1. Inadvertent Insertion of an Opposite- Side Tecnis ZM900 Multifocal IOL Wilson Takashi Hida, M.D. witaks@yahoo.com.br Celso Takashi Nakano; Jonathan Lake; Newton Kara Jose Junior; Amaryllis Avakian Research fellow in Cataract Surgery in São Paulo University School of Medicine Cataract Surgery tutor in São Paulo Santa Casa Hospital School of Medicine None of the authors has a financial or proprietary interest in any material or method mentioned.

2. Wilson Takashi Hida, MD PURPOSE To report an inadvertent insertion of a multifocal IOL with anterior aspheric and posterior diffractive platform in the opposite side.

3. Wilson Takashi Hida, MD A 51-year-old female presenting blurred vision in the both eyes had a corrected visual acuity in the right eye (OD) of 20/60 for distance vision and Jaeger 10 for near vision (30cm), and 20/40 for distance vision and Jaeger 8 for near vision in the left eye (OS). Preoperative refraction in OD was +0.50 -0.63 x 90 and +0.25 - 0.64 x 90 in OS. Keratometric values were 44.23D x 43.60D diopters at 180 degrees and 44.64D x 44.00D at 180 degrees, respectively in OD and OS. A diagnosis of senile cataract was made in both eyes and the patient was submitted to phacoemulsification and IOL implantation in both eyes. The axial length in OD was 22.80mm and 22.59mm in OS. The IOL calculation was done by a experienced examinator and IOL-Master Optical biometer (Carl Zeiss Meditec, Jena, Germany) was the technique of choice. Patient also underwent wavefront examination with OPD-Scan and data was analyzed with OPD-Station software (Nidek, Gamagori, Japan). A multifocal diffractive IOL (Tecnis ZM900, AMO, Santa Ana, USA) of +23.50 diopters was selected for OD and +24.00 diopters for OS, with respective target postoperative refraction of +0.39D and +0.27D. Conceptual illustration of a Tecnis Multifocal lens can be seem in FIGURE1 Case Report

4. Wilson Takashi Hida, MD The same senior surgeon performed both surgeries using the same surgical technique. A 2.75 mm self-sealing clear-cornea incision in the steepest axis was done in order to reduce postoperative corneal astigmatism. During IOL implantation in the second surgery (OS) the patient was no longer collaborative and the IOL rapidly unfolded into the capsular bag, but in the opposite side. FIGURE 2.

5. Wilson Takashi Hida, MD In the 6 th month postoperative exam, UCBVA in OD was 20/20 for distance vision, Jaeger 5 for intermediate vision (80cm) and Jaeger 1 for near vision (30cm). In OS, we found 20/20 for distance vision, Jaeger 2 for intermediate vision and Jaeger 1 for near vision. Postop refraction were +0.50 -0.50 x 140 degrees, and plano -0.50 x 110, respectively in OD and OS. Wavefront analysis in OD showed a total aberrations of 1.210µm. Coma of 0.322µm, trefoil of 0.545µm, tetrafoil of 0.221µm, spherical aberrations of 0.028µm and high- astigmatism of 0.036µm counted a total HOAs of 0.718µm. In OS, total aberrations was 1.063µm. Coma of 0.265µm, trefoil of 0.351µm, tetrafoil of 0.238µm, spherical aberrations of 0.079µm and high-astigmatism of 0.045µm counted a total HOAs of 0.550µm,. Corneal Z0,4 and internal Z0,4 is shown in FIGURE 2 e 3.

6. Wilson Takashi Hida, MD The results of contrast sensitivity under photopic and mesopic conditions and stereotest for near vision (Titmus, TNO, Lang tests) were normal in both eyes. The patient was satisfied with the postoperative refraction, and despite a negative shift was expected due to the anterior effective lens position this seemed not to worsen UCVA in this case. Contrast sensitivity was measured by the VCTS® 6000 (Vistech Consultants Incorporation, Dayton, OH, USA) under photopic and mesopic conditions. The chart used displays sine-wave gratings at 5 standard spatial frequencies, from 1.5 to 18 cycles/degree (cpd). Log calculations of the obtained values was then taken to obtain the contrast sensitivity values that were entered in the database for statistical analysis.

7. Wilson Takashi Hida, MD The results of defocus curve and depth of focus (with best correction) demonstrated similar correlation with focal range of 20cm in the normal side IOL and 34cm in the opposite IOL.

8. Wilson Takashi Hida, MD Even though the difference of optical performance, stereopsy, distance visual acuity and aberrometry remain normal, mild myopization and PCO occur more often when the IOL is inserted in the opposite side. Surprisingly, the combination of the inverted IOL with the normal implantation of the Tecnis MF ZM900 worked out as a Mix & Match approach, achieving satisfaction in near and intermediate vision. After this incident, we recommend to insert the IOL slowly, so that the IOLs could be correctly positioned. And, despite further comparative studies are required, in an accidental inverted IOL insertion, a conservative management could be taken as a safe option. Conclusion Correctelly positioned IOL x Opposite side IOL