1. Dr H. Razmjoo Isfahan University of Medical Sciences Multifocal IOLs

2. Presbyopia IOL options
Monovision
Refractive
Diffractive
Accommodative
Presbyopia IOL options

3. The Ideal Multifocal IOL Patient
50’s to the mid 60’s
Cataract starting to compromise quality of vision
Active lifestyle
Concerned about their appearance & ‘quality of life’
Do not want to ‘get old’
Spending on lifestyle enhancing procedures
Realistic Expectations
Motivated
Asks lots of questions

5. Who’s A Suitable Candidate?
Wants to be less dependent on glasses
Understands the limitations
Willing to accept several months to adapt to their new visual system

6. Who’s Not A Suitable Candidate?
Significant dry eyes
Corneal scarring
Pupil size < 2.5 mm
Monofocal implant in first eye
Uncorrected post-op astigmatism > 0.5 D
Unstable capsular support
Someone who demands perfect vision

7. ReZoom Multifocal IOL (AMO)
Refractive lens
Delivers good near, distance and intermediate vision

9. Is The ReZoom Perfect? The most common concerns Distance blur
Monocular diplopia
Object glow
Ghosting
Halos at night
These are the biggest post-op challenges

14. The 3.5 D add at the IOL plane provides for fairly good near vision

15. Acrysof ReStor IOL (Alcon)
Diffractive technology
Silicone material
Uses “apodization” to soften blur and sharpen vision
Provides excellent VA at near, distance and intermediate ranges

16. Strengths of the AcrySof ReSTOR IOL
High quality uncorrected near and distance vision with 20/40 or better intermediate vision without movement of the IOL
80% Overall Spectacle Freedom
Nearly 94% of patients would have the lens again

18. The ReSTOR IOL is an IOL that provides significant magnification.
Many patients spend 10 to 15 years gradually holding reading materials farther away. By the time a patient is 55 years old, with 55 to 60 years being the typical age range for presbyopic IOL exchange, the patient is holding reading materials at 14 to 20 inches away from his or her eyes.

19. After ReSTOR IOL implantation set at +0. 25 D to +0
After ReSTOR IOL implantation set at D to +0.5 D, a patient has near vision of 9 to 10 inches.
However, the ReSTOR IOL does not provide a significant increase in intermediate vision.

20. Do We currently have any aspheric multifocal IOLs?
Tecnis multifocal (AMO)
Sofport AO (Bausch & Lomb)

21. Haloes and glaare at night are common- these diminish with time
Longer adaptation period – may take weeks or months for patients to accept their “new” visual system
Near vision may be fuzzy to myopes
May need reading specs for prolonged nearpoint work

23. In the United States, a new category of intraocular lenses was opened with the approval by the Food and Drug Administration in 2003 of multifocal and accommodating lenses.
The aim of the procedure is to allow the eye to focus on near as well as distant objects without regular need to use glasses. These lenses have areas of different refractive powers and allow both near and distant images to be focused on the retina simultaneously. The brain is then able to select the required image for attention.

25. Adverse events problems with intermediate vision
reduced contrast sensitivity
halos
glare
‘Vaseline vision’ / waxy vision
reduced tolerance to astigmatism

26. Clinicians wishing to undertake implantation of multifocal (non-accommodative) IOLs during cataract surgery should ensure that patients understand the risks of the procedure, including the possibilities of halo and glare, and reduced contrast sensitivity. Patients should also be made aware that the lenses may be difficult to remove or replace. They should be provided with clear written information.

27. To incorporate the strengths of each type of IOL, some eye surgeons recommend using a multifocal IOL in one eye to emphasize close reading vision and an accommodating IOL in the other eye for further midrange vision. This is called "mix and match." Distance vision is not compromised with this approach, while near vision is optimized.

28. The TECNIS® Multifocal IOL
Spherical aberration correction to essentially zero
chromatic aberration reduction
A pupil-independent, full-diffractive posterior surface
High-quality vision in all light conditions 28

29. TECNIS® Multifocal Acrylic IOL
13.0 mm overall diameter
Posterior diffractive surface
6.0 mm optic diameter
Frosted, continuous 360° posterior square edge
TECNIS® IOL wavefront-designed aspheric surface
Posterior side
Anterior side
Haptics offset for 3 points of fixation 29

30. TECNIS® Multifocal 1-Piece IOL Specifications
Tecnis Multifocal IOL Physician Presentation
TECNIS® Multifocal 1-Piece IOL Specifications
Full diffractive posterior surface
Pupil-independent
Wavefront-designed aspheric anterior surface
Light distribution 50/50
Optical power add +4.0 D
To optimize acuity at preferred reading distance of 33 cm 30 30

31. Important Safety Information
Under low-contrast conditions, contrast sensitivity is reduced with a multifocal lens compared to a monofocal lens. Therefore, patients with multifocal lenses should exercise caution when driving at night or in poor visibility conditions. 31

33. Important Safety Information
Precautions: The central one millimeter area of the lens creates a far image focus, therefore patients with abnormally small pupils (~1 mm) should achieve, at a minimum, the prescribed distance vision under photopic conditions; however, because this multifocal design has not been tested in patients with abnormally small pupils, it is unclear whether such patients will derive any near vision benefit. 33

34. Manual Refraction
Autorefractors may not provide optimal postoperative refraction of multifocal patients; manual refraction is strongly recommended.

35. Emmetropia should be targeted as this lens is designed for optimum visual performance when emmetropia is achieved. Care should be taken to achieve centration.

36. Spherical Aberration Correction
Correcting spherical aberration (SA) to zero results in sharper focus of light and therefore sharper vision at both near and distance. * *
TECNIS® Multifocal IOL
ReSTOR® +3.0 IOL 36
*In the average cataract patient

37. Spherical Aberration Correction
There is a measurable difference
An IOL that fully corrects spherical aberration can provide a 13% increase in contrast over an IOL that leaves +0.1 residual spherical aberration 37

38. Combining Spherical and Chromatic Aberration Correction
Several studies have shown the correction of chromatic aberration and spherical aberration together is more beneficial than the sum of the two individual corrections. 38

39. TECNIS® Multifocal IOL
Full Diffractive vs. Apodized Diffractive Effect in Low Light Conditions
As the pupil widens in mesopic conditions:
TECNIS® Multifocal IOL is pupil-independent so light is still distributed equally to near and distance focal points, retaining high-quality near vision
The apodized design functions as a monofocal lens on the outer perimeter, therefore distributing more light to distance and degrading the quality of near vision
TECNIS® Multifocal IOL
ReSTOR® +3.0 IOL 39

40. Rayner Intraocular Lenses Ltd
The Rayner M-flex™
Multifocal IOL

41. The Rayner M-flex™ (630F)
Multifocal IOL

43. M-flex™ is a multi-zoned, refractive, aspheric multifocal intraocular
lens (MIOL) indicated for those patients requiring a degree of
pseudoaccommodation.

44. M-flex™
M-flex™ is a single-piece, hydrophilic acrylic injectable MIOLwhich can be considered to be the multifocal analogue of Superflex™, having an optic diameter of 6.25mm and an overall length of 12.50mm

45. Good Optic Design
M-flex™ is based on multi-zoned refractive aspheric optics with either 4 or 5 refractive zones (depending on base power), providing an additional +3.0D of refractive power in the IOL plane, which is
equivalent to +2.25D in the spectacle plane
The refractive zones around the central (1.75mm) distance zone are
annular and alternate between distance and near focus
with a 60:40 split (Distance:Near)

47. AVH™ Technology 10.5mm 10.0mm 9.5mm
The outer haptics begin to take up the
compression due to capsular contraction
Progressive resistance to the compression
forces is generated as the outer and inner
haptics engage
1) The outer and inner haptics lock together
2) The IOL assumes an oval configuration
3) The haptic dynamics change, increasing
haptic rigidity and providing superior
capsular stability
10.5mm
10.0mm
9.5mm

48. Note the perfectly symmetrical haptic
compression

49. Enhanced Square Edge™
Anterior surface
Posterior
surface

51. Power options M-flex™ (630F) Sphere
+ 14.0D to D in 1.0D increments
+ 18.0D to D in 0.5D increments
Power addition
+3.0D

52. Patient Selection for Multifocal IOLs:
Tecnis Multifocal IOL Physician Presentation
Patient Selection for Multifocal IOLs:
No contraindications
e.g., recurrent severe inflammation or uveitis
Bilateral implantation
Postoperative astigmatism <0.75 D
Postoperative emmetropia or max. <0.75 D hyperopia
Patient motivation (e.g., high diopter glasses, hyperopia, spectacle independence)
Visual expectations of the patient 52 52

53. Tecnis Multifocal IOL Physician Presentation
Exclusion Criteria
Macular pathologies, glaucoma with severe visual field loss
Monofocal IOL already in one eye (relative exclusion)
Unrealistic visual expectations
Happy with reading glasses
Surgical complications, such as capsulorhexis tear, capsular folds, fixation in sulcus
Patient is at risk for developing PCO 53 53