choosing the right iol · choosing the right intra-ocular lens g.sallet, md, febo ooginstituut...
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CHOOSING THE RIGHT INTRA-OCULAR LENS
G.SALLET, MD, FEBOOOGINSTITUUT AALST
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Decisions to make
Hydrophylic – Hydrophobic Design
Square – round edge optic Haptic design – Plate haptic
Spherical – Aspherical Full transparant – Blue blocking Spherical – Toric Accomodative Monofocal – Multifocal
Refractive - Diffractive
Extended depth of focus
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LENS DESIGN : MATERIAL & ISSUES Material :
Hydrophylic (acrylic/PMMA) contains water
Hydrophobic (acrylic or silicone) resists water
Design : square optic edge (prevent PCO) Haptic
prevent tilting, movement of IOL (capsular fibrosis)
posterior capsule striae & folds
Problems to avoid : PCO (capsular biocompatibility)
foreign body reaction (uveal biocompatibility)
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In search of the perfect optic :Asphericity
Minimize sphericalaberrations
Minimize tilting (Coma) one focal point crystal clear image better contrast sensitivity
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Standard IOLPremium asphericIOL
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Aging of the eye
Normal cornea
0 to pos sph aberr 0.33u stable troughout life
Crystalline lens
Young age
Negative sph aberrations
better contrast sensitivity
Older age
increase of sph aberr
Pos sph aberration
Less contrast sensitivity
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Aging of the eye
Normal cornea
0 to pos sph aberr 0.33u stable troughout life
Myopic LASIK
positive spherical aberratons
Hyperopic LASIK
negative spherical aberrations
Crystalline lens
Young age
Negative sph aberrations
better contrast sensitivity
Older age
increase of sph aberr
Pos sph aberration
Less contrast sensitivity
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Asphericity of IOL’s
Cornea Hyperopic LASIK
Neg sph aberr
Normal cornea 0-0.33u pos sph aberr
Myopic LASIK pos sph aberr >0.3u
Intra-ocular lenses standard spherical IOL
Positive sph aberr
aspheric IOL
Neutral to neg sph aberr
Akreos (B&L) 0 sph aberr
Tecnis (Abbott) -0.27
Acrysof IQ (Alcon) -0.20
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In search of the perfect opticAsphericity
Minimize sphericalaberrations
one focal point
crystal clear image
better contrast sensitivity
Decreases depth of focus less intermediate & near vision
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Presbyopia correction with IOL
Monovision Accomodative Extended depth of focus Multifocal
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Monovision
dominant eye distance / non-dominant -1.25 Price issue Less glare/halo but loss of stereopsis
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Accomodative or pseudo-accomodative IOL
Optic shift : 3D needs movement of 2.2mm - Forward-backward axial movement of IOL Flexibility in lens thickness Problems :
current technology, not enough accomodative effect to provide functional near vision
capsular fibrosis
aging ciliary muscle not enough muscular force ?
Posterior capsular opacification
Assymetrical vaulting and tilting
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NEW aberrated IOLs :
Extended Depth Of Focus IOL (EDOF)Multifocal IOL
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Extended depth of focus (EDOF)
First EDOF: Monofocal with positive spherical aberration Mini-Well (SIFI) : 3 zones of different asphericity giving
continuous vision WIOL-CF : Wichterle IOL Continuus Focus
Negative spherical aberrations Mimics natural lens Polyfocality Hydrogel to mimic natural lens
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Refractive Cataract Surgery :Extended depth of focus (EDOF)
Diffractive : AT-Lara (Zeiss) / Symfony (Abbott) Modification of heigth, spacing and
profiles of echelette EDOF Photic phenomena less near vision
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Refractive Cataract Surgery :Extended depth of focus (EDOF)
Refractive : Comfort (low add refractive) Bifocal +1.5 add Improved intermediate vision
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Refractive Cataract Surgery :Extended depth of focus (EDOF)
Refractive + Diffractive + spherical aberration : SAV-IOL (Swiss Advanced Vision) Lucidis & Eden central aspheric (Lucidis) 6mm refractive (Lucidis) Lucidis + 3.5mm diffractive (Eden)
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Refractive Cataract Surgery :Extended depth of focus (EDOF)
Pin-hole : IC-8 IOL irregular cornea increased depth of focus 1.36mm central aperture good distance, intermediate and near vision similar to Kamra inlay Possible for post-refractive, irregular corneas,
monofocal pseudophakia
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Refractive Cataract Surgery :Extended depth of focus (EDOF)
Sperical aberration Diffractive Refractive Pin-hole
not enough for reading vision elongated focus distance to enhance intermediate and near vision less glare and halos compared to multifocal Solution : mini-monovision , mix & match
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Refractive Cataract Surgery :Multifocality
Diffractive optics Refractive optics
Bifocal functional distance & near vision
Trifocal diffractive functional distance, near &
intermediate vision
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Optical aberrations : glare & halo
Monofocal EDOF Multifocal
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Optical aberrations : distance vision
Monofocal EDOF Multifocal
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Optical aberrations: intermediate vision
Monofocal EDOF Multifocal
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Optical aberrations : near visionMonofocal EDOF Multifocal
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Refractive pearls for the cataract surgeon
Multifocal ?
Monovision (with spherical or aspherical IOL ??)
Extended depth of focus ?
Accomodative (current technology not sufficient)
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Multifocal IOL vs Monofocal IOLCochrane study (2016)
distance VA: little difference to monofocal Near VA: multifocal better outcome Glare and halo’s : more in multifocal Patient less spectacle dependent with multifocal
20 studies (1992-2015) 6/20 trials before 2000
ECCE / Can-opener
IOL used Refractive / Diffractive (older models: Array-Rezoom-3M)
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Multifocal IOL : safety
ESCRS-ASCRS explantation study (Mammalis, 2008)
Multifocal 24% (10%market) glare & halos
Monofocal 76% (90%market) decentration / dislocation / incorrect power
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Multifocal IOL vs Monovision: Cochrane study (2016)
2 studies No difference for UCVA-distance-intermediate and near Multifocal less likely to be spectacle dependent (especially for
near) Contrast sensitivity
marginally better in Monovision(1 study)
Same in other study
More glare in multifocal Multifocal more IOL-exchange (6 eyes vs 0 in first year)
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Multifocal IOL
Critical succes factors : Achieving emmetropia
Correction of astigmatism Arcuate incisions
Toric IOL
Centration
Patient motivation
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ASTIGMATISM MANAGEMENT:TORIC IOL
20% 1.5D astigmatism 10% 2D or more astigmatism
Toric IOLStandard IOL + >1 diopter of astigmatism
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Refractive Cataract Surgery Target is to achieve emmetropia Choice of lens material & design Correct IOL-calculation
corrects spherical equivalent
Small incision surgery minimises induced astigmatism
Correction of astigmatism Toric IOL
Correction of presbyopia multifocality Mini-monovision EDOF Monovision
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Many options to choose: your decision !!
THANK YOU