1. Accommodative IOL’s Dr. H. Razmjoo
Isfahan University of Medical Sciences

2. Achieving the Desired Results in modern cataract surgery:
Astigmatism Control
Aspheric Optics
Accurate Biometry
Appropriate Formulas
Adjusting the Outcome
Accommodation

3. Presbyopia : Solutions?
Sclera?/
Cornea
Presbyopic LASIK
Corneal Inlays
Lens
Multifocal IOL
Phakic / pseudophakic
Accommodative IOL

4. Consider this issues in evaluating presbyopic Surgery:
Measuring accommodation
True versus Pseudo-Accommodation
Reading ease, speed
Accommodative reserve
Quality of vision - HOAs

5. Pseudo-accommodation
True vs Pseudo-accommodation
True Accommodation
- Transient and rapidly reversible change in optical power of the eye
- Generally requires IOL change of shape or position
Not associated with loss of contrast sensitivity
Pseudo-accommodation
- First devices available
- IOLs
Refractive – ReZoom
Diffractive – ReSTOR
Associated with loss of contrast sensitivity

7. Present IOLs – (FDA) Monofocal Pseudoaccommodative Multifocal ReSTOR
ReZoom
Accommodative
Crystalens

8. Monofocal IOLs: Excellent visual acuity Best contrast sensitivity
Need for some glasses
Monovision

9. Multifocals: (ReStor / ReZoom)
Good for some…
Few years experience
Excellent visual acuity
Decreased contrast sensitivity

10. Accommodative: Crystalens Excellent quality of vision
Minimal contrast loss
Very poor true accommodation
1-1.5D
PCO
Future ???
Only 26% spectacle free in some studies

12. Future accomodating IOL’s
Based on accommodation theories
Exact method controversial
Helmhotz’s theory
Ciliary M. contraction Decreased zonular tension
Thicker lens Bag more lax
More PLUS power

13. Accommodative IOLs Future of refractive surgery
FDA approved lens has limited accommodation
Small incision IOL
Truly accommodation will be available when :
Right IOL concept / design
Maintained long term flexibility of capsule

14. Accommodative Models Lens “filling” Deformable IOL Single optic
Dual optic

15. Single optic IOL Hinged haptics
Forward movement > effective power of IOL
Poor accommodation
Need 1.5 mm axial move to achieve 2 D ofaccommodation

17. Dual optic IOL Positive lens anterior / negative lens posterior
Lenses connected with spring like pieces
Accommodation through ciliary body contraction induced separation of lenses
Large area required

18. Sarfarazi IOL (B&L)

20. Dual optic IOL Advantage over single optic
More accommodation
Less IOL movement required
No glare or contrast issues
Inter-lenticular opacities ?
Accommodation

23. Available IOLs:

24. Single optic: Crystalens
Only FDA approved

25. The capsulorhexis must always be larger than the optic of the IOL, i.e. a capsulorhexis of 6 mm must be selected for an IOL optic of 5 mm. The anterior capsular bag must be placed outside the optic.

27. When the lens is placed in the capsular bag, it must be pushed backward until there is complete contact with the posterior capsular bag.
At this stage of the surgery, the IOL should not move forward at all; which may cause Z syn.

28. The IOL must be rotated until it fits exactly.
Then the cortex and the viscoelastic substance behind the IOL optic must be carefully removed.
Finally, the IOL must be pressed completely back onto the posterior capsular bag and may not move forward.

30. no accommodate for 3 to 5 days
The polyimide material of the haptics causes the IOL to grow firmly together with the capsular bag by fibrosis. At this stage it is important that the patient does not accommodate during the first 3-5 days after implantation.

32. Atropine
To avoid premature accommodation, the pupil is dilated after surgery with a single dose of atropine and it takes 3-5 days for this accommodation blockade to abate.

33. Zsyndrome

34. Indication:
This IOL would be appropriate for all patients.

37. The FDA approved Eyeonics Inc
The FDA approved Eyeonics Inc.’s accommodating IOL, Crystalens AT-45, in November 2003.
Bausch & Lomb acquired Crystalens in 2008 and introduced a newer model called Crystalens HD in 2008.
Crystalens is the only FDA-approved accommodating IOL currently on the market

38. Studies and Peer Reviews:
In a September 2004 FDA trial involving 325 patients:
100% could see at intermediate distances (24" to 30") without glasses; the distance for most of life's activities
98.4% could see well enough to read the newspaper and the phone book without glasses.
Some patients did require glasses for some tasks after implantation of the crystalens

39. At this time, there is no long-term, well-designed clinical trials to support the accommodating technology of the Crystalens IOL.

40. Single optic: 1 CU (Human Optics)
4 flexible haptics for axial movement

42. Single optic: BioConfold 43 E (Morcher)
Ring haptics for optic movement

43. Single optic: Opal (B&L)
Currently in clinical trials

44. Single optic: Tetraflex (Lenstec)
Depends on axial move

45. Single optic: Fluid vision (Power Vision)
Dynamic Optic with Fixed Haptics
Up to 10 D accommodation
Accommodation driven hydraulic lens shape change
NON-ACCOMMODATED
ACCOMMODATED

47. Single optic: Flex optic (AMO)
Conforms the capsular bag
Changes optic curvature
No axial movement
In trial

48. “Single optic”: NuLens (Nulens)
Flexible polymer between 2 rigid plate, one with an opening
Polymer bulges = more positive lens
D of accommodation theoritically

49. NuLens

51. Dual optic: Synchony ( Visiogen)
Dual optic(+ anterior & - posterior) / single piece
“Spring like haptics”
Up to 2.5 acc.

52. Synchony

54. Bag filling: Smart IOL (Medennium)
Ciliary muscle resumes lens shape change control - Pliable for accommodation
Thin rod that > to desired shape with body temperature
In trial

56. Accommodating Injectable Lens
Bag filling:
Accommodating Injectable Lens
(AMO)

57. Liquilens (Vision Solutions)
2 fluids with different refractive indexes in center of lens in single optic
Looking down mixes fluids creating a more positive lens
Power changes with the position of the eye

59. Light adjustable IOL (Calhorn Vision)
Residual refractive error post op laser “adjustment”
Multifocal post op “adjustment” possible ???

60. Conclusions : Future Acc. IOL’s should: Hope for:
- Be the hope for the future
- Have a physiologic concept
- Have few optical side effect
Hope for:
- Aspheric optics
- Adjustability
- Toricity
- Control of lens epithelial cells

62. Criticisms:
The main concern with accommodating IOLs is that there are no long-term, large-scale studies involving its use in patients.
potential complications include capsular bag contraction and posterior capsule opacification.

63. It is more difficult to implant an accommodating IOL (due to the attachment of hinges)
Accommodating IOLs are expensive.

64. Good candidates:
patients over 50 with cataract problems and no serious eye diseases
The patient must have functional ciliary muscles or zonules

65. patients must include ophthalmologic exercises such as puzzles and word games as a part of their daily regimen in order to tone up their ciliary muscles and attain the maximum benefit from the accommodating lenses.
These exercises should be done consistently for 3–6 months

67. Future accomodating IOL’s
Based on accommodation theories
Exact method controversial
Helmhotz’s theory
Ciliary M. contraction Decreased zonular tension
Thicker lens Bag more lax
More PLUS power

68. Thank you for your attention