1. NEWER IOLs
•Ajay Kumar Singh
•Nibha Mishra
•Department of Ophthalmology
•King George‘s Medical University, Lucknow
(INDIA)

2. An artificial lens that is implanted inside the eye
usually replacing natural crystalline lens during
cataract or refractive surgery to correct optical
power of the eye.
WHAT IS AN IOL ???

3. HISTORY
Italian scientist Tadini in mid 18th century first considered
intraocular lens implantation.
In 1795, Casamata implanted glass IOL which sank
posteriorly.
English ophthalmologist Sir Nicholas Harold Lloyd Ridley
is credited for first successful IOL implantation on November
29th 1949, at St. Thomas’ hospital in London.
Sir Harold Ridley (1906-2001)

4. EVOLUTION AND DEVELOPMENT
 Generation-I (1949-1954)
• Biconvex PMMA PCIOL
• Implanted behind iris after ECCE
• Diameter – 8.32 mm; Power – 24 D
Complications:
•Inferior decentration
•Posterior dislocation
•Inflammation
•Secondary glaucoma

5.  Generation-II (1952-1962)
• Early Anterior Chamber IOLs
• Fixation of lens in angle recess
• Advantages:
– Less decenteration
– Decreased reaction
Complications:
•Corneal decompensation
•Pseudophakic Bullous keratopathy
•Uveitis
•Secondary glaucoma
•UGH syndrome
EVOLUTION AND DEVELOPMENT

6.  Generation-III (1953 – 1975)
• Iris supported or iris fixated IOLs
• Advantages:
– It is away from angle structures hence
rate of complications like secondary
glaucoma is less.
– Rate of dislocation is less.
– Less contact with corneal endothelium
hence lesser damage to it.
•Complications:
•Iris chaffing
•Pupillary distortion
•Chronic inflammation
•CME
•Distortion on pupillary dilatation
•Endothelial decompensation
EVOLUTION AND DEVELOPMENT

7. • Iris clip lens (Binkhorst) • Iris claw lens (Worst)
EVOLUTION AND DEVELOPMENT

8. • Binkhorst’s another modification (1965)-
– Iridocapsular Lens
– Posterior haptics in capsular bag with anterior
loops removed.
• In 1970 Binkhorst and Worst employed a trans-
iridectomy suture for fixation mechanism-
MEDALLION lens.
EVOLUTION AND DEVELOPMENT

9.  Generation-IV (1963-1990)
• Intermediate ACIOLs
• Made up of flexible loops with multiple point of fixation
• More stable lesser complications
• Choyce, Mark VIII, Mark IX, flexible ACIOL, Kelman, Kelman flexible
tripod, Kelman quadraflex, Kelman multiplex 4 point fixation
Choyce KelmanMark IX
EVOLUTION AND DEVELOPMENT

10.  Generation-V (1975-1990)
– Improved PCIOLs
• Rigid tripod design (John Pierce)
• J-looped PCIOL (Steven Shearing)
• Modified J-looped PCIOL (Sinskey)
• C-looped PCIOL (Simcoe)
• One piece PCIOL (Eric Arnott)
POSITION•Major advantage-
EVOLUTION AND DEVELOPMENT

11.  Generation VI (1990- present) (Modern IOLs)
 Aspheric IOL
 Multifocal IOL
 Accommodative IOL
 Toric IOL
 Phakic IOL
 Aniridia IOL
 Scleral fixated IOL
 Glued IOL
Adjustable IOL
Telescopic IOL
Electronic IOL
EVOLUTION AND DEVELOPMENT

12. NEWER IOLs

13. • Square-edge design
• Surface Modifications
• UV absorbing material
DESIGN AND MATERIAL
Chromophores are added.
Two classes-
Hydroxybenzophenones
Hydroxyphenylbenzotriazoles
• Bio-compatible material
– Uveal compatibility
– Capsular compatibility
• Bio-active material

14. ASPHERIC IOLs
 Human eye- Aspheric Optics
 Cornea- Positive spherical aberration
 Young crystalline lens- Negative spherical
aberration
Ageing- Crystalline lens gains Positive
spherical aberration
+ -
+
+

15. ASPHERIC IOLs

16. • CONVENTIONAL SPHERICAL IOLs:
• A biconvex IOL exhibits positive
spherical aberration.
• ADD positive spherical aberration to the
already positive corneal spherical
aberration
Conventional IOL increase
the spherical aberration of the eye
ASPHERIC IOLs

17. How to overcome this ???
• Strategy 1:
– Lens with negative spherical aberrations to balance the normally positive
corneal spherical aberrations
• Strategy 2:
– Lens with minimum spherical aberrations so that no additional spherical
aberration is added to the corneal spherical aberrations
Aspheric IOLs attempt to improve pseudophakic vision by controlling spherical aberrations.
ASPHERIC IOLs

18. TYPES:
• Anterior prolate surface
– Tecnis, Advanced Medical Optics (AMO)
• Posterior prolate surface
– Acrysof IQ, Alcon Laboratories
• Both Anterior and Posterior prolate surfaces
– Akreos AO, SofPort AO and L161 AO, Bausch & Lomb
TecnisAcrysof IQSofPort AOAkreos AO
ASPHERIC IOLs

19.  Restoration of accommodation in pseudophakia-
MULTIFOCAL IOLs

20.  Single IOL with two or more focal points.
 Types
 Refractive
 Diffractive
 Combination of both
MULTIFOCAL IOLs

21.  Bull’s eye lens
o Concentric rings of different powers
o Central addition surrounded by distance optical power
 Annulus design
 3-5 rings-
o Central for distance vision
o Near vision ring
o Distance vision ring
REFRACTIVE MULTIFOCAL IOLs

22. 12345
Bright light/ Distance dominant zone
Large Near dominant zone
Low light/ Distance
dominant zone
Distance zone
Near zone Aspheric transition
REFRACTIVE MULTIFOCAL IOLs

23. REFRACTIVE MULTIFOCAL IOLs
Multiple focal points of a refractive MIOL

24.  Silicone MIOLs
 Array multifocal IOL (AMO)
 First FDA approved foldable MIOL
 Acrylic MIOLs
 ReZoom multifocal IOL (AMO)
 PREZIOL (Acrylic)(Care Group)
 Manufactured by Indian company
 Also available as non foldable PMMA lens
REFRACTIVE MULTIFOCAL IOLs

25. DIFFRACTIVE MULTIFOCAL IOLs

26.  Distance vision (white arrow)  Near vision (blue arrow)
DIFFRACTIVE MULTIFOCAL IOLs

27. • Tecnis Multifocal IOLs (AMO)
– ZM900 (Silicone)
– ZA00 (Acrylic)
• Optic Diameter 6.0 mm
• Optic Type
– Modified prolate anterior surface
– Total diffractive posterior surface
• Diffractive Power +4.0 diopters of near addition (+3.0 Diopters at spectacle plane)
Tecnis ZM900 Tecnis ZA900
DIFFRACTIVE MULTIFOCAL IOLs

28. • Acrysof IQ ReSTOR (Alcon)
 Acrylic diffractive multifocal IOL with apodized design
 Optic diameter- 6 mm
 Refractive for distance, and a diffractive lens for near.
 16 rings distributed over central 3-6 mm
 Peripheral rings placed closer to each other
 Central rings are 1.3 µm elevated are for near vision whereas
peripheral 0.2 µm elevated and for distant vision
 Anterior peripheral surface is modified to act as refractive design
 Near Addition +3.0 D at IOL plane (+2.5 D at spectacle
plane)
DIFFRACTIVE MULTIFOCAL IOLs

29. REFRACTIVE MULTIFOCAL IOLS DIFFRACTIVE MULTIFOCAL IOLS
Excellent intermediate and distance vision Excellent reading vision and very good
distance vision
Near vision fair but may not be sufficient to see
very small print
Fair Intermediate vision
Patients who read for prolonged periods of time
or in poor lighting may experience eye fatigue.
Patients who do lots of computer work may not
accept it well
PUPIL DEPENDENT LESS DEPENDENT ON PUPIL
Refractive vs Diffractive
MULTIFOCAL IOLs

30. Disadvantages
• Reduction of contrast sensitivity
• Glare, haloes
• Less satisfactory visualization of fundus- difficulty in vitreo-retinal procedures
• Requires Visual-Cortical Neuro-adaptation
• Requires
• Accurate biometry
• Precise IOL implantation
• Astigmatic reduction
MULTIFOCAL IOLs

31. PATIENT SELECTION:
Recommended for most but NOT ALL patients.
• Not recommended in:
– Monofocal lens in the other eye
– Pediatric patients
– Patient with high ametropia
– Patients with unrealistic expectations
– Moderate to severe macular
degeneration
– Irregular astigmatism or high degrees
of regular astigmatism
– Previous corneal transplantation
surgery
– Keratoconus
– Very small or fixed dilated pupils
– Where there is doubt about the
stability of IOL centration
– >83 years of age (Because age
reduces contrast sensitivity)
MULTIFOCAL IOLs

32. ACCOMMODATIVE IOLs
• Monofocal IOL
• Changes position inside the eye as the eye's
focusing muscle contracts
• 1 mm of anterior movement of lens = 1.80 D of
accommodation
• Mimicking the eye's natural ability to focus

33.  Silicone
 Crystalens (Bausch & Lomb)
 Only FDA approved IOL for correction of presbyopia
 Hydrophilic Acrylic
 BioComFold type 43E (Morcher GmbH)
 1CU (HumanOptics AG)
 Tetraflex (Lenstec Inc.)
ACCOMMODATIVE IOLs

34. ACCOMMODATIVE IOLs

36. • Anterior element with a spherical lens to correct
the overall refraction of the eye, and two cubic
optical surfaces for varifocal effect.
• Cubic optical elements are fitted by spring-like
haptics fused at the rim to allow a movement
perpendicular to the optical axis.
Akkolens IOL (Akkolens)
ACCOMMODATIVE IOLs

37. Synchrony Dual-Optic IOL (Visiogen)
One piece Silicon foldable IOL
Two optics with high plus anterior and
posterior minus lens that are connected by
spring like haptics.
When zonular tension is released –resulting
compression of optic-spring haptic releases
anterior optic forward.
ACCOMMODATIVE IOLs

38. SmartLENS (Medennium Inc.,Irvine, Calif.)
 Manufactured from thermodynamic hydrophobic acrylic material which makes it a
stable, flexible, gel polymer.
 2.0 mm rod and injected through a normally sized capsulorhexis
 Reconfigures itself
 High refractive index
 Prevent PCO
ACCOMMODATIVE IOLs

39.  Sulcus fixated lens
 Composed of silicone gel between 2 rigid
plates with an opening on the front plate
 With increased vitreous pressure, the
plate compress, the polymer bulges
through the anterior plate
aperture, resulting in increased curvature
and in increased curvature and increased
power.
 Accommodation +30 to +50 D
NuLens (NuLens Ltd., Israel)
ACCOMMODATIVE IOLs

40. FluidVision IOL (PowerVision, Belmont, Calif.)
The annular peripheral haptics- Fluid reservoir
The fluid moves back and forth naturally through this
pliable system (Microfluidic technology)
The channels in the lens are completely translucent
As the ciliary body and zonular apparatus contract and
expand, that fluid in the peripheral annular haptics is
forced radially through a channel into the centre of the
lens, causing it to increase its anterior posterior curvature
Average accommodation +5 D
ACCOMMODATIVE IOLs

41. LiquiLens (Vision Solutions)
 A dual liquid IOL (two immiscible fluids of different refractive indices)
 Gravity dependent
 Lower 3/4th – Lower refractive index- Distant vision (in straight gaze)
 Upper 1/4th – Higher refractive index- Near vision (in downgaze)
ACCOMMODATIVE IOLs

42. Disadvantages of Accommodative IOLs
• Smaller optic-more aberrations
• Failure of accommodation due to
• Fibrosis
• Capsular opacification
• Anterior
• Posterior
• Costly

43. TORIC IOLs
Vision with Cataract and
Astigmatism
Cataract corrected with IOL
but Astigmatism remaining
Cataract and Astigmatism
both corrected with Toric IOL

44.  Designed to correct astigmatism
 Axis of toric power is designed with 2 small hash-
marks
 Pre-operative marking of steep axis (greater
curvature) of cornea (in sitting position)
 Per-operative alignment of lens with corneal marking
 1º misalignment ~ 3.3% loss of cylindrical power
 Proper positioning of IOL is a must
TORIC IOLs

45. Two Types
• Silicone
– STAAR Toric IOL (STAAR Surgicals)
• Cylindrical powers: 2.0 D and 3.5 D
• Acrylic
– AcrySof Toric IOL and Acrysof IQ Toric IOL (Alcon Labs)
• Cylindrical powers of 1.5 D, 2.25 D, and 3.0 D
– T-flex (Rayner)
• 1.0 to 11.0 D in 0.25 D steps
– Acri.Comfort (Zeiss)
TORIC IOLs

46. Proposed incision is
marked at the steepest plus
meridian.
IOL is loaded into the
injection cartridge with
the toric marks on the
anterior surface
IOL is implanted in the
capsular bag and axis is
aligned
TORIC IOLs

47. ROLLABLE IOLs
•Ultrathin ~100 µ
•Hydrophilic material
•Front surface curved
•Back surface: series of steps with concentric rings
•Open up gradually
•Implanted by phakonit technique
•Acrismart
•Thin Optx ultrachoice
•Slimflex lens

48. PHAKIC IOLs
 Implantation of IOL without removing natural
crystalline lens.
 ADVANTAGE: Preserves natural accommodation
 Mostly used in Myopic eyes: -5 to -20 DS
 Also used in Hyperopic eyes
 Concern in Hyperopes:
 More chances of endothelial damage
 Increased risk of angle closure glaucoma
 Life-long regular follow up required.

49. Posterior
Chamber
Iris fixated
Angle
fixated
PHAKIC IOLs

50. Examples:
• Implantable collamer lens (ICL) (VISIAN; STAAR)
• Phakic refractive lens (Medennium)
• Sticklens
COMPLICATIONS:
– Endothelial cell damage
– Inflammation
– Pigment dispersal
– Elevated IOP
– Cataract
Posterior Chamber Phakic IOLs
PHAKIC IOLs

51.  Pre-crystalline lens made of silicone or collamer.
 The length of the lens is calculated by subtracting
0.5 mm from the white-to-white limbal diameter.
 Overall size- 11-13 mm
 Otical zone - 4.5-5.5 mm
 Toric model also available
Implantable Collamer Lens (ICL)
•COMPLICATIONS:
•Constant contact pressure
•Cataract
•Ciliary body reactions
•Prevent free passage of aqueous.- Iridectomy
required
•SPINNAKER EFFECT: Blowing sail of a boat
PHAKIC IOLs

52. VERISYSE/ARTISAN (AMO/OPTECH)
– Made of PMMA
– convexo-concave
– Length = 7.2 – 8.5 mm
– Optic size = 5-6 mm
– Haptics fixed to iris –claws
Iris Fixated Phakic IOL
PHAKIC IOLs

53. Iris Fixated Phakic IOL
• ADVANTAGES OVER ICL:
– Customized smaller size possible
– Can be examined from end-to-end under the slit lamp
microscope throughout the patient's life
•COMPLICATIONS-
•Early post op AC inflammation
•Glaucoma
•Iris atrophy on fixation sites
•Implant dislocation
•Decentration
•Endothelial cell loss
PHAKIC IOLs

54. TWO TYPES –
 4 point fixation
– Baikoff’s modification of Kelman type haptic design
• NuVita MA20 (Bausch and Lomb)
 3 point fixation
– Vivarte (IOL Tech)
• Separate optic and haptic
Angle Fixated Phakic IOL
PHAKIC IOLs

55. COMPLICATIONS –
 Endothelial cell loss
 Irregular pupil
 Iris depigmentation
 Post-op inflammation
 Halos and glare
 Surgical induced astigmatism
PHAKIC IOLs

56. PIGGYBACK IOLs
 An intraocular lens that “piggybacks” onto an
existing intraocular lens or two IOLs are
implanted simultaneously.
 First IOL is placed in the capsular bag.
 The second (piggyback) IOL is placed in the bag
or sulcus.

57. Advantages
• Easier to place 2nd IOL than to explant IOL & replace it
• Lesser risk
• More predictable
• Can change power with time-by adding IOL or explanting an IOL
• Better image quality
• Increased depth of focus
PIGGYBACK IOLs

58.  COMPLICATIONS
 Interlenticular opacification (Interpseudophakos Elshnig’s pearls) (RED ROCK SYNDROME)
 Unpredictable final IOL position
Disadvantages
PIGGYBACK IOLs

59. ADJUSTABLE IOLs
 Lens works on the principle of a piston.
 The haptic-optic junction is a piston such that the optic can be moved forwards or
backwards.
 It allows multiple adjustments.
 Useful for pediatric age group.

60. LIGHT ADJUSTABLE IOLs
A photosensitive adjustable foldable 3-piece IOL
Composed of subunits (macromers) embedded in a matrix. Focal UV irradiation (365 nm) from
a digital light delivery device (Carl Zeiss Meditec) causes polymerization of macromers.
Non-polymerised macromers diffuse and migrate into their radiated area causing a power
change
Irradiating the lens again locks in the desired configuration
Calhoun's light adjustable IOL.

61. ANIRIDIA IOLs
 Various designs
 Overall size = 12.5 to 14 mm
 Optic diameter = 3.5 to 5 mm
 Central clear optic
 Surrounding colored diaphragm

62. SCLERAL SUPPORTED IOLs
 PCIOLS sutured to the sclera through sulcus
 Widely used technique if there is no capsule or
only sections of peripheral capsule.
 No endothelial damage
 Low risk of iris chaffing
 Some risk of suture breaking
 Some risk of suture erosion

63.  Techniques of fixation:
 Ab-interno
 Ab-externo
 Single loop
 Double loop
o Single haptic fixation
o Double haptic fixation
SCLERAL SUPPORTED IOLs

64. GLUED IOLs
 Fibrin glue-assisted suture-less posterior chamber IOL implantation technique.
 INDICATION: Eyes with a deficient posterior capsule.
 The IOL is introduced through a limbal incision and both the IOL haptics are
externalized under the scleral flap with a 25-gauge MicroSurgical Technology
forceps.

65. IMPLANTABLE MINIATURE TELESCOPE
 Miniature implantable Galiliean telescope
 Implanted in posterior chamber
 Held in position by haptics loops
 Contain number of microlenses which
magnify objects in the central visual field.
 Improves central vision in ARMD.

66. • Acts as a telephoto system to enlarge images 2-3 times.
• Telephoto effect allows images in the central visual field to not be focused directly
on the damaged macula, but over other healthy areas of the central and peripheral
retina
Diseased eye: Image focused on
damaged macula
Implanted eye: Image focused on
macula and periphery
IMPLANTABLE MINIATURE TELESCOPE

67. DRAWBACKS:
 Surgically more challenging
 Difficulty due to the size and weight of the implant
 Endothelial compromise
 Blocked peripheral retinal visibility
 Difficulty in future retinal laser treatments
 Loss of peripheral vision
IMPLANTABLE MINIATURE TELESCOPE

68. TELESCOPIC IOL
 Next generation of implantable miniature telescopes.
 Uses mirrors rather than glass lenses
 25 X magnification of central images
 The LMI (Lipshitz Macular Implant) optics is 6.5mm and only
slightly thicker than a standard IOL
 Contains 2 miniature mirrors (a 2.8 mm posterior doughnut
shaped mirror that reflects light anteriorly onto a 1.4 mm central
retina–facing mirror which in turn focuses the light on retina).
 Does not affect peripheral vision.

69. Ray diagram showing the mirrored deflection of certain light rays that emerge
with magnification , the peripheral rays are not engaged by the mirror lens system and pass
through as they would in a standard lens implant thus helping to maintain a relatively normal
visual field .
TELESCOPIC IOL

70. SHAPE OF THINGS TO COME…

71. • World's first implantable lens with artificial intelligence.
ELECTRONIC IOL
Electro-active switchable element
Change in the molecular configuration of the liquid crystal to alter the optical power of the
lens
Automatically adjusts focusing power electronically, in milliseconds
Maintains constant in-focus vision for various distances and light environments.
Controlled by a micro-sized power-cell with an expected >50 year rechargeable cycle life.
CONCEPT: The pupil responds to accommodation by getting smaller. The IOL
includes sensors that detect very small changes in pupil size. The pupillary response to
accommodation is different from the pupillary response to light in regard to amplitude and
how rapidly it occurs in response to accommodation.

72. LENS: Set to correct distant
vision (with dilated pupil)
AUTO FOCAL LENS: Electro-active liquid
crystal centre for near vision (with small pupil)
BATTERY:
Rechargeable Li-ion
battery
MICRO CHIP:
Regulates the auto-focal
lens
PHOTO SENSOR: Detects
the external light
FRONT (CUT-AWAY)
VIEW OF ELENZA®
ELECTRONIC IOL
ELECTRONIC IOL

73. • Remaining safety and
technological issues…
– What happens to the electronic
components if the lens is hit with a
YAG laser ???
– Are any of the materials toxic ???
– What if there's leakage ???
ELECTRONIC IOL