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Accomodative and Multifocal IOL implantations

i s t a n b u l c e r r a h i h a s t a n e s i. Accomodative and Multifocal IOL implantations. DR. FAİK ORUCOV İSTANBUL SURGERY HOSPİTAL DEPARTMANT OF CATARACT AND REFRACTİVE SURGERY. Crystalens AT-45. Accomodative,monofocal IOL,pupil independent

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Accomodative and Multifocal IOL implantations

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  1. i s t a n b u l c e r r a h i h a s t a n e s i Accomodative and Multifocal IOL implantations DR.FAİK ORUCOV İSTANBUL SURGERY HOSPİTAL DEPARTMANT OF CATARACT AND REFRACTİVE SURGERY

  2. Crystalens AT-45 Accomodative,monofocal IOL,pupil independent 4.5 mm silicon optic (now also available as 5 mm) Plate haptic 1.5 mm thickness Lens responds to the natural accommodative response(with the ciliary muscle contraction vitreus pressure increases pushes the IOL optic forward) 11.5 mm diameter i s t a n b u l c e r r a h i h a s t a n e s i

  3. i s t a n b u l c e r r a h i h a s t a n e s i Crystalens • 56 eyes of 30 patients • Cataract surgery between december 2002- september 2005 with facoemulsification • AT-45 Crystalens implantation • 14 male 16 female • 4 years follow up

  4. i s t a n b u l c e r r a h i h a s t a n e s i Review: multifocal IOLs • Retrospective analysis of 124 patients(223 eyes) • Surgeries from October 05 –May 07 • Postop expected bcva 20/40 or over (can be measured by potential acuity meter)with No anterior segment or retinal pathology • Small incision facoemulsification • Monoculer,binoculer implantation • Mix-match

  5. i s t a n b u l c e r r a h i h a s t a n e s i Demographics: • Female: 62 % Male: 38 % • Age: 7-82 (Mean=60.7) • Preop refraction Seq -14.25 to +9.25 78 myopic 26 emetropic 119 hypermetropic eyes • 6 months to 2 years follow up time • Average one year • 28 % ≤ 6 months • 72 % ≥ 6months

  6. Optical Principles of IOLs Refractive monofocal far focus Diffractive near focus far focus 1st generation zonal refractive near focus far focus

  7. i s t a n b u l c e r r a h i h a s t a n e s i AMO Rezoom-Refractive multifocal IOL • Large distant dominant central zone in bright light conditions and four periferal zones that provide near,intermediate and distance focus • Pupil dependent • +3.5 D near add • acrylic hydrophobic • OptiEdge (less capsule opasification) • Biconvex ModC, Angle 5° • Haptics PMMA • Optic 6.0, length 13.0mm • Power +6.0 +30.0 D (steps 0.5D) • A-constant 118.4

  8. i s t a n b u l c e r r a h i h a s t a n e s i Rezoom

  9. 1st generation zonal refractive principle near focus far focus

  10. i s t a n b u l c e r r a h i h a s t a n e s i Tecnis IOL • Diffractive posterior surface with 32 concentric rings • Light distribution of 50 % for distance vision, 50% for near vision • add +4:0 D • Tecnis:distribution of focus is independent of pupil size • 5-34 D • Silicon • A-constant 119

  11. + ACE Cornea near focus far focus Diffractive TECNIS ZM001

  12. i s t a n b u l c e r r a h i h a s t a n e s i Acri.lisa IOL • Distance –dominant -diffractive multifocal IOL • Independent of pupil size • Smooth steps in the refractive diffractive structure • Light distribution is not equal for far and near vision (Asymmetrical light distribution) 65/35% • Acrylic • A-constant 118 • 10-30 dpt

  13. i s t a n b u l c e r r a h i h a s t a n e s i ReSTOR multifocal IOL • Appodized(gradually decreasing steps) diffractive optic at the center of the anterior surface ,refractive optical zones towards periphery • 10-3o dpt • A-constant 118.2 • +4.0 Add • Reduced photic phenomena like glare,halos,low contrast sensitivity

  14. Pre-op examinations i s t a n b u l c e r r a h i h a s t a n e s i • Preop full examinations: • Bcva • Dominant –nondominant eye selection • Oculer Tension • Retina and anterior segment examination • Topography • Oculyzer –Pentacam • Contrast sensitivity • Potential acuity meter • Pupillometry • Biometry • Pachymeter • Tear film quality (punctum plugs if required)

  15. IOL selection i s t a n b u l c e r r a h i h a s t a n e s i Expectations should be well discussed in detailbefore the operation Driving,computer usage,reading,working distance • Distance vision may be affected by glare at low light conditions • Neuro-adaptation (takes time) • Possibility of another procedure(lasik) for better vision • May need reading glasses in dim light

  16. Biometry i s t a n b u l c e r r a h i h a s t a n e s i • Repeated measurements • Check keratometer measurements • Srk-t for emetropics,myopics • Haigis for high hyperopias • Check first eye’s refraction at least one week after the operation and then plan the second eye • For crystalens binoculer implantations postop -0.5 D myopia planning for the first eye , emmetropia for the second eye

  17. Surgery i s t a n b u l c e r r a h i h a s t a n e s i • Facoemulsification • Topical anesteshia • Corneal tunnel incision in the steepest axis (don’t consider astigmatism due to crystalline lens) • Capsulorexis smaller than optic diameter • Posterior capsule polishing • Care to the optic of the IOL • Intracapsuler ring may be implanted if necessary!

  18. Post-op testing i s t a n b u l c e r r a h i h a s t a n e s i • Ucva at distant, intermediate and near • Bcva at distant, distant corrected intermediate and near • Contrast sensitivity and glare was checked by Ophtec 6500 sine wave gratings of 5 different spatial frequencies: 1.5, 3, 6, 12, cycle per degree • Patient satisfaction questionarie

  19. Crystalens – Four Year Results i s t a n b u l c e r r a h i h a s t a n e s i • First week after the surgery with the back and front movement of the IOL -0.5 and -2.0D transient myopia was found but disappeared in one week • Post op mean refractive error Seq was :±0.75 • Bcva for distant is between 20/32-20/20 • Distance corrected near vision (40 cm) is between J 7 –J9 • Distance corrected intermediate vision (80 cm) is between J5 - J7 • Mean addition required for reading was 1.5 ± 0.35 D 6 months after the operation 2.25±0.25 D 4 years after operation, increased in time

  20. Crystalens results i s t a n b u l c e r r a h i h a s t a n e s i • According to the two years follow up, accomodative IOLs are satisfactory for the daily activities but 85 % patients need glasses for near reading • Near vision reading capacity decreased in time • Overall patient satisfaction mean score was 2 over 4 • Patient satisfaction depends on occupation and daily activities • High patient satisfaction for distance

  21. Multifocal IOL - Results i s t a n b u l c e r r a h i h a s t a n e s i • Capsuler ring was placed in two eyes because of zonnuler defect • 3 implantations to sulcus (posterior capsula perforation) • Three eyes had inflammation 2 weeks after Tecnis IOL implantation • Two of them undergone seconder IOL exchange operation • Yag capsulotomy was needed in 7 patients • Postop secondary excimer lazer treatment was performed in 12 patients (5 %) • Mean monoculer post operative refractive error Seq after secondary treatment was ±0.50

  22. Contrast Sensitivity-Results i s t a n b u l c e r r a h i h a s t a n e s i • Contrast sensitivity functions of all multifocal and accomodating IOLs were within the reference rate of normal limits, but lower than monofocal group • At the middle and high spatial frequencies contrast sensitivity in the diffractive groupwas lower than refractive group

  23. 3 Main groups i s t a n b u l c e r r a h i h a s t a n e s i • Mix-match: Rezoom-Tecnis 26 patients Rezoom-Acri.Lisa 21 patients • Bilateral -multifocal same IOL: Rezoom-Rezoom 21 patients Acri.Lisa-Acri.Lisa 12 patients • Monoculer- multifocal implantation(other eye not operated): Rezoom one eye 22 patients Acri.Lisa one eye 13 patients Tecnis 9 patients

  24. MIX-MATCH i s t a n b u l c e r r a h i h a s t a n e s i

  25. BINOCULER SAME IOL i s t a n b u l c e r r a h i h a s t a n e s i

  26. MONOCULER DISTANCECORRECTED VISUAL ACUITIES i s t a n b u l c e r r a h i h a s t a n e s i

  27. i s t a n b u l c e r r a h i h a s t a n e s i Questionnaries • Halo,glare(subjective experience) • Near,intermediate, distant vision • Driving (day,night) • Reading (newspaper,maps,prescriptions) • Activities(sports, shopping) • Patient satisfaction 1-bad 2-fair 3-good 4-very good

  28. PATIENT SATISFACTION i s t a n b u l c e r r a h i h a s t a n e s i

  29. Overall glare i s t a n b u l c e r r a h i h a s t a n e s i Room light None Always At bright light Night driving Night

  30. i s t a n b u l c e r r a h i h a s t a n e s i Glare • Rezoom 76 % • Tecnis 62 % • Acrilisa 58 % • ReStor 56 % • Crystalens 50%

  31. i s t a n b u l c e r r a h i h a s t a n e s i Multifocal IOL Patient Satisfaction • Overall satisfaction rate is 3.5 • 92% of the patients would have the same implant again • 70% of the patients have some complaints while night driving • 79 % glasses free(computer, newspaper,outdoor activities) • 18 % wear glasses for reading smallprints • 3 % wear glasses for distant (driving)

  32. i s t a n b u l c e r r a h i h a s t a n e s i Conclusions • Diffractive IOLs are pupil independent and for myopic patients who read alot • Reezoom more pupil-size dependet • Too small (pupils) poor reading ability , • Too large - more halos • Refractive IOL’s (Rezoom) optical performance is better for intermediate vision • With monofocal-multifocal combination :satisfactory binoculer near vision (%70) • Best near vision with acri.Lisa is from 30-35 cm with ReZoom 45 cm

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