1. Global Meta-Analysis on Visual and Optical Quality Comparison for Aspheric vs Spherical IOL Technology James P. McCulley, MD Department of Ophthalmology University of Texas Southwestern Medical Center at Dallas Dr McCulley is a consultant for Alcon Laboratories, Inc.

2. Purpose To address the question of whether patient visual and optical quality outcomes are benefited by implantation with aspheric IOLs instead of spherical IOLs Modeling suggests a difference should exist 1 Literature of controlled clinical studies has matured enough to merit systematic review to yield collective answers 1. Holladay JT, et al. J Refract Surg. 2002;18:683-691

3. Methods: Literature Searches for Published Articles OvidSP Database (MEDLINE, EMBASE pooled) Keyword searches: 1. “intraocular lens” AND aspheric* 2. “intraocular lens” AND prolate 53 unique English-language results Discard reviews, editorials, case reports, methodology recommendations, preclinical trials Discard studies about multifocal or accommodative IOLs Discard studies without spherical controls 24 journal articles *Wildcard asterisk symbol returns “aspheric” or “aspherical,” etc.

4. Methods: Society Database Searches for Congress Abstracts 2008 only (assumption: abstracts from earlier meetings had time to reach publication) ASCRSASCRS ESCRSESCRS ARVOARVO † No wildcard functionality ‡ Not searchable; browsed free paper sessions AAO had 15 hits but no relevant results (not shown). keyword † intraocular + lens + aspheric Intraocular + lens + aspherical browsing ‡ “Aspheric IOLs,” “IOL technology” 8 abstracts 24 abstracts 17 abstracts Discard abstracts without relevant visual acuity outcomes reported Discard abstracts about multifocals or without spherical controls 2 abstracts 7 abstracts 1 abstract 10 abstracts keyword † intraocular + lens + aspheric Intraocular + lens + aspherical

5. Methods: Pooled Source Data 34 studies, 2832 eyes Aspheric IOLsSpherical Control IOLs ModelCompanyStudies, nModelCompanyStudies, n TecnisAMO19SensarAMO11 AcrySof IQAlcon13AcrySof NaturalAlcon9 Akreos Adapt AOB & L1AcrySof SA60ATAlcon8 SofPort AOB & L1ClariFlexAMO2 XL Stabi ZOZeiss1CeeOn EdgeAMO5 AcriSmart 36 AAcri.Tec1XL Stabi SkyZeiss1 Acri.Smart 46 SAcri.Tec1 ACR6D SECorneal1 AA4207VFStaar1 StabibagIoltech1 AcrySof MA60BMAlcon1 Older IOL names or manufacturers updated to most recent. Control design Groupwise: 17 studies Contralateral/intraindividual: 13 studies Unclear/unspecified: 4 studies

6. Results: Optical Quality Outcomes  In no case did a spherical lens outperform an aspheric lens  Study marked “yes” if aspheric IOL performed better than spherical IOL under any condition (eg, pupil size) –100% of studies (n = 23) found aspheric  reduction of spherical aberration –73% (n = 11) found aspheric  reduction of total high-order aberration Aspheric significantly better? 0

7. Results: Visual Acuity  In no case did a spherical lens outperform an aspheric lens  Study marked “yes” if aspheric IOL performed better than spherical IOL at any time point –11% of studies (n = 1) found aspheric  superior uncorrected visual acuity –7% (n = 2) found aspheric  superior best-corrected visual acuity –50% (n = 2) found aspheric  superior low-contrast visual acuity Aspheric significantly better?

8. Results: Contrast Sensitivity (CS)  In no case did a spherical lens outperform an aspheric lens  Study marked “yes” if aspheric IOL performed better than spherical IOL at any spatial frequency –62% of studies (n = 16) found aspheric  superior photopic CS –86% (n = 18) found aspheric  superior mesopic CS –82% (n = 9) found aspheric  superior mesopic + glare CS Aspheric significantly better?

9. Results: Depth of Focus (Range of Accommodation)  Only two studies reported this parameter –50% (n = 1) found aspheric IOL superior AcrySof IQ superior over AcrySof Natural –50% (n = 1) found aspheric not different from spherical IOL Akreos Adapt AO not superior over Sensar

10. Conclusions  Aspheric IOL performance was never inferior to spherical IOLs on any metric  Aspheric IOLs were superior on many metrics of optical quality and visual quality (especially contrast sensitivity)  Surgeons should consider aspheric IOLs for their patients

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