1. Effect of Ocular Deviation on Pupil size with Implanted Multifocal Intraocular Lens Yoshihiko Iida, MDKimiya Shimizu, MD Misae Ito, CO Kitasato University The authors have no Financial Interest.

2. Department of Ophthalmology Kitasato University School of Medicine Background Multifocal intraocular lenses(IOL) are increasingly used to correct presbyopia. We experienced unsatisfactory results in a patient who underwent bilateral implantation of refractive multifocal IOLs, and considered that ocular deviation may influence pupil size. We report a patient with unsatisfactory results, and evaluate the effect of ocular deviation on pupil size using implanted IOLs.

3. Department of Ophthalmology Kitasato University School of Medicine 54-year old female Preoperative data : Vd = 0.04 ( 0.3 x -5.00 Vs = 0.04 ( 0.4 x -6.00 ) ( ) Cyl-1.00 Ax 80 ) Hirschberg : orthophoria Alternate prism cover test : 14 ⊿ X’(Near), 4 ⊿ X (Far) Pupil size (monocular vision) : R) 4.0 mm,L) 4.4 mm 1. Case report Selected the use of refractive multifocal IOL (APCT)

4. Department of Ophthalmology Kitasato University School of Medicine Near 2.1 mm 3.4 mm Far Implanted refractive multifocal IOL Bil) PEA + IOL was performed IOL : Array SA40N (AMO) L) 12.0 D IOL design R) 11.5 D

5. Department of Ophthalmology Kitasato University School of Medicine Course Far : Vd = 1.2 x IOL At 3 months postop. BV = 1.2 x IOL Vs = 1.2 x IOL Near : BV = 0.4 x IOL Vd = 1.0 x IOL Vs = 0.9 x IOL Binocular uncorrected visual acuity(UCVA) was worse than monocular UCVA. APCT : 16 ⊿ X’(Near) With spectacle lenses of 3Δ base-in to each eye BV = 1.0 x IOL Binocular near UCVA was improved.

6. Department of Ophthalmology Kitasato University School of Medicine 1) Far vision / Binocular FarBV = 1.2 x IOL 2.8 mm 2) Near vision / Monocular Vd= 1.0 x IOL Vs= 0.9 x IOL 3.1 mm Evaluation of the Pupil size (1)

7. Department of Ophthalmology Kitasato University School of Medicine 3) Near vision / Binocular NearBV = 0.4 x IOL 2.4 mm Evaluation of the Pupil size (2) 2) Near vision / Monocular Vd= 1.0 x IOL Vs= 0.9 x IOL 3.1 mm

8. Department of Ophthalmology Kitasato University School of Medicine Evaluation of the Pupil size (3) 3) Near vision / Binocular NearBV = 0.4 x IOL 2.4 mm 4) Near vision / Binocular + 3 ⊿ base in NearBV = 1.0 x IOL 2.7 mm

9. Department of Ophthalmology Kitasato University School of Medicine 4 8 12 14 Exophoria angle( ⊿ ) 0 0 1 2 3 4 5 Pupil diameter (mm) p=0.0017, R 2 = 0.4679 Pupil diameter was negatively correlated with exphoria angle. n=17 Dominant eye 2. Effect of ocular deviation on pupil size in near vision 17 exphoric patients implanted with IOL Near vison

10. Department of Ophthalmology Kitasato University School of Medicine Binocular NearBV = 0.4 Binocular + 3 ⊿ base in NearBV = 1.0 Near : 3.4 mm Discussion Far : 2.1 mm pupil diameter 2.4 mm pupil diameter 2.7 mm With spectacle prism lenses for the decrease of exophoria angle, the pupil diameter was increased and the binocular near UCVA was raised.

11. Department of Ophthalmology Kitasato University School of Medicine Exophoria Discussion When large exophoria angle, excess miosis might be caused by fusional convergence. Poor near visual acuity with refractive multifocal IOL. Orthophoria convergence miosisexcess miosis

12. Department of Ophthalmology Kitasato University School of Medicine Conclusions Ocular deviation affects pupil size. Ocular deviation is an important factor in the selection of patients with refractive multifocal IOLs.