Dr H Razmjoo Isfahan University of Medical Sciences

• Dr H. Razmjoo • Isfahan University of Medical Sciences • Multifocal IOLs

Presbyopia IOL options • Monovision • Refractive • Diffractive • Accommodative

The Ideal Multifocal IOL Patient • 50’s to the mid 60’s • Cataract starting to compromise quality of vision • Active lifestyle • Concerned about their appearance & ‘quality of life’ • Do not want to ‘get old’ • Spending on lifestyle enhancing procedures • Realistic Expectations • Motivated • Asks lots of questions

Who’s A Suitable Candidate? • Wants to be less dependent on glasses • Understands the limitations • Willing to accept several months to adapt to their new visual system

Who’s Not A Suitable Candidate? • Significant dry eyes • Corneal scarring • Pupil size < 2. 5 mm • Monofocal implant in first eye • Uncorrected post-op astigmatism > 0. 5 D • Unstable capsular support • Someone who demands perfect vision

Re. Zoom Multifocal IOL (AMO) • Refractive lens • Delivers good near, distance and intermediate vision

Is The Re. Zoom Perfect? • The most common concerns • Distance blur • Monocular diplopia • Object glow • Ghosting • Halos at night • These are the biggest post-op

• The 3. 5 D add at the IOL plane provides for fairly good near vision

Acrysof Re. Stor IOL (Alcon) • Diffractive technology • Silicone material • Uses “apodization” to soften blur and sharpen vision • Provides excellent VA at near, distance and intermediate ranges

Strengths of the Acry. Sof Re. STOR IOL • High quality uncorrected near and distance vision with 20/40 or better intermediate vision without movement of the IOL • 80% Overall Spectacle Freedom • Nearly 94% of patients would have the lens again

• The Re. STOR IOL is an IOL that provides significant magnification. • Many patients spend 10 to 15 years gradually holding reading materials farther away. By the time a patient is 55 years old, with 55 to 60 years being the typical age range for presbyopic IOL exchange, the patient is holding reading materials at 14 to 20 inches away from his or her eyes.

• After Re. STOR IOL implantation set at +0. 25 D to +0. 5 D, a patient has near vision of 9 to 10 inches. • However, the Re. STOR IOL does not provide a significant increase in intermediate vision.

Do We currently have any aspheric multifocal IOLs? • Tecnis multifocal (AMO) • Sofport AO (Bausch & Lomb)

• Haloes and glaare at night are commonthese diminish with time • Longer adaptation period – may take weeks or months for patients to accept their “new” visual system • Near vision may be fuzzy to myopes • May need reading specs for prolonged nearpoint work

• In the United States, a new category of intraocular lenses was opened with the approval by the Food and Drug Administration in 2003 of multifocal and accommodating lenses. • The aim of the procedure is to allow the eye to focus on near as well as distant objects without regular need to use glasses. These lenses have areas of different refractive powers and allow both near and distant images to be focused on the retina simultaneously. The brain is then able to

Adverse events • problems with intermediate vision • reduced contrast sensitivity • halos • glare • ‘Vaseline vision’ / waxy vision • reduced tolerance to

• Clinicians wishing to undertake implantation of multifocal (nonaccommodative) IOLs during cataract surgery should ensure that patients understand the risks of the procedure, including the possibilities of halo and glare, and reduced contrast sensitivity. Patients should also be made aware that the lenses may be difficult to remove or replace. They should be provided with clear written information.

• To incorporate the strengths of each type of IOL, some eye surgeons recommend using a multifocal IOL in one eye to emphasize close reading vision and an accommodating IOL in the other eye for further midrange vision. This is called "mix and match. " Distance vision is not compromised with this approach, while near

The ® TECNIS IOL Multifocal • Spherical aberration correction to essentially zero • chromatic aberration reduction • A pupil-independent, fulldiffractive posterior surface • High-quality vision in all light conditions 28

TECNIS® Multifocal Acrylic IOL 13. 0 mm overall diameter TECNIS® IOL wavefrontdesigned aspheric surface Frosted, continuous 360° posterior square edge Posterior diffractive surface 6. 0 mm optic diameter 29 Anterior side Haptics offset for 3 points of fixation Posterior side

TECNIS® Multifocal 1 -Piece IOL Specifications • Full diffractive posterior surface • Pupil-independent • Wavefront-designed aspheric anterior surface • Light distribution 50/50 • Optical power add +4. 0 D • To optimize acuity at preferred reading distance of 33 cm 30

Important Safety Information Under low-contrast conditions, contrast sensitivity is reduced with a multifocal lens compared to a monofocal lens. Therefore, patients with multifocal lenses should exercise caution when driving at night or in poor visibility conditions. 31

Important Safety Information Precautions: The central one millimeter area of the lens creates a far image focus, therefore patients with abnormally small pupils (~1 mm) should achieve, at a minimum, the prescribed distance vision under photopic conditions; however, because this multifocal design has not been tested in patients with abnormally small pupils, it is unclear whether such patients will derive any near vision benefit. 33

Manual Refraction Autorefractors may not provide optimal postoperative refraction of multifocal patients; manual refraction is strongly recommended.

Emmetropia should be targeted as this lens is designed for optimum visual performance when emmetropia is achieved. Care should be taken to achieve centration.

Spherical Aberration Correcting spherical aberration (SA) to zero results in sharper focus of light and therefore sharper vision at both near and distance. * TECNIS® Multifocal IOL 36 *In the average cataract patient * Re. STOR® +3. 0 IOL

37 Spherical Aberration Correction There is a measurable difference An IOL that fully corrects spherical aberration can provide a 13% increase in contrast over an IOL that leaves +0. 1 residual spherical aberration

Combining Spherical and Chromatic Aberration Correction Several studies have shown the correction of chromatic aberration and spherical aberration together is more beneficial than the sum of the two individual corrections. 38

Full Diffractive vs. Apodized Diffractive Effect in Low Light Conditions As the pupil widens in mesopic conditions: • TECNIS® Multifocal IOL is pupil-independent so light is still distributed equally to near and distance focal points, retaining highquality near vision • The apodized design functions as a monofocal lens on the outer perimeter, therefore distributing more light to distance and degrading the quality of near vision TECNIS® Multifocal IOL 39 Re. STOR® +3. 0 IOL

Rayner Intraocular Lenses Ltd The Rayner M-flex™ Multifocal IOL

The Rayner M-flex™ (630 F) Multifocal IOL

M-flex™ is a multi-zoned, refractive, aspheric multifocal intraocular lens (MIOL) indicated for those patients requiring a degree of pseudoaccommodation.

M-flex™ is a single-piece, hydrophilic acrylic injectable MIOLwhich can be considered to be the multifocal analogue of Superflex™, having an optic diameter of 6. 25 mm and an

Good Optic Design M-flex™ is based on multi-zoned refractive aspheric optics with either 4 or 5 refractive zones (depending on base power), providing an additional +3. 0 D of refractive power in the IOL plane, which is equivalent to +2. 25 D in the spectacle plane The refractive zones around the central (1. 75 mm) distance zone are annular and alternate between distance and near focus with a 60: 40 split (Distance: Near)

AVH™ Technology 10. 5 mm The outer haptics begin to take up the compression due to capsular contraction 10. 0 mm Progressive resistance to the compression forces is generated as the outer and inner haptics engage 9. 5 mm 1) The outer and inner haptics lock together 2) The IOL assumes an oval configuration 3) The haptic dynamics change, increasing haptic rigidity and providing superior capsular stability

Note the perfectly symmetrical haptic compression

Enhanced Square Edge™ Anterio r surface Posterior surface

Power options M-flex™ (630 F) Sphere + 14. 0 D to + 25. 0 D in 1. 0 D increments + 18. 0 D to + 24. 0 D in 0. 5 D increments Power addition +3. 0 D

Patient Selection for Multifocal IOLs: 52 • No contraindications • e. g. , recurrent severe inflammation or uveitis • Bilateral implantation • Postoperative astigmatism <0. 75 D • Postoperative emmetropia or max. <0. 75 D hyperopia • Patient motivation (e. g. , high diopter glasses, hyperopia, spectacle independence) • Visual expectations of the patient

Exclusion Criteria • Macular pathologies, glaucoma with severe visual field loss • Monofocal IOL already in one eye (relative exclusion) • Unrealistic visual expectations • Happy with reading glasses • Surgical complications, such as capsulorhexis tear, capsular folds, fixation in sulcus • Patient is at risk for developing PCO 53