1. Dominic McHugh Royal Society of Medicine 2010

2. ARMD Leading cause of blindness (“SVL”) in the Western World 2.7 million in the UK have some loss. 54% increase in >75s over the next 25 yrs.

3. ARMD Quality of Life With ARMD Without ARMD Home Care23%5% Falls16%8.3% Falls With Fractures3.5%1.5% Healthcare Costs€12,579€1,300 (£8,521)(£885)

4. LVA Possibilities

5. Intraocular Miniature Telescope Intraocular Miniature Telescope Galileian telescope 2.2- 3.5x intra (Lipshitz) Galileian telescope 2.2- 3.5x intra (Lipshitz) Hanita Ben-Sira implant Hanita Ben-Sira implant Galileian telescope 2x Galileian telescope 2x IOL+spectacle IOL+spectacle Surgical Rehabilitation for ARMD Difficulty maintaining coaxial alignment Monovision VF 20° 11 mm incision

6. IOL-VIP System BCC IOL in the capsular bag = telescope ocular BCX IOL in AC= telescope objective

7. IOL-VIP System PC IOL AC IOL -66D +55D

8. IOL CHARACTERISTICS ANTERIOR CHAMBER IOL (BCX) Optic Material PMMA with UV filter Diameter 5.0 Thickness 1.5mm Haptics Loop shapeZ Material PMMA-1P Angle10° IOL power +55.00 D PC IOL (BCC) Optic Material PMMA with UV filter Diameter 5.0 Thickness1.5mm Haptics Loop shape C Material PMMA-1P Angle7° IOL power -66.00 D

9. Inclusion criteria for IOL-VIP surgery Bilateral stable macular degeneration/macular hole Bilateral stable macular degeneration/macular hole VA 6/18-6/60 VA 6/18-6/60 Good peripheral field Good peripheral field Adequate AC depth Adequate AC depth Adequate endothelial cell count Adequate endothelial cell count Predicted benefit by IOL-VIP simulator Predicted benefit by IOL-VIP simulator

10. Exclusion criteria for IOL-VIP Surgery Active exudative macular degeneration Active exudative macular degeneration Glaucoma Glaucoma Cornea guttata Cornea guttata PAS PAS Endothelial cell count < 1600 cell/mm2 Endothelial cell count < 1600 cell/mm2 Shallow anterior chamber with depth < 3 mm Shallow anterior chamber with depth < 3 mm Corneal diameter < 11 mm Corneal diameter < 11 mm no visual acuity improvement using the IOL-Vip simulator

11. IOL-VIP Proposed mechanism of action Prismatic deviation of Image to PRL. Image magnificiation ~1.3

12. Image shift to PRL (MP) Post-op Pre-op RE preop BCVA : 0.25 postop BCVA: 0.5 LE preop BCVA : 0.3 postop BCVA: 0.7 (Fasciani et al, 2008)

13. IOL-VIP Simulator Prism

14. IOL-VIP Preoperative assessment Best VA without and with simulator prism, rotated to achieve PRL

15. 12 3 9 6 3 9 6 Left EyeRight Eye 12 6 9 3 6 9 3 IOL-VIP System Optimal simulator orientation determines relative IOL position

16. 12 3 9 6 3 9 6 Left Eye Right Eye 9 3 1-2 8-7 1-2 8-7 12 6 1-2 8-7 IOL-VIP System Optimal simulator orientation determines relative IOL position

17. Corneal tunnel (superior/temporal depending on IOL orientation Large (6-7 mm) CCC Phacoemulsification if phakic Enlarge corneal incision to 7 mm PC IOL: bag if phakic, sulcus if pseudophakic PI+miochol A/C IOL Corneal sutures

18. IOL-VIP Surgery

19. IOL-VIP Visual Outcome Orzalesi et al 2007

20. IOL-VIP Postoperative findings Low surgical complication rate Endothelial cell loss 7% PCO 18% High hyperopia in emmetropes; better if myopic Recent availability of “bespoke” implants

21. Advantages Improves reading/distance vision in suitable cases (6/18- 6/60 pre op; small-moderate central scotoma) Patients comment favourably on scotoma shifting away from centre Disadvantages Careful selection required: pathology; psychology; costs Lengthy (6 week) postoperative rehabilitation training Suture removal Refractive error : hyperopia and astigmatism (reduced with new implants