1. Unilateral Implantation of Presbyopic Correcting IOLs – A Comparison of ReZoom, ReSTOR, Crystalens 5.0, and Crystalens HD Frank A. Bucci, Jr, MD Bucci Laser Vision Institute Wilkes Barre, PA - USA No Financial Interest

2. Purpose: To evaluate pt. satisfaction & the visual outcome of 295 pts. having received either 1 ReZoom (RZ), 1 ReSTOR (RS), 295 pts. having received either 1 ReZoom (RZ), 1 ReSTOR (RS), 1 Crystalens-5.0 (CR-5.0), or 1 Crystalens HD (CR-HD) for the 1 Crystalens-5.0 (CR-5.0), or 1 Crystalens HD (CR-HD) for the correction of presbyopia correction of presbyopia KPE KPE RL RL Hyperopic Myopic Emmetopia ReZoom ReZoom8058 25% 39% 36% 25% 39% 36% ReSTOR ReSTOR2125 39% 26% 35% 39% 26% 35% CR- 5.0 CR- 5.03512 40% 45% 15% 40% 45% 15% CR-HD CR-HD4717 23% 47% 30% 23% 47% 30% Methods:

3. ReZoomReSTOR CR 5.0 CR HD CR HD n = 138 n = 46 n = 47 n = 64 Mean Age 57596061 SCVA (preop) 20 / 315 20 / 126 20 / 279 20 / 329 SCVA (post op) 20 / 28 20 / 29 20 / 43 20 / 37 Sph.Equiv. (postop) - 0.21 0.19 - 0.52 - 0.66 Near mean J mean J2.01.63.22.7 Intermediate3.64.03.02.8 Results Unilateral Presbyopic IOLs

4. June 05 -- December 05 46 ReSTOR implanted Subjective Response of Patients - High % of pts. Very Disappointed Subjective Response of Patients - High % of pts. Very Disappointed poor inter. (no computer vision) perceived near focal point too close poor inter. (no computer vision) perceived near focal point too close generalized waxy vision at all focal points generalized waxy vision at all focal points SUBTLE, but distinct loss of UDVA & BCDVA dist. acuity SUBTLE, but distinct loss of UDVA & BCDVA dist. acuity Poor Patient Satisfaction - Vaseline Vision Dysphotopsia Poor Patient Satisfaction - Vaseline Vision Dysphotopsia 3/46 Eyes ( 6.52 %) 3 emmetropic lensectomy pts. 3/46 Eyes ( 6.52 %) 3 emmetropic lensectomy pts. mean age = 50 years 3 explantations (exchanged for 3 ReZoom) mean age = 50 years 3 explantations (exchanged for 3 ReZoom) Overall Outcomes Overall Outcomes Consistent objective data Very poor subjective responses Consistent objective data Very poor subjective responses Final Outcome Final Outcome Use of ReSTOR 4.0 as unilateral IOL Abandoned Use of ReSTOR 4.0 as unilateral IOL Abandoned

5. January 06 – January 08 138 ReZoom Implanted Subjective Response of Patients High % of patients very satisfied High % of patients very satisfied pleased with distance vision (esp. during the day) pleased with distance vision (esp. during the day) pleased with enhanced intermediate vision pleased with enhanced intermediate vision gained substantial amounts of reading gained substantial amounts of reading non haloed image in opposite eye at night with CL or emmetropia non haloed image in opposite eye at night with CL or emmetropia Pearls for Success Careful Pre op Counseling Careful Pre op Counseling avoided disappointments re: need for reading glasses for fine print avoided disappointments re: need for reading glasses for fine print avoided disappointments re: need of neuroadaptation for halos at night avoided disappointments re: need of neuroadaptation for halos at night Less halos and more rapid neuroadaptation observed with Less halos and more rapid neuroadaptation observed with ReZoom vs. Array ReZoom vs. Array

6. Success is dependent upon 3 key factors as observed with bilateral presbyopic IOLs as observed with bilateral presbyopic IOLs Knowledge of and efficient placement of PC IOL Knowledge of and efficient placement of PC IOL Strong Dr. Communication skills to facilitate Strong Dr. Communication skills to facilitate ▪ proper pt. selection ▪ proper pt. selection ▪ effective pre op counseling ▪ effective pre op counseling ▪ management of post op expectations ▪ management of post op expectations Aggressive reduction in residual refractive errors Aggressive reduction in residual refractive errors Discussion

7. Discussion ReZoom Discussion ReZoom ReZoom was successful as a unilateral Broad range of vision Broad range of vision ▪ distance ▪ intermediate ▪ near ▪ distance ▪ intermediate ▪ near Pre op counseling was provided on the need for Pre op counseling was provided on the need for patience with neuroadaptation for halos patience with neuroadaptation for halos Unilaterally, need for neuroadaptation much less Unilaterally, need for neuroadaptation much less because of the non-haloed image in opposite eye because of the non-haloed image in opposite eye Conversion to bilateral with TMF diffractive has Conversion to bilateral with TMF diffractive has been shown to be very successful, if necessary been shown to be very successful, if necessary

8. TMF may be successful as a unilateral diffractive TMF may be successful as a unilateral diffractive multifocal IOL, even though the ReSTOR failed multifocal IOL, even though the ReSTOR failed European data 1,2,3 has shown superior intermediate European data 1,2,3 has shown superior intermediate vision for TMF vs. RS vision for TMF vs. RS Outstanding near vision in both moderate and Outstanding near vision in both moderate and bright light bright light Wider near focal range vs. RS Wider near focal range vs. RS No waxy vision No waxy vision 1 Scheider A., et al, European Society of Cataract and Refractive Surgery, 2006 2 Toto, L., et al, Journal of Cataract and Refractive Surgery, 2007 3 Hutz, W., et al, Journal of Cataract and Refractive Surgery, March 2008 Discussion TECNIS Multifocal Discussion TECNIS Multifocal

9. Discussion Crystalens Excellent distance with no halos at night Excellent distance with no halos at night the only lens with entirely no light phenomenon at night the only lens with entirely no light phenomenon at night Excellent intermediate in high percentage Excellent intermediate in high percentage note that the mean J intermediate for CR-HD is better than RZ note that the mean J intermediate for CR-HD is better than RZ but it has a higher variance and some patients may lack minimal but it has a higher variance and some patients may lack minimal intermediate intermediate Improved near Improved near note that the CR-HD has one half J line improved near note that the CR-HD has one half J line improved near vision compared to the CR- 5.0 without influencing quality vision compared to the CR- 5.0 without influencing quality of distance of distance

10. Unfortunately, even with the improved near (J 2.7 vs. 3.2 ) Unfortunately, even with the improved near (J 2.7 vs. 3.2 ) and intermediate (J 2.8 vs. 3.0 ) vision of the CR-HD and intermediate (J 2.8 vs. 3.0 ) vision of the CR-HD compared to the CR -5.0 compared to the CR -5.0 A significant % of patients would still be less than A significant % of patients would still be less than satisfied at near unless some degree of monovision satisfied at near unless some degree of monovision was pursued with sacrificing of distance vision was pursued with sacrificing of distance vision There is also significantly less predictability with all There is also significantly less predictability with all Crystalens for both distance and near targets which Crystalens for both distance and near targets which would be more accentuated when used unilaterally would be more accentuated when used unilaterally Conversion to bilateral with TMF would likely be very Conversion to bilateral with TMF would likely be very successful successful Discussion Crystalens

11. Discussion ReSTOR Discussion ReSTOR One would expect the ReSTOR 3.0 with improved intermediate and a more comfortable focal point to function better than the ReSTOR 4.0. However, the ReSTOR 3.0 still reads poorly in dim light. Thus if a surgeon is considering a diffractive IOL, the TECNIS multifocal with excellent near vision at all levels of light (and pupil size) should be the lens of choice.

12. Conclusions / Final Comments 1. With proper preop counseling and surgical planning all of the current presbyopic IOLs (except the ReSTOR 4.0) can work well for reducing the patients dependency on glasses (except the ReSTOR 4.0) can work well for reducing the patients dependency on glasses or contact lenses. or contact lenses. 2. Strengths and weaknesses of each IOL are obviously similar to what is observed in bilateral circumstances. The RZ has the broadest range of vision observed in bilateral circumstances. The RZ has the broadest range of vision which is an important “unilateral” characteristic, but less halos would be which is an important “unilateral” characteristic, but less halos would be ideal. Conversion to RZ/TMF is synergistic, and powerful. ideal. Conversion to RZ/TMF is synergistic, and powerful. 3. On average, unilateral results for the CR-HD are encouraging with no halos being a plus. Conversion to bilateral with TMF is very synergistic and a solution to being a plus. Conversion to bilateral with TMF is very synergistic and a solution to the 30 % that are ≤J 4 at near because of a wide variance in results. the 30 % that are ≤J 4 at near because of a wide variance in results. 4. Even though RS 3.0 will be an improvement to RS 4.0, the TMF will be the 4. Even though RS 3.0 will be an improvement to RS 4.0, the TMF will be the diffractive lens of choice with excellent near vision in all lighting conditions. diffractive lens of choice with excellent near vision in all lighting conditions. TMF could likely become the unilateral presbyopic lens of choice. TMF could likely become the unilateral presbyopic lens of choice.

13. Thank You Thank You