Rotationally Asymmetric Multifocal

Intraocular Lenses versus

Rotationally Symmetric Multifocal Intralocular Lenses

Professor Johnny Moore Cathedral Eye Clinic, Belfast

46th EFCLIN Congress and Exhibition Brussels

Intraocular Lenses to treat presbyopia

- Bifocal - Trifocal - Extended depth of focus - Accommodating IOL- Small aperture optics

• There are various multifocal intraocular lenses (IOLs) available with different designs

• All designed to provide a range of clear vision from distance to near with the fewest visual side effects, and ultimately to provide spectacle independence

Methods:Full ophthalmological assessment. Clinical measures:Unaided vision, refractive error, visual acuity, contrast

sensitivity, pupil size, angle kappa, stereoacuity, corneal topography, aberrometry, IOP.

QOV questionnaire

Preoperative assessment

Important preoperative considerations• Range of lenses available • Extensive preoperative examination helps determine

what is suitable• Pupil size• Lifestyle demands – VDU use all day/frequent driver etc• Personality

• Combination of different IOL designs• Power of near addition required• Placement of IOL (asymmetric multifocal IOLs)

Design and principles

Symmetric multifocal IOLs

Rotationally Asymmetric Multifocal IOLs

DESIGN - Lentis Mplus• Rotationally asymmetric

• Aspheric distance-vision zone combined with a posterior sector shaped near-vision zone

• Seamless transition between the zones

Lentis Mplus IOL - Design and principles

Distance Near

Design and principles

DESIGN - Lentis Mplus• Foldable one-piece multifocal

acrylic IOL• Hydrosmart - a copolymer

consisting of acrylates with a hydrophobic surface and ultraviolet-filtering components

• More recent hydrophobic addition

• Optic size 6mm• Overall length 12mm• Aspherical surface - posterior,

sector shaped near-vision segment

• The IOL has a 360-degree continuous square optic and haptic edge

Lentis Mplus IOL - Design and principles

• Rotationally asymmetric

• Dual Optic IOL

• 3.0 diopter sector-shaped addition

• A small wedge-shaped transition zone separating the (superior) distance from the near power zone

• The percentage of optic that is occupied by the near segment is 42%.

Asymmetric Multifocal IOL

Lenstec SBL-3

Lenstec SBL-3

• Optic Size: 5.75mm

• Optic Type: Bi-Aspheric

• Length: 11.00 mm

• Haptic Style: Modified Plate

• Angulation: 0 Degrees

• Position Holes: 0

• A neutral aberration profile

• Construction: 1 Piece

• Optic Material: Acrylic (26% water)

Presbyopic patients:• All cataract patients with otherwise healthy eyes • Presbyopic patients with clear lenses – myopes, hyperopes, emmetropes

Pre-presbyopic patients:• Traumatic cataract • High levels of hyperopia unsuitable for other forms of laser or phakic IOL surgery and

intolerant to contact lenses• High hyperopes with astigmatism• High myopes should always be suitable for safer ICL surgery (unless with cataract)

(Rotationally asymmetric multifocal intraocular lenses: preoperative considerations and postoperative outcomes. Moore et al, Current opinion in ophthalmology 2016)

Patient Suitability

Quality of Vision (QoV) Questionnaire Questions regarding following visual symptoms - Accompanied by a picture to aid understanding Responses: not at all / a little / quite / very

Glare Haloes

Hazy vision

Starbursts

Blurred vision Distortion

Double vision

• Requirement of reading glasses. Respond: never, occasionally, quite often, always

• Patients also rate their overall QoV out of 10; 0 the worst, 10 the best.

Pupil diameter & QOV: 1-month and 3-month post-opA B

Patient Suitability: Pupil size

Bilateral Inferonasal Superotemporal and InferonasalA B

Preoperative considerations: Near add placement

• +1.50 D/ +2.00 D/ +3.00 D near addition powers are available.

• Alio et al (JCRS, 2011): No significant difference in UDVA between +3.00 D and +1.50 D addition IOLs

• UNVA significantly better with +3.00 D addition

• UIVA significantly better with +1.50 D addition

• A lower powered near addition may be more suited to patients with significant intermediate visual demands

Preoperative considerations: Near add power

Asymmetric Multifocal IOL outcomes

J Cataract Refract Surg 2017; 43:1020–1026

Mplus vs SBL-3

Purpose: To compare the 12-month postoperative quality of vision and visual performance of 2 different refractive rotationally asymmetric multifocal intraocular lenses (IOLs).

Mplus 8.84 ± 0.90 SBL-3 8.87± 1.16

Subjective Outcomes

Objective Outcomes

Multifocal IOL placement study

Multifocal IOL placement study

• To compare postoperative quality of vision (QoV) between different bilateral placements of near segments of rotationally asymmetric refractive multifocal IOLs and to determine how this affects visual performance.

Mplus SBL-3

Inferonasal placement

– manufacturers guidelines are near segment placed inferiorly with slight nasal deviation

• Bilateral superotemporal (ST) vs bilateral inferonasal (IN)

• No significant difference in objective or subjective findings 3 months postoperatively J Cataract Refract Surg 2015; 41:945–955

Near segment addition• Mplus (+1.50D addition) in dominant eye• Mplus (+3.00D addition) in non-dominant• Visual acuity and quality of life

• Binocular UNVA M0.57 ± 0.18

J Cataract Refract Surg 2011; 37:441–445

Patient satisfaction• 93.8% reported they were “very satisfied” or “satisfied”• Ability to read small print such was significantly improved or improved in 1862 patients (85.7%).• Postoperative ability to drive at night was impaired in 474 patients and significantly impaired in 100 patients• 154 patients (7.1%) experienced severe halo and starburstsymptoms and • 124 (5.7%) rated their glare at night as severe 3 monthspostoperatively.

ST placement in the dominant eye IN placement in the non-dominant eye

RE LE

Pazo E, Richoz O, McNeely R, Millar Z, Moore T, Moore JE. Optimised visual outcome after asymmetrical multifocal IOL rotation. JRS 2016

Case Report

J Cataract Refract Surg 2016; 42:1721–1729

DemographicsSBL-3 IN & IN Mplus IN & IN ST† & IN P Value

Patients 60 60 60Eyes 120 120 120Male, n (%) 16 (27) 28 (47) 18 (30)Female, n (%) 44 (73) 32 (53) 42 (70)Age (y)Mean ± SD 59.43 ± 8.14 63.50 ± 9.30 58.65 ± 6.23 0.002Median 60 66 56Range 47, 73 51, 88 46, 70Sphere (D)Mean ± SD 1.31 ± 3.11 0.75 ± 5.12 0.50 ± 3.59 0.285Median 1.50 2.00 1.50Range -10.75, 8.75 -16.50, 8.00 -10.75, 6.50Cylinder (D)Mean ± SD -0.54 ± 0.53 -0.75 ± 0.61 -0.52 ± 0.46 0.002Median -0.50 -0.75 -0.50Range -2.25, 0 -2.50, 0 -2.00, 0LogMAR CDVAMean ± SD -0.05 ± 0.12 -0.02 ± 0.10 -0.03 ± 0.11 0.261Median -0.10 0 -0.10Range -0.20, 0.32 -0.20, 0.30 -0.10, 0.30

0

1

2

3

4

5

6

7

8

9

10

SBL-3 IN & IN Mplus IN & IN ST & IN

QO

V Sc

ore

QOV scores

8.30 ± 1.21 (n=30) 8.93 ± 0.94 (n=30)8.30 ± 1.18 (n=30)

3 months postoperative

Subjective Outcomes

P = .001 (ANOVA)

SBL-3 IN & IN Mplus IN & IN ST & IN P valueBinocular logMAR UDVAMean ± SD -0.05 ± 0.10 -0.08 ± 0.08 -0.07 ± 0.07 0.195Median -0.08 -0.10 -0.1Range -0.20, 0.20 -0.22, 0.10 -0.20, 0.24Binocular LogMAR CDVAMean ± SD -0.11 ± 0.07 -0.10 ± 0.07 -0.09 ± 0.06 0.525Median -0.10 -0.10 -0.10Range -0.20, 0.10 -0.22, 0.10 -0.20, 0.20Binocular UNVA (M notation)Mean ± SD 0.10 ± 0.14 0.11 ± 0.11 0.12 ± 0.11 0.622Median 0.10 0.10 0.10Range -0.20, 0.50 -0.10, 0.40 0, 0.40Binocular UIVA (M notation)Mean ± SD 0.18 ± 0.10 0.16 ± 0.07 0.18 ± 0.12 0.742Median 0.20 0.20 0.20Range 0, 0.40 0, 0.30 0, 0.50

Objective Outcomes

CONCLUSIONST in the dominant eye (+2.00D addition) & IN placement in the non-dominant eye (+3.00D addition) • Improves overall QOV• Reduces complaints of starbursts, hazy vision and blurred vision • Does not affect unaided visual acuity.

• +1.50 D/ +2.00 D/ +3.00 D near addition powers are available.

• Alio et al (JCRS, 2011): No significant difference in UDVA between +3.00 D and +1.50 D addition IOLs

• UNVA significantly better with +3.00 D addition

• UIVA significantly better with +1.50 D addition

• A lower powered near addition may be more suited to patients with significant intermediate visual demands

Preoperative considerations: Near add power

Advantages of Asymmetrical Placement of Near ADD in Asymmetric IOLs• Early and high levels of satisfaction eg day one or two • Protects against mismatch of position of either near or distance add

from impacting on both eyes• Small pupils, Angle Kappa, Mismatch or tilt of capsular bag with the

pupil• Age related changes – increasing meiosis with age

• Ongoing issues:- Glare at night

Rotationally Symmetric Multifocal IOLs

Panoptix IOL- Design and principlesThe Panoptix multifocal IOL is a• Quadrafocal IOL manipulated to act as a trifocal IOL• It has a 6mm optical zone composed of 4.5mm large diffractive area

with 15 diffractive zones and an outer refractive rim

Purpose• To outline:

1) postoperative visual and refractive outcomes 2) subjective quality of vision (QoV) and quality of life (QoL)

Following bilateral implantation of the Acrysof IQ Panoptix (Alcon Surgical, Inc.) multifocal intraocular lens (IOL) 3 months postoperatively.

MethodologyPatients: 32 consecutive patients (64 eyes) implanted

with a Panoptix IOL.

• Full ophthalmological assessment; Preoperatively, and postoperatively (3 months).

Clinical measures:• Unaided visual acuity (distance, intermediate at 70cm and near at 40cm)• Refractive error • QoV questionnaire• QoL questionnaire

Results Postop 3 monthsMonocular UDVA (LogMAR)

Mean ± SD 0 ± 0.09Median 0Range -0.18, 0.22Binocular UDVA (LogMAR)

Mean ± SD -0.02 ± 0.08Median -0.05Range -0.18, 0.14Monocular UIVA (LogMAR)

Mean ± SD 0.41 ±0.12Median 0.40Range 0.20, 0.60Binocular UIVA (LogMAR)Mean ± SD 0.37 ± 0.10 Median 0.40Range 0.20, 0.60Monocular UNVA (LogMAR)

Mean ± SD 0.14 ± 0.11Median 0.10Range 0, 0.50Binocular UNVA (LogMAR)

Mean ± SD 0.08 ± 0.08Median 0.10Range 0, 0.30

Postop 3 monthsSphere (D)

Mean ± SD 0.21 ± 0.34Median 0Range -0.50, 1.00Cylinder (D)

Mean ± SD -0.30 ± 0.31Median -0.25Range -1.00, 0Spherical Equivalent

Mean ± SD -0.30 ± 0.31Median 0Range -0.75, 0.75

0.0% 1.5%

25.0%

42.2%

23.4%

7.8%

0.0%0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

-1.50 to -1.01

-1.00 to -0.51

-0.50 to -0.14

-0.13 to+0.13

+0.14 to+0.50

+0.51 to+1.00

+1.01 to+1.50

% o

f eye

sPostoperative spherical equivalent refraction (D)

Subjective QoV outcomesPostop 3 months

Glare 0.59 ± 0.76

Haloes 0.69 ± 0.82

Starburst 0.19 ± 0.59

Hazy vision 0.06 ± 0.25

Blurred vision 0.19 ± 0.54

Distortion 0

Double vision 0

Vision fluctuation 0.13 ± 0.42

Depth perception difficulty 0.03 ± 0.18

Grading scale: 0 = Not at all; 1 = A little; 2 = Quite; 3 = Very 0

1

2

3

4

5

6

7

8

9

10

Night Day

QoV

Scor

e

• 90.1% patients reported complete spectacle independence• Remaining patients reported using reading glasses

occasionally

Subjective QoL outcomesPostop 3 months Postop 3 months

% reporting vision is completely clear

Distance vision 1 0.38 ± 0.61 68.8%

Distance vision 2 0.09 ± 0.30 90.1%

Intermediate vision 1

0.13 ± 0.42 90.1%

Intermediate vision 2

0 100%

Near vision 1 0.13 ± 0.34 87.5%

Near vision 2 0 100%

Grading scale: 0 = Clear; 1 = slight; 2 = moderate; 3 = severe; 4 = intolerable

How were your expectations fulfilled?

• 90.1% (29 out of 32 patients) fulfilled or more than fulfilled

• The 3 remaining patients reported to be sufficiently fulfilled

• No patients reported to be ”not fulfilled at all”

Conclusions

• This new diffractive quadrafocal IOL provides a good range of unaided visual acuity for distance, intermediate and near.

• This IOL provides high patient satisfaction with minimal postoperative visual disturbances, and provides a high level of functional vision and spectacle independence

Panoptix IOL Defocus curve-0.20

0.00

0.20

0.40

0.60

0.80

1.00

-6-5-4-3-2-1012

Visu

al A

cuity

(log

MAR

)

Defocus (Dioptre)

Binocular defocus curves, n = 13 patients

Zeiss IOL combination

Zeiss AT Lara 829MP • Next generation extended depth of focus (EDoF) IOL• Designed to provide a high degree of spectacle independence and

reduce dysphotopsias• Is based on a diffractive opticalpattern. • Smooth Microphase (SMP) technologyminimizes light scattering and thus visual side effects.

https://www.zeiss.com/meditec/int/products/ophthalmology-optometry/cataract/iol-implantation/mics-platform/mics-at-lara-iol/at-lara-829mp.html: accessed 5.4.18

Zeiss AT Lisa 839MP • Diffractive trifocal IOL• Light is distributed into 3 foci: distance, intermediate and near.• The additions are +3.33 D for near (40 cm) and +1.66 D for intermediate (80 cm)• The corresponding additions projected onthe spectacle plane are +2.50 D and +1.25 D.

AT Lara 829MP & AT Lisa 839MP Combination

AT Lisa 839MP IOL implanted in the nondominant eye

AT Lara 829MP IOL implanted in the dominant eye

Purpose

• To outline the 1-month postoperative visual performance, quality of vision (QoV) and quality of life (QoL) following implantation of an extended depth of focus (EDoF) intraocular lens (IOL) in the dominant eye combined with a trifocal IOL in the fellow eye.

Demographics Patients (n) 29Male, n (%) 12 (57)Female, n (%) 9 (43)Age (y) Mean ± SD 60 ± 6.63Median 60Range 49, 75Sphere (D)Mean ± SD 0.85 ± 3.12Median 1.75Range -12.00, 5.25Cylinder (D)Mean ± SD -0.47 ± 0.43Median -0.50Range -1.50, 0LogMAR CDVAMean ± SD -0.03 ± 0.12Median -0.10Range -0.20, 0.30

EDoF IOL Trifocal IOL BinocularUDVA (logMAR)Mean ± SD -0.01 ± 0.08 -0.02 ± 0.10 -0.08 ± 0.06Median 0 0 -0.1Range -0.14, 0.14 -0.20, 0.24 -0.20, 0.10UIVA (LogMAR)Mean ± SD 0.21 ± 0.14 0.21 ± 0.15 0.15 ± 0.14Median 0.20 0.20 0.10Range 0, 0.70 0, 0.70 0, 0.70UNVA (LogMAR)Mean ± SD 0.37 ± 0.14 0.19 ± 0.15 0.17 ± 0.11Median 0.40 0.20 0.10Range 0, 0.60 0, 0.60 0, 0.50DCIVA (LogMAR)Mean ± SD 0.13 ± 0.10 0.18 ± 0.11 0.11 ± 0.10Median 0.10 0.20 0.10Range 0, 0.30 0, 0.40 0, 0.30DCNVA (LogMAR)

Mean ± SD 0.35 ± 0.13 0.18 ± 0.13 0.15 ± 0.08Median 0.30 0.20 0.10Range 0, 0.60 0, 0.60 0, 0.30

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2 Worse 1 Worse Same 1 or More Better

Perc

enta

ge o

f eye

s

Difference between UDVA and CDVA

-1.50 to -1.01

-1.00 to -0.51

-0.50 to -0.14

-0.13 to+0.13

+0.14 to+0.50

+0.51 to+1.00

+1.01 to+1.50

Datenreihen1 0% 6.9% 17.2% 34.5% 31.0% 10.3% 0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Perc

enta

ge o

f eye

s

Quality of Vision questionnaire Mean ± SDGlare 0.41 ± 0.78Halos 0.66 ± 0.86Starburst 0.41 ± 0.78Hazy 0.24 ± 0.51Blurred vision 0.34 ± 0.72Distortion 0.07 ± 0.37Double vision 0Vision fluctuation 0.34 ± 0.61Depth perception difficulty 0.03 ± 0.19Grading scale: 0 = Not at all; 1 = A little; 2 = Quite; 3 = Very

Quality of Life questionnaire Mean ± SDDistance vision activity 1 0.17 ± 0.54

Distance vision activity 2 0.14 ± 0.52

Intermediate vision activity 1 0.21 ± 0.57

Intermediate vision activity 2 0.11 ± 0.42

Near vision activity 1 0.25 ± 0.59

Near vision activity 2 0.04 ± 0.20

Grading scale: 0 = Clear; 1 = slight; 2 = moderate; 3 = severe; 4 = intolerable

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Never Occasionally Quite often Always

Perc

enta

ge fr

eque

ncy

Mean daytime QoV score 8.79 ± 1.15 Mean night time QoV score 8.17 ± 1.42

Binocular defocus curve

-0.2

-0.1

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

-5.5-5-4.5-4-3.5-3-2.5-2-1.5-1-0.500.511.52

Visu

l Acu

ity (l

ogM

AR)

Defocus (D)

Panoptix IOL Defocus curve-0.20

0.00

0.20

0.40

0.60

0.80

1.00

-6-5-4-3-2-1012

Visu

al A

cuity

(log

MAR

)

Defocus (Dioptre)

Binocular defocus curves, n = 13 patients

IC-8 IOL 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

-5.50-5.00-4.50-4.00-3.50-3.00-2.50-2.00-1.50-1.00-0.500.000.501.001.502.00

Visu

al A

cuity

(log

MAR

)

Defocus (Dioptre)

Monocular defocus curves, n = 13 patients

CONCLUSIONS:

• The combination of an EDoF and trifocal IOL provides good unaided visual acuity for distance, intermediate and near distances. This IOL combination provides high postoperative QoV and functional vision, with minimal postoperative visual disturbances.

Subjective Comparison IC-8 3 months Postop

(n = 22 patients)Panoptix 3 months Postop

(n= 32 patients)SBL-2/Mplus

combination 3 months Postop

(n=60 patients)

Zeiss IOL combination3 month postop(n=44 patients)

Glare 0.88 ± 1.09 0.59 ± 0.76 0.30 ± 0.65 0.25 ± 0.50

Haloes 0.75 ± 1.06 0.69 ± 0.82 0.17 ± 0.42 0.25 ± 0.50

Starburst 0.25 ± 0.58 0.19 ± 0.59 0.25 ± 0.60 0.14± 0.30

Hazy vision 0.25 ± 0.77 0.06 ± 0.25 0.13 ± 0.43 0.06 ± 0.25

Blurred vision 0.50 ± 0.82 0.19 ± 0.54 0.23 ± 0.53 0.17 ± 0.44

Distortion 0 0 0 0

Double vision 0.06 ± 0.25 0 0.22 ± 0.58 0

Vision fluctuation 0.38 ± 0.62 0.13 ± 0.42 0.25 ± 0.57 0.12 ± 0.32

Depth perception difficulty 0.06 ± 0.25 0.03 ± 0.18 0.08 ± 0.42 0.02± 0.18

Grading scale: 0 = Not at all; 1 = A little; 2 = Quite; 3 = Very

QoV Day 8.50 ± 0.89 9.00 ± 0.88 9.12 ± 0.88 9.10 ± 0.82

QoV Night 7.63 ± 1.31 7.78 ± 1.21 7.84 ± 1.61 8.10 ± 1.16

Summary

• Preoperative selection important • Positioning of near segment of rotationally asymmetric can improve

overall QoV for the asymmetric IOLs• 1 In 100 where one still needs to do something to the IOL• Symmetric Bi or Trifocal IOLs higher adds more symptoms longer

adaptation time• Combination of EDoF and trifocal IOLs provides better overall

nighttime QoV outcomes and importantly early adaptation :-‘Wow effect’