Lecture at European Meeting of Young Ophthalmologists. Oviedo 2016

1. Update in
intraocular lenses
DR. ALVARO RODRÍGUEZ RATÓN
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

2. Historical Evolution
0
50
100
150
200
250
300
350
1949 1970 1990 2015
Number of available IOL
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

3. 298 available IOL at ULIB
Colaborative online free resource
TAKE HOME MESSAGE
ULIB
http://ocusoft.de/ulib/c1.htm
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

4. Main IOL characteristics
Optical features Determines
Refractive power Defocus (myopia/hyperopia)
Asphericity LSA (Longitudinal Spherical Aberration)
Toricity Astigmatism
Multifocality Distance-independent VA
Platform Design Determines
Material Biocompatibility, glistening
Border Design PCO
Haptic Refractive stability, rotation
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

5. Platform and Toricity
Variable cylinder correction range
Platform stability
Controlled 1 year follow up (SN6AT, 100 eyes)
◦ Final axis-intented axis 3.2±3 ( 1>15º)
◦ Relocation needed 1%
ANSI standard for stability (≥ 90% of eyes with ≤ 5° of rotation between visits)
TAKE HOME MESSAGE
Toric IOL
Great rotational stability
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

6. Multifocal IOL. Defocus curve
1. Best distance corrected VA (logMAR)
2. Defocus = variable distance simulation
-0.10
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
-4 -3.5 -3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5
<30years
Monofocal IOL
Bifocal IOL
Trifocal IOL
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

7. Multifocal designs
REFRACTIVE
DIFFRACTIVE
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

8. Refractive multifocal IOL
+3.00D
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

9. MplusX refractive map
(NIDEK OPD3 Aberrometer)
DR. ALVARO RGUEZ. RATÓN. SECOIR 2014
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

10. Refractive multifocal IOL:
mPlus Vs mPlus X
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
-4 -3.5 -3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5
Mplus
MplusX
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

11. Diffractive multifocal IOL
Step design
◦ Wide determine focal length
◦ Height determines light energy
Counterpart
◦ Glare and Halo increase1
◦ Decrased Contrast Sensitivity2
1BJO. 2015. Visual outcomes in eyes with a distance-dominant diffractive multifocal intraocular lens with low near addition power. Hayashi K
2Aberration and contrast sensitivity comparison of aspherical and monofocal and multifocal intraocular lens eyes. Clin Exp Ophthalmol. 2007
One-step structure: Bifocal Design
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

12. Trifocal diffractive IOL
Combining two bifocal structures
◦ Constructive interference between
near add of both structures
◦ Intermediate 2nd order interferes with near
second order
◦ Creates an intermediate focus
without optical quality loss1
1Comparative analysis of the visual performance after cataract surgery with implantation of a bifocal or trifocal diffractive IOL. JRS 2014
Two structures: Trifocal Design
0
1
2
3
4
5
6
A B C D E
TRImedia
ZMB
*own data
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

13. Bifocal difractive IOL
optimizing the near add
1Clinical Outcomes Following Implantation of Diffractive Multifocal Intraocular Lenses With Varying Add Powers
2IOVS 2015. Halo and Through-Focus Performance of Four Diffractive Multifocal Intraocular Lenses.
Near Visual Quality
outperforms +4.00 Tecnis1
+2.50 Restor and LISA TRI2
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

14. Bifocal difractive IOL
optimizing the near add
1Clinical Outcomes Following Implantation of Diffractive Multifocal Intraocular Lenses With Varying Add Powers
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

15. But still bifocal IOL…
0.00
0.10
0.20
0.30
0.40
0.50
0.60
-4 -3.5 -3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5
Bifocal IOL
Trifocal IOL
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

16. Trifocal difractive IOL
getting the best at all distances
1. Zeiss LISA TRI
2. Alcon PANOPTIX
3. PhysIOL FINEVISION
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

17. Zeiss LISA TRI
Pupil independent
◦ Loss of optical quality at bigger pupils1
Central 4.3mm trifocal design
◦ Bifocal periphery
1Invest Ophthalmol Vis Sci. 2015. Halo and Through-Focus Performance of Four Diffractive Multifocal Intraocular Lenses. Vega F
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

18. Zeiss LISA TRI
Pupil independent
◦ Loss of optical quality at bigger pupils1
Central 4.3mm trifocal design
◦ Bifocal periphery
1Invest Ophthalmol Vis Sci. 2015. Halo and Through-Focus Performance of Four Diffractive Multifocal Intraocular Lenses. Vega F
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

19. Alcon PANOPTIX
Central 4.5mm trifocal design
◦ Monofocal periphery
EnLighEn design
◦ Non apodized
◦ High distance and intermediate light energy
◦ Lower loss of light energy (12%)
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

20. PhysIOL FINEVISION
100% trifocal optic
Convoluted
◦ Apodized
◦ Reduces step height
Platform
◦ Micro
◦ Pod
BMC Ophthalmol. 2015. Visual outcomes after bilateral trifocal diffractive intraocular lens implantation. Carballo-Alvarez J
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

21. Differential characteristics
ZEISS
AT LISA TRI (0-32)
ALCON
PANOPTIX (13-34)
Finevision
Micro (10-35)Pod(6-35)
Intermediate (D) +1.66 +2.17 +1.75
Near (D) +3.33 +3.25 +3.50
Distance Light Energy 42.85% 44% 43%
Intermediate Light Energy 17.14% 22% 15%
Near Light Energy 25.71% 22% 28%
Lost Light Energy 14.3% 12% 14%
Matherial Hydrophilic (25% water)
hydrophobic surface
Hydrophobic1,2 Hydrophilic (25% water)
LSA (μm) -0.09 -0.20 -0.113
Diameter Optic 6 mm
Plate 11 mm
Optic 6 mm
Total 13 mm
Optic 6.15mm (6)
Total 10.75mm (11.4)
Difractive system Smooth Micro Phase EnLighten Convoluted
1Evaluation of loss in optical quality of multifocal intraocular lenses with glistenings. JCRS 2016
2 Lens epithelial cell growth on the anterior optic of 2 hydrophobic intraocular lens models. JCRS 2016
3Clinically Relevant Optical Properties of Bifocal, Trifocal, and Extended Depth of Focus Intraocular Lenses. JRS 2016
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

22. LISA TRI / PANOPTIX / FINEVISION
BCVA 3 foci
(logMAR. Distance/Intermediate/Near)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
6m 66cm 33cm
TRILISA
PANOPTIX
FINEVISION
*own data
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

23. Defocus curve
LISA TRI / PANOPTIX / FINEVISION
0.00
0.10
0.20
0.30
0.40
0.50
0.60
-3.5 -3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1
MediaTRI
Panoptix
Pod
*own data
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

24. Monofocal control / LISA TRI / PANOPTIX / FINEVISION
Contrast Sensitivity Test
(Vistech, mesopic)
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
1 2 3 4 5
SA60AT
TRI LISA
Panoptix
Pod
*own data
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

25. Photic phenomena
*own data: 10 patients/group: LISA - 2 eyes (1 patient) / PAN - 0 / F - 0
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

26. Photic phenomena
208 eyes implanted TRISA TRI1
◦ 20% halo
◦ frecuent
◦ persistant
FINEVISION
◦ No Halo report 2,3
Comparative study4
1Evaluation of visual outcomes and patient satisfaction after implantation of a diffractive trifocal intraocular lens. JCRS 2016
2Visual outcomes after bilateral trifocal diffractive intraocular lens implantation. BMC Oph 2015
3Visual and refractive outcomes after implantation of a fully diffractive trifocal lens. Clin Ophthalmol. 2012
4Comparison of visual outcomes of 2 diffractive trifocal intraocular lenses. JCRS 2015
LISA TRIFINEVISION
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

27. Difractive trifocal IOL
strength and weaknesses
Strength Weaknesses
Zeiss LISA TRI Optical performance Halos
Plate
Hydrophilic
Alcon PANOPTIX C-loop platform
Hydrophobic
Low near performance
Physiol FINEVISION Optical performance
Low Halo
Hydrophilic
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

28. Conclusions
1. Wide portfolio of IOLs; shared constants (ULIB)
2. Toric IOL show great rotational stability despite of chosen platform
3. Multifocal IOL
◦ Refractive depend on pupil size and centration
◦ Difractive designs
◦ Bifocal – VARIABLE NEAR ADITION
◦ Trifocal – VARIABLE DESIGN AND PLATFORM
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016

29. THANK YOU
Presentation available at www.alvarorodriguezraton.com
DR. ALVARO R. RATON LECTURE AT OVIEDO, EMYO 2016