1.
Premium intraocular lenses The
past, present and future
Dr.MUSHTAQ AHMAD
ASSOCIATE PROFESSOR
FIO Peshawar

2.
Back ground
 Premium Iols
 Restore+4 add 2005 Non –aspheric then aspheric
 Crystalens 2005
 Rezoom 2005
 Crystalens 5.0 2007
 Crystalens HD 2008
 Restore+3 add 2009 Aspheric
 Acrysof Toric 2009
 Technis 2009

3.
Introduction
 Cataract presents the leading cause of preventable blindness in the world
 As number of surgical procedures increases every year.
 Patients expects excellent visual results and perfect vision without spectacles at
both distance and proximity.
 Premium IOL technology and advanced surgical techniques have significantly
improved postoperative visual outcomes and addresses patients expectations.
 Premium IOL technology refers to IOLs biomaterial, aspheric design, and special
refractive properties.

4.
History
(PMMA) IOL
1949
hydrophilic
acrylic
hydrophobic
acrylic
PMMA
biomaterials
silicone
first bifocal IOL
1986.
first EDOF IOL
2016
first toric IOL
1992
first FDA
approved
accommodative
IOL in 2003

5.
Success of premium IOLs depends on
 Patient has realistic Expectation
 Patient selection and counseling
 Informed patient about potential optical aberrations
 understands the limitations of premium IOLs
 Under promise and over deliver
 Educate the patient –short n to the point
 Recommend the best option for them
 Detailed preoperative ophthalmic examination

6.
Types of premium IOL lenses
 Multifocal Refractive and
 Multifocal Diffractive IOLs
 Toric lenses
 Accommodating IOLs
 Monofocal IOLs

7.
SELECTION OF LENS TYPE
DISEASE TYPE OF LENS Visual outcome
ARMD multifocal IOLs
glaucoma suspects with
posterior eye segment
changes,
monofocal
monovision
Astigmatism toric IOL

8.
Multifocal Intraocular lenses
 spectacle independence at near, intermediate, and distant vision

9.
Classification Regarding the optical
design
multifocal IOLs
Refractive
multifocal IOLs
Diffractive
multifocal IOLs

10.
MultifocalIOLs
Bifocal, Trifocal
Extended depth of
focus (EDOF)
ON THE BASIS OF FOCI
Classification Regarding the focality

11.
Contraindications for Multifocal IOL
 Ocular disorders with capsular instability
 Pre-existing ocular comorbidities
 Ocular pathologies of progressive nature
 Retinal diseases(retinitis pigmentosa and Statgart disease)
 uveitis,

12.
Visual out come uncorrected distance
visual Acuity
Type of IOL UDVA Patients ratio
Unilateral
multifocal IOL
0.03 logMAR(20/40) 82.3%–95.7%
EDOF
multifocal IOL
BL
0.03 logMAR(20/40) 99.9%
Monofocal
Toric IOL
0.3 logMA 70%–95%
Multifocal toric
IOLs
0.3 logMAR 92%–97%

13.
Spectacle Independence
Type of IOL Patients ratio SID
Multifocal IOLs 93.5%–99.9% Spectacle independence distance
Monofocal IOLs. 52.4%–85% Spectacle independence distance
Multifocal IOLs 81.3%–84.9% Spectacle independence near
Monofocal IOLs. 7.5%–12% Spectacle independence near
unilateral toric
Monofocal IOL
60%–85% Spectacle independence distance
Multifocal toric IOLs 79%–90% Complete freedom of spectacles
Accommodative IOLs 30%–60% Spectacle independence near

14.
Most commonly used multifocal
intraocular lenses (IOLs).
Multifocal
IOL
Material IOL design IOL/optic
diameter
(mm)
Optical principle Intermed/ne
r add (D)
Focality/Princi
ple
Symmetry/
Structure
Restor
AcrySof
(Alcon)
Hydrophobic
acrylic
Single piece
loop haptics
13.0/6.0 Bifocal,
Refractive-
diffractive
Rotationaly
symmetric,
Apodized
0/4
PanOptix
AcrySof
(Alcon)
Hydrophobic
acrylic
Single piece
loop haptics
13.0/6.0 Trifocal,
Refractive
Rotationaly
symmetric,
Constant
2.17/3.25

15.
Most commonly used multifocal
intraocular lenses (IOLs).
Mplus Lentis
(Oculentis)
Hydrophilic
acrylic
Single
piece
plate
haptics
11.0/6.0 Bifocal
Refractive
Rotationally
asymmetric.
Segmental
0/2
Comfort Lentis
(Oculentis)
Hydrophilic
acrylic
Single
piece
plate
haptics
11.0/6.0 EDOF
Refractive
Rotationally
asymmetric.
Segmental
1.5/0
SBL 2 and 3
(Lenstec INC)
Hydrophilic
acrylic
Single
piece
plate
haptics
11.0/5.75 Bifocal
Refractive
Rotationally
asymmetric.
Segmental
0/2-3

16.
Most commonly used multifocal
intraocular lenses (IOLs).
ReZoom
Abbot
Medical
Optics
Hydrophilic
acrylic
Three piece
modified C
loop haptics
13.0/6.0 Refractive Zonal-
progressive
0/3.5
Tecnis
b
(Johns
on &
Johnson)
Hydrophobi
c acrylic
Single piece C
loop haptics
13.0/6.0 Diffractive Rotationally
symmetric,
Constant
+2.75 + 3.25
+4.0
FineVision
(PhysIOL)
Hydrophilic
acrylic
Double loop
haptics
10.75/6.15 Trifocal
diffractive
Rotationally
symmetric,
Constant
+1.75/+3.5

17.
Most commonly used multifocal
intraocular lenses (IOLs).
Multifoca
IOL
Material IOL IOL/optic
diameter
(mm)
Intermed/
near add
(D)
Focality/Pr
inciple
Symmetry
/
Structure
At Lisa
a
(Carl Zeiss
Meditec)
Hydrophili
c acrylic
with
hydropho
bic surface
Single
piece
plate
haptics
11.0/6.0 Bifocal/Trif
ocal
Diffractive
Rotational
y
symmetric,
Constant/
Zonal
1.67/3.75–
3.3

18.
Most commonly used multifocal
intraocular lenses (IOLs).
Mini Well
(Sifi Meditec)
Hydrophilic
acrylic
Single
fenestrated
haptics
10.75/6.0 EDOF,
refractive
Rotationall
symmetric.
Progressive
0/3
Diffractiva
(Human Optics)
Hydrophilic
acrylic
Single piece
loop haptics
12.5/6.0 Bifocal,
Refractive-
diffractive
Rotationally
symmetric,
Apodized
0/3.5
Symfony Tecnis
(AMO)
Hydrophobic
acrylic
Single piece
loop haptics
13.0/6.0 EDOF,
Diffractive
Rotationally
symmetric.
Achromate
1.78/0

19.
Toric intraocular lenses
 Astigmatism, an eye defect that causes the lens to deviate from the proper
curvature, creates distorted vision.
 When someone with astigmatism develops cataracts and is in need of surgery and
an IOL implant, Toric IOLs are the right choice.

20.
Methods of measuring astigmatism
 Manual keratometry
 Automated keratometry
 Corneal topography
 Scheimpflug imaging

21.
Selection of toric lens
Preoperative corneal astigmatism accurate measurement.
Posterior cornea acts as a minus lens and affects with-the-rule (WTR) and against-the-
rule (ATR) astigmatism differently and that anterior corneal astigmatism continues to
change towards ATR astigmatism years after the cataract surgery.
Therefore, in cases of WTR astigmatism, calculated corneal astigmatism can be
decreased by 0.5 D and in cases of ATR astigmatism it should be increased by 0.3 D.
An additional factor is surgically induced astigmatism (SIA), which has to be
incorporated in IOL power calculation.

22.
Visual outcome of toric iols
TYPE OF IOL UNDVA Patient ratio residual
astigmatism
monofocalToric IOL 0.3 logMAR
(6/12)
70%–95% small amount
0.97 logMAR
(6/48p)
64%
67%–88% 1.0 D <
67% 0.5 D<
Multifocal toric
IOLs
0.3 logMAR 92%–97%
89% 1.0D<
0.97LogMAR 71%

23.
Most commonly used toric multifocal intraocular
lenses (IOLs).
Toric IOL Material IOL
design
IOL
diam
eter
(mm)
Multifoc
l
technolo
gy
Near
addition
(D)
Spherica
power
(D)
Cylinder
power
(D)
Incision
size
Acrysof
IQ Restor
toric
(Alcon)
Hydrophobic
acrylic
Loop
13.0
Diffractiv
e + refra
ctive
+3.0 +6.0 to
34.0
1.0 to 3.0
(0.5–0.75
steps)
2.2
Acri.Lisa
Toric Carl
Zeiss
meditec
Hydrophilic
acrylic with
hydrophobic
surface
Plate
11.0
Diffractiv
e
+3.75 −10.0 to
+32.0
1.0 to
12.0 (0.5
steps)
<2.0
M-flex T
(Rayner)
Hydrophilic
acrylic with
hydrophobic
surface
Loop 12.0/
12.5
Refractiv
e
+3.0 to
+4.0
+14.0 to
32.0
+1.5 to
+6.0 (0.5
steps)
<2.0

24.
Most commonly used toric multifocal intraocular
lenses (IOLs).
Toric
IOL
Material IOL
design
IOL
diam
eter
(mm)
Multifocal
technology
Near
additio
n (D)
Spherical
power (D)
Cylinder
power (D)
Incision
size (mm)
Lentis
Mplus
toric
Oculen
tis
Hydrophili
c acrylic
with
hydropho
bic
surface
Plate 11.0 Sector shaped
refractive
segment
+3.0 0.0 to
+36.0
+0.25 to
+12.0 (0.75
steps custom)
2.6
Tecnis
ZMT
Abbot
Hydropho
bic acrylic
Loop 13.0 Diffractive +4.0 +5.0 to
34.0
+1.5 to +4.0
(0.5 steps)
2.2

25.
Accomodative IOLs
 Accommodating IOLs can provide
vision in far, medium and close
distances.
 These lenses are able to respond to
the eye’s muscle movements to allow
for different focal lengths to offer
vision at different distances.
 For those with presbyopia where the
ability to switch focal lengths is
diminished due to the sagging of the
muscle, accommodating IOLs are
used to restore normal vision without
needing bifocal lenses.

26.
Accommodating IOL design
 Position-changing single or dual optic IOLs,
 Shape changing IOLs,
 Refractive index modulating accommodative IOL designs
 Lens filling surgical techniques

27.
IOL Material IOL design IOL/optic
diameter
(mm)
Mechanis
m of
action
Location Measured
accomm
(D)
Incision
size (mm)
Crystalens
(Bausch
Lomb)
Silicone Biconvex
hinged
plate
haptic
11.5–
12.0/5
Single
optic
forward
motion
Capsular
bag
>0.4 2.8
1CU Lens
(Human
optics)
Hydrophili
c acrylic
4 flexible
haptics
9.8/5.5 Single
optic
forward
motion
Capsular
bag
1.36–2.25 3.0
Accomm
Most commonly used accommodative intraocular lenses (IOLs).

28.
Most commonly used accommodative
intraocular lenses (IOLs).
IOL Material IOL design IOL/optic
diameter
(mm)
Mechanis
m of
Location Measured
accomm
(D)
Incision
size (mm)
Tetraflex
(Lenstec
Inc)
Hema Closed
loop
haptics
11.5/5.75 Single
optic
forward
motion
Capsular
bag
2 2.8
Synchrony
(Abbott)
Silicone 2 optics
with 4
spring
haptics
9.8/5.5–6.0 Dual optic
IOL
Capsular
bag
1 3.8
Lumina
(AkkoLens
Int)
Acrylic Elastic
loop with a
spring
function
Customize
d
Alvarez
principle
Ciliary
sulcus
2–3 2.8

29.
NuLens
(Herzliya Pituah)
PMMA-
Silicone
4 PMMA
haptics
with
posterior
piston
2.0
central
piston
10.0
overall
Axial
motion
Ciliary
sulcus
50–70
a
9.0
Tek-Clear
(Tekia, Inc.)
Hydrophil
ic
acrylic
360° full
bag
haptic
10.0–
11.0/5.5
Single
optic
forward
motion
Capsular
bag
NA 3.0
WIOL-CI
(Medicem)
Methycryl
ic
copolyme
r
Bioanalog
product
10.0/8.6–
8.9
Axial
motion
Capsular
bag
NA 2.8
FluidVision (PowerVis) Hydropho
bic acrylic
fluid
2Fluid
filled
haptics
10.0/6.0 Fluid
movemen
t within
the IOL
Capsular
bag
3 3

30.
Limitations and complications
Limitation/complication Patient ratio Dissatisfaction causes
dysphotopsias
Dec.contrast sensitivity
blurred vision ametropia
Photic phenomena IOLdecentration,
dry-eye-syndrome,
PCO 12% @ 1yr
21% @ 3yr
28% @5 yr
pseudophakic cystoid macular
edema
1.17% and 4.2%
posterior vitreous detachment 7.8% and 73.3%,
retinal detachment 0.7%,
IOL dislocation 0.28%

31.
Future developments
 Improved IOL design, material.
 Additional refinements in surgical technique, IOL calculation, IOL design, and
alignment
 Laser-assisted cataract surgery
 Computer-controlled femtosecond laser-assisted cataract surgery (FLACS) .

32.
Discussion
 Premium IOLs, appropriately selected patients can achieve spectacle independence
and good visual outcomes at both near and distance.
 However, premium IOLs show significant sensitivity to minor ocular aberrations;
therefore, adequate preoperative clinical evaluation is crucial to postoperative
success
 Long-term prevention of PCO is defectively an issue that also needs to be
addressed with the IOL implantation in the ciliary sulcus or some other strategy for
in the bag implantation.