Trifocal IOLs - Livemedia.gr...Fine Vision AT LISA PanOptix Symfony Manufacturer PhysIOL Zeiss Alcon...

Trifocal IOLsClinical Evaluation

Alaa Eldanasoury, MD

Magrabi Hospitals & Centers

Samos, 1996

Alaa Eldanasoury, HSIOIRS-2018

Athens, 2007


Athens, 2009


Athens, 2013


Athens, 2018


Trifocal IOLsClinical Evaluation

Alaa Eldanasoury, MD

Magrabi Hospitals & Centers

Financial Disclosures

Consultant to:

• Nidek

• Staar Surgical

• PhysIOL


At least in my practiceBifocal IOLs were never the standard of careIssues:

1. Poor Intermediate vision.

2. Photic Phenomena.

Consequences:

1. Long chair time.

2. Relatively high rate of unsatisfied patients.


Multifocal IOLs

ReStor (Alcon) Tecnis (AMO) Fine Vision (PhysIOL) AT Lisa (Zeiss) PanOptix (Alcon)

Bifocals Trifocals

Symfony (AMO)

EDOF


Fine Vision AT LISA PanOptix Symfony

Manufacturer PhysIOL Zeiss Alcon Abbott

Concept Trifocal Trifocal Trifocal EDOF

MaterialHydrophilic/ Hydrophobic

Hydrophilic/hydrophobic surface

propertiesHydrophobic Hydrophobic

Haptic Design Double C loop Plate Haptic C loop C loop

Optic Diameter 6.00 mm 6.00 mm 6.00 mm 6.00 mm

Diffractive zone 6.00 mm 4.34 mm 4.5 mm -

Apodization Yes Non apodized Non apodized Non apodized

Asphericity -0.11 µm -0.18 µm -0.10 µm -0.27 µm


Fine Vision AT LISA PanOptix Symfony

Available power +6.0 to +35.0 D 0.00 to +32.0 D +6.0 to +34.0 D +5.0 to +34.0 D

Near Add (IOL plane) 3.50 D (40 cm) 3.33 D (40 cm) 3.25 D (40 cm) -

Int Add (IOL plane) 1.75 D (80 cm) 1.66 D (80 cm) 2.17 D (60 cm) 1.75 D*

Total energy loss 14% 14% 12% -

Toric design POD FT 939MP Panoptix Toric ZXT

Cylinder (IOL plane) 1.00 to 6.00 D 1.00 to 12.00 D 1.5 to 6.00 D 1.00 to 3.75 D


PODF (PhysIOL)


Clinical Evaluation of Trifocal IOLsInterim Results

• Prospective Study on consecutive patients.

• 32 patients (64 eyes)

• 24 patients (48 Eyes) completed the 3 months exam.

• Inclusion criteria:• Bilateral cataract.• No ocular co-morbidity.

• Phacoemulsification with trifocal POD-F / PODFT (PhysIOL)

• Both eyes treated during the same week

• Excluded:• Patients with high corneal irregularities.• Significant dry eyes.• Macular pathology.• Glaucoma.


Clinical Evaluation of Trifocal IOLs:

I. Visual Acuity: “FINe”• Uncorrected.• Distance corrected.

II. Range of pseudoaccommodation:• Defocus curve

III. Quality of vision:• Scatter (OSI, HD Analyzer).• Modulation transfer function (cut off ratio).• Contract Sensitivity (HACSS, CTS).

IV. Patients satisfaction:• Subjective questionnaire.


I- Evaluation of Visual Acuity

Visual acuity testing

Clinical Trial Suite (CTS):

• Eliminate technician bias

• Sloan letters

• Randomized

• Configured for intermediate and near vision testing

• Generates automated defocus curves



Glare Conditions


III- Evaluation of Visual Acuity

Near (40 cm) & Intermediate Vision (80 cm)



Refractive Outcome at 3 months48 Eyes – 24 patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% 83%

100% 100%P

erc

en

t o

f To

tal E

ye

s

MRSE at 3 months

Refractive outcome - Percentage within | Attempted |



Cumulative UDVA at 3 month (monocular)48 Eyes of 24 patients

0%

20%

40%

60%

80%

100%

0%

18%

73%

91%100% 100%

0%Pe

rce

nt

of

To

tal E

ye

s

UDVA at 3 months

Cumulative UDVA



Monocular DCIVA at 80 cm48 Eyes of 24 patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

25% 25%

75%

100% 100%P

erc

en

t o

f To

tal E

ye

s

DCIVA at 80 cm

Cumulative DCIVA - Percentage



Monocular DCNVA at 40 cm50 Eyes of 25 patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

63%

100%100%

Pe

rce

nt

of

To

tal E

ye

s

DCNVA at 40 cm

Cumulative DCNVA at 40 cm


II- Evaluation of Range of “pseudoaccommodation”

Defocus Curve

-0.20

-0.10

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1.10

1.20

1.5 1 0.5 0 -0.5 -1 -1.5 -2 -2.5 -3 -3.5 -4 -4.5 -5

DC

VA

(Lo

gMA

R)

Defocus (Variable Distance Simulation)

<30 YO

Monofocal

Bifocal

Trifocal

Near VisionDistance Vision

80 cm 40 cm

Intermediate Vision


II- Evaluation of Range of “pseudoaccommodation”

Defocus Curve

-0.20

-0.10

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

1.10

1.20

1.5 1 0.5 0 -0.5 -1 -1.5 -2 -2.5 -3 -3.5 -4 -4.5 -5

DC

VA

(Lo

gMA

R)


Trifocal Binocular (3 mo)

Trifocal Monocular (1mo)

Near VisionDistance Vision

80 cm 40 cm

Intermediate Vision


III- Evaluation of Quality of Vision – Clinical Trial Suite

Mesopic Contrast Sensitivity with Glare


III- Evaluation of Quality of Vision

Average Contrast Sensitivity Curve 48 Eyes of 24 Patients @ 3 months

-0.02

0.40

0.82

1.24

1.66

2.08

2.50

1.5 CPD 3 CPD 6 CPD 12 CPD

Log

Co

ntr

ast

Mesopic HACSS

Trifocal

Normal


Objective Scatter Measurement


Objective Scatter Index


PREOP 3 Mo Post PODF


PREOP 3 Mo Post PODFT


IV- Evaluation of Patients Satisfaction

Subjective Questionnaire at 3 months

• All patients are very satisfied or satisfied with FINe vision

• 12.5% patients reported halos at night.

• 87.5% patients had non-disturbing photic phenomena when asked.

• No patients were dissatisfied with vision at any distance.

• No patients is using spectacles at any distance.

• All patients would have the same lens again.


What we learned so far:

• Trifocal IOLs give satisfactory far, Intermediate and near vision.

• Well informed patient.

• Night vision phenomena remain but the trade-in is very acceptable.

• Essentials for proper clinical evaluation:• Distance corrected Near and Intermediate vision charts / CTS.

• Defocus curve.

• Scatter measurement (OSI).

• Contrast Sensitivity.

• Tear film assessment.


AcknowledgmentCornea & Refractive Surgery Team – Magrabi Main Hospital• Alaa Eldanasoury, MD

• Sherif Tolees, MD

• Ahmed Zaid, MD

• Carlos Arana, OD

• Ahmed Qassem, OD

• Christina Arana, OD

• Tamer Mabrouk, MBA

• Marj Aldeguer, RN

• Mabelle Boco, RN

• Irish Yabanez, RN

• Sophia Sorbito, RN

• Ms. Marwa Abu Elsaoud.

• Ms. Arwa Bajamal.Alaa Eldanasoury, HSIOIRS-2018

Thank You!

Best candidates for Trifocals

• Patients with OSI above 1.0

• Normal tear film.

• Hyperopes.


Missing

• CTS photos


• Distance beach

• Intermediate laptop

• Near iphone


DIFFRACTIVE STEPS

• The IOL curvature determines the power for distant vision


I - Surgical Reversal of Presbyopia1- Silicone Expansion Plug Implant “SEP”


Surgical Reversal of PresbyopiaScleral Spacing Procedure “SSP”


Pseudo-accommodationCorneal Inlays


Pseudo-accommodationAccommodative IOL


Pseudo-accommodationVivarte Presbyopic lens

Distant

Near

Distant

Courtesy, Prof G. Baikoff


Central Myopic Island

Multifocal Cornea

Courtsey, A. TelandroAlaa Eldanasoury, HSIOIRS-2018

Kamra - 2011


DIFFRACTIVE STEPS• The diffractive grating is providing the addition

• For each step, the light focuses at two foci + some lost light energy


DIFFRACTIVE STEPS• The added power is a function of the step width:

• The wider the steps, the smaller the addition.

• The narrower the steps, the higher the addition.


DIFFRACTIVE STEPS• Energy Distribution is a function of the step height:

• The lower the steps, the higher the quantity of energy for far vision

• The higher the steps, the higher the quantity of energy for near vision


Objective Scatter Index


Average Defocus Curve at 1 month

-0.20

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.5 1 0.5 0 -0.5 -1 -1.5 -2 -2.5 -3 -3.5 -4 -4.5 -5

40 cm66 cm 30 cm1 mDistance


Objective Evaluation of Accommodation Range


Subjective Questionnaire at 3 months

• How satisfied are you with the far vision?

• How satisfied are you with near vision?

• How satisfaction are you with Intermediate vision?

• Do you experience difficulty at night?


COMBINATION OF TWO DIFFRACTIVE STRUCTURES

1st diffractive structure 2nd diffractive structure

Order 2 + 7 D Lost light + 3.5 D Near vision

Order 1 + 3.5 D Near vision + 1.75 D Intermediate vision

Energy gain allowing a significant improvement in intermediate vision whilemaintaining far and near vision

Order 0 FAR VISION


Intermediate Vision


Clinical Outcomes

• 12 Eyes of 6 patients

• All had bilateral trifocal POD F IOL (PhysIOL)

• Both eyes treated within 1 week

• All had excellent visual potential


DIFFRACTIVE STEPS• Decreasing step height from the center to the periphery = variable repartition of the energybetween far and near vision with respect to the pupildiameter


Criteria of an ideal Multifocal

• Covers the full range of vision

• No photic phenomena


Defocus Curve

-0.4

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

1.5 1 0.5 0 -0.5 -1 -1.5 -2 -2.5 -3 -3.5 -4 -4.5 -5

eye1

eye2

eye3

eye4


Available Trifocal IOLs

➢ Diffractive➢ Apodized➢ Hydrophilic

➢ Diffractive➢ Non-apodized➢ Hydophilic with Hydrophobic

coat

➢ Diffractive➢ Non-apodized➢ Hydrophobic


Evaluation of accommodative potentialDefocus Curve

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

1.5 1 0.5 0 -0.5 -1 -1.5 -2 -2.5 -3 -3.5 -4 -4.5 -5

DC

VA

(Lo

gMA

R)


<30 YO

Monofocal

Monofocal2

Bifocal

TrifocalNear VisionDistance

VisionIntermediate

Vision


Evaluation of clinical outcomes of Trifocals2- Defocus Curve (Pseudo-accommodative potential)

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

1.5 1 0.5 0 -0.5 -1 -1.5 -2 -2.5 -3 -3.5 -4 -4.5 -5

DC

VA

(Lo

gMA

R)


<30 YO

Monofocal

Bifocal

Distance VisionNear Vision

40 cm80 cm

Intermediate Vision

60 cm>6 m


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