EUROTIMES | Volume 17/18 | Issue 12/1

Two mirror telescopic implantable lenses now available allow surgeons to provide improved vision in both phakic and pseudophakic patients

with dry or wet AMD.Dr Isaac Lipshitz from Israel designed

the first intra-ocular telescopic device in the form of the Implantable Miniaturized Telescope based on the principles of a Galilean telescope containing a concave and a convex lens with air compartments in between. Though it does enlarge the image up to 2.2 to 2.7 times the normal size, surgical disadvantages include the need for a large incision, more difficult implantation, greater possibility for endothelial cell loss and a long and complex patient rehabilitation process.

Dr Lipshitz then designed a miror telescopic IOL – the Lipshitz Macular Implant (LMI, OptoLight, Israel) based on magnification provided by intra-ocular mirrors (Figure 1).

“It makes possible optical treatment for both dry and wet ARMD, scar stage as well as other similar macular lesions using reflective optics. We do not cure the disease or even stop its progress, we only enable the patient to function better with the disease. Treatment requires a long commitment, coordinated with a retinal specialist. Patient selection process is very important and complex. We should remember that the patients that suffer from these dreadful diseases are never completely happy and satisfied. Nevertheless, it can give encouraging results in patients who are highly motivated to read and improve visual capabilities and who know the risks and potential benefits,” says Dr Lipshitz.

The first prototype of the LMI was introduced in 2005. Now two models are available. The phakic implant (LMI) has an optic size of 5.5 x 6.5mm and an overall length of 13.5mm. A routine phacoemulsification is followed by implanting the IOL in the bag through an extended clear corneal incision of about 6mm or through a separate scleral tunnel incision.

The pseudophakic implant (OriLens – OptoLight, Israel) is implanted as a piggyback lens over the existing IOL of the patient (Figures 2A, B). This offers the advantages of the mirror reflective optics even in long-standing pseudophakic patients

without having to perform complicated IOL explantation procedures. The OriLens may also be implanted in phakic patients after first performing a cataract surgery, implanting a regular IOL according to the patient's biometry and then placing it as a piggyback lens in the sulcus. It has an oblong optic of 5.00 x 6.00mm, an overall length of 13.5mm and central thickness of 1.25mm. It can also be explanted easily.

"The ageing baby boomers need immediate help, which right now can only be achieved by an implanted telescopic optical solution. This requires no additional equipment or investment. By using the

new intraocular mirror telescope, cataract surgeons can now improve vision of AMD patients and treat both dry and wet type AMD. It is in fact the cataract surgeon’s solution to a retinal problem!” noted Dr Lipshitz.

The surgery can be performed by any cataract surgeon. Follow-up is carried out in conjunction with the retinal surgeon. A close watch is kept for formation of synechiae or IOP spikes, which if they occur, are treated accordingly. The IOL is made from biocompatible material and it magnifies only the image on the central retina. It may preserve at least part of the

peripheral vision, thus bilateral surgery is possible (Figure 3).

If needed, it is also safe and easy to remove the OriLens leaving behind the in-the-bag IOL thus reverting the patient back to normal pseudophakic status. It is complementary to other medical treatments which can also be carried out simultaneously, he explained.

Potential candidates for this lens need to be tested preoperatively with an external telescope of x 2.5 magnification using ETDRS charts. OptoLight has also developed a special computer-based testing program for pre- and postoperative visual testing. Patients with a preoperative visual acuity ranging from 20/60 to 20/800 and showing improvement in visual acuity for distance and/or near when tested with a x 2.5 magnification external telescope are suitable candidates.

“The system has two visual fields – central and peripheral, each of which can be modified for distance or for near and modified relative to each other by changes such as colour, contrast, focal distance etc. The pupil size is also important as the peripheral vision is pupil dependent. A pupil between 2.5 to 4.0mm diameter gives a good peripheral and a good magnified central image. Hence, the pupil size has to be controlled postoperatively for optimal performance,” says Dr Lipshitz.

It is important that there should be no tilt, which can affect the functioning of the implant. The pupil should not be eccentric and should overlie the central mirror. If required, a pupilloplasty may be performed in such cases to centralise the pupil, and also in rigid, non-dilating, miotic pupils to enlarge the pupil. Fundus evaluation, laser treatment as well as other treatments such as anti-VEGF remain possible after implantation of this implant.

Dr Lipshitz chose reflective optics technology because it does not depend on the index of refraction of the medium and can achieve high magnification in a small volume/thickness. It can be used in combination with diffractive and/or refractive optical elements and can be partly hidden under the iris.

Prof Amar Agarwal who implanted the first LMI and the first OriLens commented, “The cataract surgeon is often faced with co-morbid pathologies because of an increasingly ageing population. Implanting a normal IOL in such patients would not lead to a great improvement in central vision. The other big advantage of the OriLens is that it does not require any complicated power calculations or require an inventory of different powers to be maintained as it is a standard implant which fits all patients. It is therefore implanted over the in-the-bag IOL which is the one selected according to biometry.”

Soosan Jacob – dr_soosanj@hotmail.com

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NEW TECHNOLOgY FOR AMdThe cataract surgeon’s solution to a retinal problemby Soosan Jacob, MS, FRCS, DNB

30 News

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Figure 1: Illustration demonstrating the optical mechanism of the mirror reflective technology. Central light rays are magnified

by the mirrors whereas the peripheral rays pass unchanged. Magnification of central rays is possible through the internal

reflection occurring between the mirrors within the LMI/OriLens

Figure 2B: Image shows ultrasound bio microscopic image of the same eye. In-the-bag IOL as well as the sulcus

placed OriLens are seen

Figure 2A: Image shows a pseudophakic mirror telescopic IOL (OriLens) implanted in a piggy back manner over a regular in-the-

bag IOL. The implant is well centred over the optics of the IOL and the mirror reflective elements can be seen

Figure 3: A computer-generated image as seen by an eye with Mirror Telescopic Technology is shown.

The central image is enlarged up to 2.5 times whereas the periphery remains unaltered