Multifocal Intraocular LensesMultifocal Intraocular LensesAbdullah Al-assiriAbdullah Al-assiriMansour FarooquiMansour Farooqui

Abdulrahman Al-MuammarAbdulrahman Al-Muammar

Saudi Ophthalmology Meeting 2009

Course OutlineCourse OutlinePart IPart I

Optical principles of multifocal lensesOptical principles of multifocal lensesDesigns of multifocal lensesDesigns of multifocal lensesPatient selectionPatient selectionIntraocular lenses calculationIntraocular lenses calculation

Part IIPart IIVisual results following implantation of multifocal lensesVisual results following implantation of multifocal lenses

• Personal dataPersonal data• Literature reviewLiterature review

Part IIIPart IIIMultifocal IOLs and pupil sizeMultifocal IOLs and pupil sizeMultifocal IOLs and preoperative corneal astigmatismMultifocal IOLs and preoperative corneal astigmatismMultifocal IOLs and posterior capsular opacificationMultifocal IOLs and posterior capsular opacificationPostoperative residual refractive errorPostoperative residual refractive errorControversial issuesControversial issues

Multifocal IOLs and pupil sizeMultifocal IOLs and pupil size

Preoperative evaluation and Preoperative evaluation and inclusion/exclusion criteria for MIOL must inclusion/exclusion criteria for MIOL must include pupil sizeinclude pupil sizePupil size affects various visual functions in Pupil size affects various visual functions in pseudophakic patients with MIOLs includingpseudophakic patients with MIOLs including

Glare and haloes disabilityGlare and haloes disabilityBinocular visionBinocular visionContrast sensitivityContrast sensitivityFar and near VA Far and near VA

Multifocal IOLs and pupil sizeMultifocal IOLs and pupil size

Previous studies have shown that pupil Previous studies have shown that pupil size decreases as age increases in a size decreases as age increases in a linear fashion to all luminance levellinear fashion to all luminance level

Winn et al, Invest Ophthalmol Vis Sci 1994Winn et al, Invest Ophthalmol Vis Sci 1994

Nakamura found that photopic and Nakamura found that photopic and scotopic pupil sizes decreased with age scotopic pupil sizes decreased with age up to 60 yearsup to 60 years

Nakamura et al, J Cataract Refract Surg 2009Nakamura et al, J Cataract Refract Surg 2009

Multifocal IOLs and pupil sizeMultifocal IOLs and pupil size

Kurz measured monocular and Kurz measured monocular and binocular pupil sizes and reported that binocular pupil sizes and reported that pupil diameters were larger when the pupil diameters were larger when the measurement was monocularmeasurement was monocular

Kurz et al, J Cataract Refract Surg 2004Kurz et al, J Cataract Refract Surg 2004

Multifocal IOLs and pupil sizeMultifocal IOLs and pupil size

Postoperative pupil size cannot always be Postoperative pupil size cannot always be predicted from the preoperative diameter predicted from the preoperative diameter because the pupil can be substantially because the pupil can be substantially impaired by cataract surgeryimpaired by cataract surgery

Koch et al,J Cataract Refract Surg 1996Koch et al,J Cataract Refract Surg 1996

Newer phacoemulsification surgical Newer phacoemulsification surgical techniques have shown unchanged pupils techniques have shown unchanged pupils after surgeryafter surgery

Hayashi at al, J Cataract Refract Surg 2004Hayashi at al, J Cataract Refract Surg 2004

Multifocal IOLs and pupil sizeMultifocal IOLs and pupil size

Pupil size under mesopic and photopic Pupil size under mesopic and photopic conditions must be determined prior to conditions must be determined prior to surgerysurgery

Restor Rezoom Tecnis

Pre-existing astigmatismPre-existing astigmatism

Approximately 30% of cataract surgical Approximately 30% of cataract surgical patients will have pre-existing astigmatismpatients will have pre-existing astigmatismRoutine corneal topography to qualify the Routine corneal topography to qualify the type of astigmatism and to quantify the type of astigmatism and to quantify the amount of astigmatism should be done amount of astigmatism should be done preoperativelypreoperativelyIrregular astigmatism should eliminate Irregular astigmatism should eliminate patients as candidates for MIOLspatients as candidates for MIOLs

Pre-existing astigmatismPre-existing astigmatism

Surgeons using MIOL should manage pre-existing Surgeons using MIOL should manage pre-existing regular astigmatism in order to allow patients to gain regular astigmatism in order to allow patients to gain the full benefit of MIOL technologythe full benefit of MIOL technology

Available options areAvailable options are< 0.75 D Cyl, perform on axis incision< 0.75 D Cyl, perform on axis incision0.75-1.5 D Cyl, perform intraoperative limbal relaxing incision0.75-1.5 D Cyl, perform intraoperative limbal relaxing incision> 1.5 D Cyl, perform intraoperative limbal relaxing incision + > 1.5 D Cyl, perform intraoperative limbal relaxing incision + pot-op laser refractive surgerypot-op laser refractive surgery

WWW.LRIcalculator.comWWW.LRIcalculator.comAstigmatic keratotomyAstigmatic keratotomy

Decrease postoperative visual Decrease postoperative visual acuityacuity

Most common causes of decrease visual Most common causes of decrease visual acuity after MIOLs implantation areacuity after MIOLs implantation are

Residual refractive errorResidual refractive errorPosterior capsular opacificationPosterior capsular opacificationCystoid macular edemaCystoid macular edemaOcular surface diseaseOcular surface diseasePoor adaptationPoor adaptation

Buznego et al, curr Opinion in ophthalmology 2009Buznego et al, curr Opinion in ophthalmology 2009

Surgical tipsSurgical tips

Surgical tips for MIOLs implantationSurgical tips for MIOLs implantation• Well dilated pupilWell dilated pupil• Proper capsulorrhexis size with good centrationProper capsulorrhexis size with good centration• Proper cortical cleaningProper cortical cleaning• Lens implantationLens implantation

Effect of posterior capsular Effect of posterior capsular opacification in patients with opacification in patients with

MIOLsMIOLsPosterior capsular opacification (PCO) Posterior capsular opacification (PCO) causes forward and backward light scattering causes forward and backward light scattering and reduces visual acuity and contrast and reduces visual acuity and contrast sensitivitysensitivitySince MIOLS reduces contrast sensitivity, it is Since MIOLS reduces contrast sensitivity, it is not known if this can be exacerbated by the not known if this can be exacerbated by the development of PCO, which may lead to an development of PCO, which may lead to an increased rate of Nd:YAG capsulotomy increased rate of Nd:YAG capsulotomy

Effect of posterior capsular Effect of posterior capsular opacification in patients with opacification in patients with

MIOLsMIOLsIncidence of PCO with MIOLs is about Incidence of PCO with MIOLs is about 10 %10 %

De Vries at al, J Cataract Refract surg 2008De Vries at al, J Cataract Refract surg 2008

Elgohary found that the effect of PCO Elgohary found that the effect of PCO on visual function in patients with on visual function in patients with monofocal and multifocal IOLs is monofocal and multifocal IOLs is comparablecomparable

Elgohary et al, Eye 2008Elgohary et al, Eye 2008

Effect of posterior capsular Effect of posterior capsular opacification in patients with opacification in patients with

MIOLsMIOLsRecent literatures didn’t report Recent literatures didn’t report complication with Nd:YAG capsulotomy complication with Nd:YAG capsulotomy in patients with MIOLS in patients with MIOLS Surgeons should proceed with Surgeons should proceed with capsulotomy only if the possibility of IOL capsulotomy only if the possibility of IOL exchange has been excludedexchange has been excluded

Postoperative residual refractive Postoperative residual refractive errorerror

Emmetropia is critical to a good Emmetropia is critical to a good performance of multifocal IOLsperformance of multifocal IOLsNot all patients achieve emmetropia Not all patients achieve emmetropia with lens surgery alonewith lens surgery aloneLaser refractive surgery can be done to Laser refractive surgery can be done to correct residual errorcorrect residual error

Postoperative residual refractive Postoperative residual refractive errorerror

Knorz had reported good outcome using Knorz had reported good outcome using wavefront-guided ablation in patients with wavefront-guided ablation in patients with diffractive multifocal IOLsdiffractive multifocal IOLs

Knorz et al, J Refract surg 2008Knorz et al, J Refract surg 2008Campbell performed wavefront Campbell performed wavefront measurements in an artificial eye and found measurements in an artificial eye and found that diffractive IOLs could be measured that diffractive IOLs could be measured reliably whereas refractive multifocal IOLs reliably whereas refractive multifocal IOLs could not could not

Campbell, J Refract Surg 2008Campbell, J Refract Surg 2008

Controversial issuesControversial issues

NeuroadaptationNeuroadaptationMIOLS by definition, deliver more than one MIOLS by definition, deliver more than one simultaneous image to the visual cortexsimultaneous image to the visual cortexSurgeons must consider patients ability to Surgeons must consider patients ability to neuroadaptneuroadapt

Controversial issues Controversial issues

Mixing and Matching MIOLsMixing and Matching MIOLsMixing different MIOLs designs is not Mixing different MIOLs designs is not generally agreed upon conceptgenerally agreed upon conceptBilateral implantation of the same design Bilateral implantation of the same design and mixing different designs are viable and mixing different designs are viable optionoptionDecision regarding which MIOL should be Decision regarding which MIOL should be used for the second eye should be based used for the second eye should be based on the result of the first eyeon the result of the first eye

Controversial issuesControversial issues

Patients with Unilateral cataractPatients with Unilateral cataractPatients with monofocal IOL in the first Patients with monofocal IOL in the first eyeeyeTime between first and second eye Time between first and second eye surgerysurgery

Controversial issuesControversial issues

Complicated surgery in the second eyeComplicated surgery in the second eyePatients who may have diabetes or Patients who may have diabetes or glaucoma after cataract surgeryglaucoma after cataract surgeryFuture vitreo-retina surgeryFuture vitreo-retina surgery

Lim et al, Ophthalmology 2000Lim et al, Ophthalmology 2000

Pediatric cataract surgeryPediatric cataract surgery Jacobi et al, Ophthalmology 2001Jacobi et al, Ophthalmology 2001

Thank you for your attention