Managing Astigmatism and Residual Ametropia in

Monofocal and Multifocal Monofocal and Multifocal Pseudophakes

Michael C. KnorzFreeVis LASIK Center,

Medical Faculty Mannheim of the University of Heidelberg,Mannheim, Germany

How do we achieve spectacle independence in spectacle independence in

everybody ?

„Refractive Package“

• Multifocal IOLs or monofocal IOLs are offered as a package with LASIK !are offered as a package with LASIK !

Part I: IOL

Alcon ReStor Multifocal IOL

• Diffractive aspheric multifocal IOL– 3 D add power

• Good distance vision,• Good distance vision,good intermediate vision,excellent near vision

Tecnis Aspheric Multifocal IOL

• Diffractive aspheric multifocal IOL– 4 D add power

• Good distance vision,moderate intermediate vision,excellent near vision

Patient Selection

• Multifocal IOLs are a compromise

– M-IOLs are indicated only if patient does – M-IOLs are indicated only if patient does not want to wear glasses

– Some side effects must be acceptable (e.g., halos, glare)

VISION SIMULATOR Home Page

Residual Refractive Errors

• Multifocal IOLs work only if patient is emetropic !

– Perform laser vision correction in case of residual refractive errors !

– Offer multifocal IOLs and laser vision correction as a package !

LASIK after IOL: When ?

Option 1: LASIK after IOL

• Indication:– Corneal astigmatism less than 2 D

• Customized LASIK after 3 months, if residual error

Option 2: IntraLase Flap prior to IOL !

• Indication: – Corneal astigmatism 2 D or more

• IntraLase to create flap prior to RLE without lifting it

• Customized LASIK after 3 - 4 weeks

IntraLase 5th Generation iFS

Flap creation < 10 sec.Flap creation < 10 sec.

Customized LASIK - Visx STAR S4

Why Customized LASIK ?

• Customized LASIK provides perfect match of measured and treated area

– Astigmatism is treated more precisely

– High higher-order aberrations are minimized or reduced

• B. Jendritza, M.C. Knorz, S. MortonWavefront-guided excimer laser vision correction after multifocal IOL implantation.implantation.J Refract Surg 2008; 24

Multifocal Bioptics -Clinical Results

• 27 eyes (19 patients)– 9 eyes IntraLase flaps pre-IOL

• CustomVue LASIK after multifocal IOL– Tecnis multifocal (n = 20)– ReSTOR (n = 4)– ReZoom (n = 3)

Multifocal BiopticsRefraction – Tecnis MIOL

1,061,13

0,8

1

1,2

0,03

0,14

0

0,2

0,4

0,6D

Sphere Cylinder

Pre- LASIK Post - LASIK

Use of Near – Add

40

60

80

100

%

0

20

40

Pre-LASIK Post-LASIK

additional near add no near add

Multifocal BiopticsHigher-Order Aberrations (Tecnis)

0,14

0,18

0,15

0,2

0,080,09

0,040,05

0,07

0,09

0

0,05

0,1RMS

HOA Coma SA Trefoil

Pre- LASIK Post - LASIK

Wavefront – Guided LASIK

• Does it work in all multifocal IOLs ?

– Diffractive multifocal IOLs (e.g., Tecnis multifocal IOL) can be measured and multifocal IOL) can be measured and treated reliably

– Refractive multifocal IOLs cannot be measured reliably with aberrometers today !

Shack -Hartmann spot patterns diffractive multifocal IOL (Tecnis)

Centered on pupil Vertically de-centered 0.2 mm

Corneal reflex

• Tecnis +25 D diffractive IOL can be measured

Spot doubling Spot doubling disappears as phase jump location changes

Spot doubling Spot doubling disappears as phase jump location changes

Shack-Hartmann spot patterns -refractive multifocal IOL (ReZoom)

Centered on pupil Vertically de-centered 0.5 mm

Change in centration causes change in spot pattern

Change in centration causes change in spot pattern

• ReZoom+25 D refractive multifocal IOL cannot be measured !

Summary

• Monofocal IOLs or diffractivemultifocal IOLs can be combined with IntraLase flap creation and CustomVue wavefront-driven ablations to achieve wavefront-driven ablations to achieve perfect vision

• Standard ablation should be used in refractive multifocal IOLs !

Summary

• IntraLase bioptics can be used to treat high astigmatism in refractive or cataract surgery

• IntraLase flap creation prior to lens surgery allows for earlier laser vision correction

Thank you !Thank you !