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’