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David F. Chang, MD
2014
Subjective Assessment of Accommodation and
Extended Depth of Focus (EDF)
Surgeon Expectations
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Consultant for: Abbott Medical Optics: C Calhoun Vision Inc: O Clarity: C,O; Powervision: C, O
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1. 10% - like wearing glasses 2. 10% - limited BCVA 3. 15% - hate glasses 4. 2/3 – interested but
depends on cost/tradeoffs
Based on clinical experience
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Reduced Spectacle Dependence
1. Good "quality" vision 2. Minimal unwanted images (tradeoff) 3. Low risk 4. Affordable
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23.4%
32.0% 19.5%
14.5%
10.7%
Percent of current cataract procedures that involve presbyopia-correcting IOLs
None
1% to 5%
5% to 10%
11% to 20%
21 to 40%
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23.4%
32.0% 19.5%
14.5%
10.7%
Percent of current cataract procedures that involve presbyopia-correcting IOLs
None
1% to 5%
5% to 10%
11% to 20%
21 to 40%
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23.4%
32.0% 19.5%
14.5%
10.7%
Percent of current cataract procedures that involve presbyopia-correcting IOLs
None
1% to 5%
5% to 10%
11% to 20%
21 to 40%
Average % of cataract procedures that is presbyopia-correcting IOLs is 7.9%
(7% US, 9% Non-US)
Average % targeted for monovision = 18.9% (15.2% US , 23.1% Non-US)
ASCRS 2013 Survey
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Zhang F, Sugar A, Jacobsen G, Collins M.
Visual function and spectacle independence after cataract surgery: bilateral diffractive
multifocal intraocular lenses versus monovision pseudophakia.
J Cataract Refract Surg. 2011 May;37:853-858
MONOVISION VS MULTIFOCAL IOLS
(RESTOR)
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MONOVISION VS MULTIFOCAL IOLS
(TECNIS MF)
Wilkins MR, Allan BD, Rubin GS, et al. Randomized trial of multifocal intraocular
lenses versus monovision after bilateral cataract surgery.
Ophthalmology 2013 Dec; 120: 2449-2455
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High Satisfaction Mono – better intermediate
MF – better near MF – more dysphotopsia
MONOVISION VS MULTIFOCAL IOLS
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23.4%
32.0% 19.5%
14.5%
10.7%
Percent of current cataract procedures that involve presbyopia-correcting IOLs
None
1% to 5%
5% to 10%
11% to 20%
21 to 40%
Average % of cataract procedures that is presbyopia-correcting IOLs is 7.9%
(7% US, 9% Non-US)
Average % targeted for monovision = 18.9% (15.2% US , 23.1% Non-US)
ASCRS 2013 Survey
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1. Cost 2. Intermediate not optimized 3. Halos/unwanted images 4. Contrast sensitivity loss
1. Ocular co-morbidity 2. Residual refractive error
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1. Reduced dependence vs independence 2. Intermediate vs near 3. Accommodating vs
pseudoaccommodating? 4. Optical risks? Corrected with
spectacles? Permanence? 5. Options – individualize (cost/tradeoffs)
Based on clinical experience
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1. Reduced dependence vs independence 2. Intermediate vs near 3. Accommodating vs
pseudoaccommodating? 4. Optical risks? Corrected with
spectacles? Permanence? 5. Options – individualize (cost/tradeoffs)
Based on clinical experience
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1. Social vs occupational vision
2. Lifestyle
3. Most patients willing to wear glasses
for certain tasks
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1. Reduced dependence vs independence 2. Intermediate vs near 3. Accommodating vs
pseudoaccommodating? 4. Optical risks? Corrected with
spectacles? Permanence? 5. Options – individualize (cost/tradeoffs)
Based on clinical experience
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1. Computer, mobile devices
2. Dashboard
3. ReSTOR 4.0 versus 3.0
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1. Reduced dependence vs independence 2. Intermediate vs near 3. Accommodating vs
pseudoaccommodating? 4. Optical risks? Corrected with
spectacles? Permanence? 5. Options – individualize (cost/tradeoffs)
Based on clinical experience
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1. Mechanism not important to patients
2. MDs – want to understand
3. Mechanism
1. Static – few long term questions 2. Dynamic – long term questions
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1. Reduced dependence vs independence 2. Intermediate vs near 3. Accommodating vs
pseudoaccommodating? 4. Optical risks? Corrected with
spectacles? Permanence? 5. Options – individualize (cost/tradeoffs)
Based on clinical experience
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1. Halos, higher order aberrations
2. Correctable with spectacles
3. IOL Exchange
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1. Reduced dependence vs independence 2. Intermediate vs near 3. Accommodating vs
pseudoaccommodating? 4. Optical risks? Corrected with
spectacles? Permanence? 5. Options – individualize (cost/tradeoffs)
Based on clinical experience
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1. Motivation for spectacle independence
2. Ocular co-morbidity
3. Refractive error (e.g. astigmatism)
4. Optical trade-offs – risk tolerance
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1. Accommodating 1. Range 2. Long term follow-up
2. Pseudo-accommodating 1. DOF, intermediate 2. Binocular results
3. Safety 1. Ocular 2. Optical
4. Efficacy 1. Subjective vs objective
Based on clinical experience
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1. Static Mechanism
1. Optical Bench Testing important 2. Clinical testing - confirm 3. Control – necessary?
2. Dynamic Mechanism 1. Clinical testing more important 2. Longer follow-up
Based on clinical experience
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Gupta N, Wolffshon JSW, Naroo SA Optimizing measurement of subjective amplitude
of accommodation with defocus curves. J Cataract Refract Surg 2008;34:1329-1338
SUBJECTIVE ACCOMMODATION
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Win-Hall DM, Glasser A Objective accommodation measurements in
pseudophakic subjects using an autorefractor and an aberrometer.
J Cataract Refract Surg 2009;35:282-290
SUBJECTIVE VS OBJECTIVE
ACCOMMODATION
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mesopic pupil
scotopic pupil
50% contrast
DOF
DOF
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Wavefront Sensor
Deformable Mirror
Feedback Control
Model Eye
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Far Intermediate Near
AcrySof Monofocal
ReSTOR 3D Apodized MF
Tecnis Full-Aperture MF
Crystalens HD Bi-spherical
accommodating
Optical Bench Testing
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Distance Near ⇒ Beyond ∞
0D -0.5D +0.5D +1.0D +1.5D +2.0D +2.5D +3.0D
0D -0.5D +0.5D +1.0D +1.5D +2.0D +2.5D
0D -0.5D +0.5D +1.0D +1.5D +2.0D +2.5D
0D -0.5D +0.5D +1.0D +1.5D +2.0D +2.5D +3.0D +3.5D +4.0D
Spherical Monofocal vs Premium IOL’s Intermediate
Pupil = 3.0 mm
0D -0.5D +0.5D +1.0D +1.5D +2.0D +2.5D +3.0D +3.5D +4.0D +4.5D
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Astigmatism Reduces Multifocal IOL Depth of Field
Scott MacRae, M.D
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1. Safety?
2. Optical tradeoffs?
3. Label?
4. Patient satisfaction?
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