Comparison of vision with an accommodating IOL versus a multifocal IOL GEORGE H.H. BEIKO, B.M.,B.Ch.,FRCSC ST. CATHARINES, CANADA ASSIST PROF, MCMASTER UNIV LECTURER, UNIV OF TORONTO george.beiko@sympatico.ca Financial Disclosure: Abbott Medical Optics – Consultant, Research support Visiogen, Inc. - Research support Lenstec/Clarion - Research support

Introduction: Ability to see at near is dependent upon accommodation (lens displacement, shape change and refractive power change) and pseudoaccomodation (pinhole effect, residual myopia, with the rule astigmatism, corneal multifocality due to higher order aberrations such as spherical aberration and depth of field) Pseudoaccommodation can provide 1.5-2.0 D of accommodative power in most eyes To evaluate the accommodative effect of a pseudophakic lens, it is essential to control for pseudoaccommodation Would JE, Hu A, Chen S, Glasser A. Subjective and objective measurement of human accommodative amplitude. J Cataract Refract Surg 2003; 29: 1878-88. Ostrin LA, Glasser A. Accommodation measurements in a prepresbyopic and presbyopic population. J Cataract Refract Surg. 2004; 30: 1435-44.

Purpose: To compare vision in patients with bilateral B&L Crystalens HD, and AMO Tecnis Multifocal Acrylic IOLs, after controlling for pseudoaccommodation

AMO TECNIS® Multifocal Acrylic IOL B & L Crystalens HD Hydrophopic acrylic, Refractive Index 1.47 UV-blocking 6.0 mm optic,13.0mm Overall Diameter OptiEdge design 3 piece design with PMMA haptics +5 D to +34 D in 0.5 D increments Optical power add +4.0D +3.00 at spectacle plane Full diffractive posterior surface Pupil-independent Wavefront-designed aspheric anterior surface Biosil, Refractive Index 1.427 Non UV-blocking 5.0mm optic, 11.5- 12.0 mm Overall Diameter Plate haptic design with polyimide haptics +10.0 D to +33 D in 0.5 D increments Biconvex design of optic “Proprietary optic design modification to increase depth of focus while providing a single image to the retina” Only lens to be labeled as an accommodating IOL by FDA

Methods: One surgeon, similar technique and post-op care in all cases Patients groups were taken from concurrent studies; one comparing accommodating IOLs and the other comparing multifocal IOLs Capsulorhexis greater than optic with Crystalens HD; smaller than optic with Tecnis MF Acrylic IOL Target refraction (as recommended by manufacturers) +0.25D hyperopia for B&L Crystalens HD and emmetropia for AMO Tecnis MF Acrylic

Methods: The Oculus Easygraph was used to measure the spherical aberrations of the anterior corneal surface Pupil diameter was meaured with Neuroptics Pupillometer in Crystalens HD group, and Colvard Pupillometer in Tecnis MF Acrylic group Vision tested at 8 or more weeks post-op, ensuring distance corrected for target refraction Vision tested using EDTRS charts at 4 M, 70 cm and comfortable near distance Contrast sensitivity was measured using Vector Vision CSV 1000 ANOVA used to compare readings

Patient Profile: B&L Crystalens HD AMO Tecnis Acrylic MF P value Number 10 Age (years) 67.80 +/- 4.76 69.1 +/- 8.2 0.670 Spherical Aberr. (microns) 0.281 +/- 0.100 0.259 +/- 0.073 0.594 Photopic Pupil (mm) 3.03 +/- 0.42 3.44 +/- 0.53 0.484 Mesopic Pupil (mm) 4.49 +/- 0.51 4.56 +/- 0.73 0.904 IOL Power Implanted (D) 21.93 +/- 3.60 20.11 +/- 3.08 0.257 By controlling for age, corneal spherical aberration, pupil size IOL power and astigmatism (all patients had < 1D or corneal astigmatism), pseudoaccomodation should be similar in both groups

Vision, Both Eyes Best Distance Corrected, using EDTRS Charts: B&L Crystalens HD AMO Tecnis Acrylic MF P value Vision (EDTRS) 9 Distance (4 M) 38.25 +/- 4.60 (20/20-) 37.78 +/- 6.22 0.862 Intermediate (70 cm) 63.50 +/- 8.99 (20/25-) 63.33 +/- 5.10 0.963 Near 57.38 +/- 7.07 (20/40+) 65.67 +/- 5.52 (20/25+) 0.016 The data shows that the study groups were comparable, except for the value of SA. 8

Photopic Contrast Sensitivity: The data shows that the study groups were comparable, except for the value of SA. B&L Crystalens HD AMO Tecnis Acrylic MF P value Spatial Freq. 9 3 7.50 +/- 0.76 7.11 +/- 1.54 0.527 6 7.13 +/- 1.13 6.22 +/- 2.77 0.405 12 7.00 +/- 1.93 5.44 +/- 3.47 0.280 18 6.75 +/- 1.83 5.56 +/- 2.96 0.341

Mesopic Contrast Sensitivity: The data shows that the study groups were comparable, except for the value of SA. B&L Crystalens HD AMO Tecnis Acrylic MF P value Spatial Freq. 9 3 7.38 +/- 1.06 7.11 +/- 1.97 0.740 6 6.00 +/- 2.62 5.56 +/- 2.40 0.720 12 4.50 +/- 3.82 5.44 +/- 2.70 0.561 18 3.88 +/- 2.80 4.44 +/- 2.07 0.638

Conclusions: Pseudoaccommodation was controlled as study patient parameters were similar for B&L Crystalens HD and AMO Tecnis Multifocal Acrylic IOL groups Distance and intermediate vision was similar in the two groups, but near vision was significantly better for Tecnis MF Acrylic (20/25+) vs Crystalens HD (20/40+) Quality of vision (photopic and mesopic contrast sensitivity) was similar in all groups AMO Tecnis Multifocal Acrylic IOL provides significantly better near visual acuity without any signifcant decrease in contrast sensitivity, than B&L Crystalens HD