acri.LisaJ1.5J220/2 0 RestorJ2J2.220/20 i s t a n b u l c e r r a h i h a s t a n e s i

Questionnaries Halo,glare(subjective experience) Near,intermediate, distant vision Driving (day,night) Reading (newspaper,maps,prescriptions) Activities(sports, shopping) Patient satisfaction 1-bad 2-fair 3-good 4-very good i s t a n b u l c e r r a h i h a s t a n e s i

PATIENT SATISFACTION HALO GLARE NEARINTERMADIATEDISTANT Rezoom Tecnis Acri.Lisa Restor i s t a n b u l c e r r a h i h a s t a n e s i

Overall glare i s t a n b u l c e r r a h i h a s t a n e s i Night driving Night At bright light Always None Room light

Glare Rezoom 76 % Tecnis 62 % Acrilisa 58 % ReStor 56 % Crystalens 50% i s t a n b u l c e r r a h i h a s t a n e s i

Multifocal IOL Patient Satisfaction Overall satisfaction rate is % of the patients would have the same implant again 70% of the patients have some complaints while night driving 79 % glasses free(computer, newspaper,outdoor activities) 18 % wear glasses for reading smallprints 3 % wear glasses for distant (driving) i s t a n b u l c e r r a h i h a s t a n e s i

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 cm with ReZoom 45 cm i s t a n b u l c e r r a h i h a s t a n e s i