W. A. Maxwell, MD, PhD ASCRS 2008 Comparison of the Optical Image Quality for Presbyopia Correcting IOLs using Modulation Transfer Function Testing W. Maxwell, MD, PhD California Eye Institute Fresno, California Financial Disclosure: Consultant & Travel (Alcon Research, Ltd.)

W. A. Maxwell, MD, PhD ASCRS 2008 Testing Methodology Study Objective To compare the image quality of various Presbyopia Correcting IOLs with different designs ( accommodative or multifocal; aspheric or spherical) using the modulation transfer function (MTF) testing method and U.S. Air Force 1951 Resolution Target (AFT) testing Modulation Transfer Function (MTF) Testing Objective method of measuring image contrast degradation at different spatial frequencies 1 Modified ISO model eye The standard ISO Model Eye 1 configuration incorporates a 35 mm doublet lens to converge light to simulate the refractive power of a human cornea The model cornea in the ISO Model Eye is an aberration free lens, and is not representative of a typical human cornea with its inherent positive spherical aberration Thus, a modified ISO model eye, representing an average human cornea, was used in this study Study Objective To compare the image quality of various Presbyopia Correcting IOLs with different designs ( accommodative or multifocal; aspheric or spherical) using the modulation transfer function (MTF) testing method and U.S. Air Force 1951 Resolution Target (AFT) testing Modulation Transfer Function (MTF) Testing Objective method of measuring image contrast degradation at different spatial frequencies 1 Modified ISO model eye The standard ISO Model Eye 1 configuration incorporates a 35 mm doublet lens to converge light to simulate the refractive power of a human cornea The model cornea in the ISO Model Eye is an aberration free lens, and is not representative of a typical human cornea with its inherent positive spherical aberration Thus, a modified ISO model eye, representing an average human cornea, was used in this study Ref 1: ISO Ophthalmic implants – Intraocular lenses – Part 2 Optical properties and test methods, 2000.

W. A. Maxwell, MD, PhD ASCRS 2008 The optical bench setup Pinhole Target IOL Light Source CCD Camera Optikos Video MTF measurement system 1024 element detector, a 550 nm narrow band filter, and a 20X microscope objective IOLs were mounted in a lens holder under 10 mm of compression, and aligned on the optical axis in a wet cell filled with deionized (DI) water at 35 ± 2 °C with the anterior side of the IOL facing the incident light 3 and 5 mm apertures used to simulate pupil size Green light illuminates a single slit object located on the front focal plane of a 180 mm collimator The collimated light passes through the model cornea and IOL system that simulates the vergence of a human eye Optikos Video MTF measurement system 1024 element detector, a 550 nm narrow band filter, and a 20X microscope objective IOLs were mounted in a lens holder under 10 mm of compression, and aligned on the optical axis in a wet cell filled with deionized (DI) water at 35 ± 2 °C with the anterior side of the IOL facing the incident light 3 and 5 mm apertures used to simulate pupil size Green light illuminates a single slit object located on the front focal plane of a 180 mm collimator The collimated light passes through the model cornea and IOL system that simulates the vergence of a human eye MTF Bench IOL Models Tested  ReSTOR SN6AD3 (Aspheric)  ReSTOR SA60D3 (Spherical)  Tecnis ZM900  Acri.Lisa 366D  ReZoom NXG1  Crystalens AT-50SE

W. A. Maxwell, MD, PhD ASCRS 2008 Modulation Transfer Function 5 mm Aperture, Distance Focus Spatial Frequencies of 0 to 100 lp/mm Frequency (lp/mm) MTF %

W. A. Maxwell, MD, PhD ASCRS 2008 Modulation Transfer Function 5 mm Aperture, Distance Focus, Discrete frequency of 100 lp/mm

W. A. Maxwell, MD, PhD ASCRS 2008 Modulation Transfer Function 5 mm Aperture, Distance Focus, Discrete frequency of 50 lp/mm

W. A. Maxwell, MD, PhD ASCRS 2008 MTF of ReSTOR ® & ReSTOR ® Aspheric IOLs 3 mm Aperture

W. A. Maxwell, MD, PhD ASCRS 2008 Modulation Transfer Function 3 mm Aperture, Distance Focus, Discrete frequency of 100 lp/mm

W. A. Maxwell, MD, PhD ASCRS 2008 Modulation Transfer Function 3 mm Aperture, Distance Focus, Discrete frequency of 50 lp/mm

W. A. Maxwell, MD, PhD ASCRS 2008 U.S. Air Force 1951 Resolution Target Test (AFT) Optikos Optical Testing System as described for the MTF test The setup for the AFT test was identical to that of the MTF test, except the single slit object was replaced with the AFT An image of the AFT was photographed through each IOL The AFT test includes paired 3-bar target sets used to qualitatively measure resolution efficiency U.S. Air Force 1951 Resolution Target Test (AFT) Optikos Optical Testing System as described for the MTF test The setup for the AFT test was identical to that of the MTF test, except the single slit object was replaced with the AFT An image of the AFT was photographed through each IOL The AFT test includes paired 3-bar target sets used to qualitatively measure resolution efficiency

W. A. Maxwell, MD, PhD ASCRS 2008 U.S. Air Force 1951 Resolution Target test 5 mm Aperture, Distance Focus Crystalens AT-50SE ReSTOR Spherical SA60D3 ReSTOR Aspheric SN6AD3 Tecnis ZM900 ReZoom NXG1 Acri.Lisa 366D

W. A. Maxwell, MD, PhD ASCRS 2008 Conclusions The AcrySof ReSTOR SN6AD3 aspheric IOL produced the highest overall image quality for MTF and AFT testing compared to several presbyopia- correcting IOLs The Acri.Lisa IOL produced the second highest optical quality, while the ReZoom IOL had the lowest optical quality Clinical investigation is needed to determine whether superior IOL optical quality demonstrated in optical bench testing results in measurable visual improvements in clinical practice The AcrySof ReSTOR SN6AD3 aspheric IOL produced the highest overall image quality for MTF and AFT testing compared to several presbyopia- correcting IOLs The Acri.Lisa IOL produced the second highest optical quality, while the ReZoom IOL had the lowest optical quality Clinical investigation is needed to determine whether superior IOL optical quality demonstrated in optical bench testing results in measurable visual improvements in clinical practice