Transcript Sarfarazi IOL (B&L)

Accommodative IOL’s
Dr. H. Razmjoo
Isfahan University of Medical Sciences
Achieving the Desired Results in
modern cataract surgery:

Astigmatism Control

Aspheric Optics

Accurate Biometry

Appropriate Formulas

Adjusting the Outcome

Accommodation
Presbyopia : Solutions?
 Sclera?/
 Cornea
Presbyopic LASIK
 Corneal Inlays
 Lens
 Multifocal IOL
• Phakic / pseudophakic
 Accommodative IOL

Consider this issues in
evaluating presbyopic Surgery:
Measuring accommodation
True versus Pseudo-Accommodation
Reading ease, speed
Accommodative reserve
Quality of vision - HOAs
True vs Pseudoaccommodation
Pseudoaccommodation
- First devices available
- IOLs
Refractive – ReZoom
Diffractive – ReSTOR
Associated with loss of
contrast sensitivity
True Accommodation
- Transient and rapidly reversible
change in optical power of the eye
- Generally requires IOL change of
shape or position
Not associated with loss of
contrast sensitivity
Present IOLs – (FDA)
 Monofocal
 Pseudoaccommodative

Multifocal
• ReSTOR
• ReZoom
 Accommodative

Crystalens
Monofocal
IOLs:
Excellent visual acuity
 Best contrast sensitivity
 Need for some glasses
 Monovision

Multifocals:
(ReStor / ReZoom)
Good for some…
 Few years experience
 Excellent visual acuity
 Decreased contrast sensitivity

Accommodative:

Crystalens
 Excellent
quality of vision
 Minimal contrast loss
 Very poor true accommodation
 1-1.5D
 PCO
 Future ???
 Only 26% spectacle free in some
studies
Future accomodating
IOL’s

Based on accommodation theories


Exact method controversial
Helmhotz’s theory
Ciliary M. contraction
Thicker lens
Decreased zonular tension
Bag more lax
More PLUS power
Accommodative IOLs
 Future
of refractive surgery
 FDA approved lens has limited
accommodation
 Small incision IOL
 Truly accommodation will be available
when :
 Right IOL concept / design
 Maintained long term flexibility of
capsule
Accommodative Models
 Lens
“filling”
 Deformable IOL
 Single
 Dual
optic
optic
Single optic IOL

Hinged haptics

Forward movement
Poor
> effective power of IOL
accommodation
Need 1.5 mm axial move to achieve 2 D
ofaccommodation

Dual optic IOL




Positive lens anterior / negative lens
posterior
Lenses connected with spring like pieces
Accommodation through ciliary body
contraction induced separation of lenses
Large area required
Sarfarazi IOL (B&L)
Dual optic IOL

Advantage over single optic
• More accommodation
• Less IOL movement required
• No glare or contrast issues

Inter-lenticular opacities ?
Accommodation
Available IOLs:
Single optic:
Crystalens
 Only
FDA approved
 The
capsulorhexis must always
be larger than the optic of the
IOL, i.e. a capsulorhexis of 6
mm must be selected for an
IOL optic of 5 mm. The anterior
capsular bag must be placed
outside the optic.
 When
the lens is placed in the
capsular bag, it must be pushed
backward until there is complete
contact with the posterior capsular
bag.
 At
this stage of the surgery, the
IOL should not move forward at all;
which may cause Z syn.
 The
IOL must be rotated until it fits
exactly.
 Then
the cortex and the viscoelastic
substance behind the IOL optic must
be carefully removed.
 Finally,
the IOL must be pressed
completely back onto the posterior
capsular bag and may not move
forward.
no accommodate for 3 to 5 days
 The
polyimide material of the haptics
causes the IOL to grow firmly together
with the capsular bag by fibrosis. At
this stage it is important that the
patient does not accommodate during
the first 3-5 days after implantation.
Atropine
To
avoid premature
accommodation, the pupil is
dilated after surgery with a
single dose of atropine and it
takes 3-5 days for this
accommodation blockade to
abate.
Zsyndrome
Indication:
 This
IOL would be appropriate
for all patients.
 The
FDA approved Eyeonics Inc.’s
accommodating IOL, Crystalens AT45, in November 2003.
 Bausch & Lomb acquired Crystalens
in 2008 and introduced a newer
model called Crystalens HD in 2008.
 Crystalens is the only FDAapproved accommodating IOL
currently on the market
Studies and Peer Reviews:
 In



a September 2004 FDA trial involving
325 patients:
100% could see at intermediate distances
(24" to 30") without glasses; the distance
for most of life's activities
98.4% could see well enough to read the
newspaper and the phone book without
glasses.
Some patients did require glasses for
some tasks after implantation of the
crystalens
 At
this time, there is no long-term,
well-designed clinical trials to
support the accommodating
technology of the Crystalens IOL.
Single optic:
1 CU (Human Optics)
4
flexible haptics for axial movement
Single optic:
BioConfold 43 E (Morcher)
 Ring
haptics for optic movement
Single optic:
Opal (B&L)
Currently in clinical
trials
Single optic:
Tetraflex (Lenstec)
 Depends
on axial move
Single optic:
Fluid vision (Power Vision)

Dynamic Optic
with Fixed Haptics

Up to 10 D
accommodation

Accommodatio
n driven
hydraulic lens
shape change
NON-ACCOMMODATED
ACCOMMODATED
Single optic:
Flex optic (AMO)
 Conforms
the capsular
bag
 Changes optic
curvature
 No axial movement
 In trial
“Single optic”:
NuLens (Nulens)

Flexible polymer between 2 rigid plate,
one with an opening
 Polymer bulges = more positive lens
 30 - 50 D of accommodation theoritically
NuLens
Dual optic:
Synchony ( Visiogen)
optic(+ anterior & - posterior) / single
piece
 “Spring like haptics”
 Up to 2.5 acc.
 Dual
Synchony
Bag filling:
Smart IOL (Medennium)
 Bag
filling
 Ciliary muscle resumes lens shape change
control - Pliable for accommodation
 Thin rod that > to desired shape with body
temperature
 In trial
Bag filling:
Accommodating Injectable
Lens
(AMO)
Liquilens (Vision Solutions)
2
fluids with different
refractive indexes in
center of lens in single
optic
 Looking down mixes
fluids creating a more
positive lens
 Power changes with the
position of the eye
Light adjustable IOL
(Calhorn Vision)
 Residual
refractive error post op
laser “adjustment”
 Multifocal
post op “adjustment”
possible ???
Conclusions : Future
Acc. IOL’s should:
- Be the hope for the future
- Have a physiologic concept
- Have few optical side effect
Hope for:
- Aspheric optics
- Adjustability
- Toricity
- Control of lens epithelial cells
Criticisms:
 The
main concern with accommodating
IOLs is that there are no long-term,
large-scale studies involving its use in
patients.
 potential
complications include capsular
bag contraction and posterior capsule
opacification.
 It
is more difficult to implant an
accommodating IOL (due to the
attachment of hinges)
 Accommodating
expensive.
IOLs are
Good candidates:
 patients
over 50 with cataract
problems and no serious eye
diseases
 The
patient must have
functional ciliary muscles or
zonules
 patients
must include ophthalmologic
exercises such as puzzles and word
games as a part of their daily regimen in
order to tone up their ciliary muscles and
attain the maximum benefit from the
accommodating lenses.
 These
exercises should be done
consistently for 3–6 months
Future accomodating
IOL’s

Based on accommodation theories


Exact method controversial
Helmhotz’s theory
Ciliary M. contraction
Thicker lens
Decreased zonular tension
Bag more lax
More PLUS power
Thank you for your attention