1. Multi focal IOL

2. 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

3. 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

4. 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

5. 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 = 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

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

7. 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)

8. 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
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9. still requires target of mild myopia in non-dominant eye

10. 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

11. 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 ↓

12. 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
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13. 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 %
Near %
Intermediate %
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:
Cons

14. 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

15. 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
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16. Key limitation of ReSTOR
Apodized Diffractive IOLs
In mesopic condition,
(pupil dilation)
Near & intermediate vision would reduce significantly
Acrysof Restor ™ (Alcon)
2mm pupil : near %
distance %
lost % (to higher diffraction order)
5mm pupil : near %
distance %
lost %
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

17. 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

18. 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)

19. 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

20. 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, Revised 01 Mar, 2005.

21. 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, Revised 01 Mar, 2005.

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

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

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

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

26. 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 Ø
Apodized diffractive multifocal for Distant through Near within 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

27. 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

28. 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

29. 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:

30. 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: ]

33. Case M/65 VA distance : OD 0.125 (0.8 x +2.00Ds)
OS (0.8 X +1.75Ds)
VA near : OD (0.65 add +1.50Ds)
OS (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

34. 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
phaco+PCL (OD)  ReZoom +19.5D
phaco +PCL (OS)  Tecnis +20.5D

35. 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)

36. 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

37. : 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

38. 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.

39. 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.

40. 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

41. 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

42. 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

43. 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

44. 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

45. Customized vision : Pupil dynamics
Patients who underwent ReSTOR IOL implantation were divided according to their photopic pupil diameter
: mm, mm, and mm
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 ! “

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

47. 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.

48. 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.

49. 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