Cataract Surgery IOL Selection- What to Ask and What to Tell Patients

1. IOL Selection
What to Ask and What to Tell
Dr. Inderjit Singh FRCS(London),FRCOPTH ,FRANZCO
Chatswood Eye Centre
Suite 5, 16-18 Malvern Av, Chatswood
Tel 94114877
1

2. IOL what to ask
What is your Ultimate Goal
• 72yr old very fit lady with visually significant
cataracts – surgery discussed, straight forward
consult for cataract surgery and IOL to improve
visual function
• but pt also mentions that she travels frequently,
• And her next trip =

3. CATARACT SURGERY- THE
CONVERGENCE
• The pt’s visual goal
• The surgeon’s expertise with technique and use
of IOLS – need a variety of IOLs, one fits all not
possible;
• Predictable results = <2.2mm astigmatic neutral
incision; consistent round central capsulorhexis
for consistent central IOL position
• The technology – improvements of IOL design.
Better understanding of visual optics

4. The Best IOL choice for outcomes and pt
satisfaction
 Visual quality- all about vision with good contrast
 Pts expectations and pt selection (co morbidities)
 Pts visual needs
 IOL technology that can deliver above – keep up with IOL technology
 Surgeons experience with IOL technology
 Pt selection - every pt is different – not a cookie cutter answer; pts
near and intermediate va can differ - mobile phone, book, computer
screen,dashboard
 Neural adaptation - visual cortex has to adapt to multifocal IOLs or
monovision
 Binocular summation- 2 eyes with good distance vision have 40%
better binocular contrast sesitivity compared to monocular vision

5. Choosing an IOL what to ask
• Mary 72 yr- needle work without
glasses,happy to wear glasses for distance
• Fred 69yr-car enthusiast loves driving , wants
to see as well as possible at night
• Jack 55yr- keen golfer/ surfer- wants distance
and some near vision, glasses for reading
• Esther 68yr- traveller camper hiker near and
distance vision without glasses

6. AGEING EYES, CHANGING VISIONAGEING EYES, CHANGING VISION
 Increased ocular densities
 Blue end of visible spectrum filtered out
 Older lens absorbs 1000x>at 400nm
 Increased higher order aberrations
 Scatter due to cataract formation causing glare
disability (? MVA)
 Decreased cone sensitivity-25% for each decade
starting at adolescence
 Neural losses

7. The Ageing Eye
For Glasses free high quality vision vision = Removal
of cataract +correction of aberrations of the eye
• Lower order aberrations
• Higher order aberrations
Distortion of wavefront of
light when it passes
through eye with
irregularities of its
refractive components-
tear film,cornea,lens

8. Visual Function Test- VF7Visual Function Test- VF7
•Reading signs – traffic,street,store
•Seeing steps,stairs,or curbs
•Watching TV
•Night driving
•Reading small print
•Doing fine handiwork
•Cooking

9. Lower order aberrations
have familiar names
• Myopia Astigmatism-87%ofcat pt
• 33
•
Hypermetropia

10. Proper technique has advantages
over Femtosec laser assisted
cataract surgery
Correction of lower order aberrations

11. Higher Order Aberrations
spherical Aberration is the most prevalent HOA in humans
•Higher-order
aberrations comprise many
varieties of aberrations. Some of
them have names such as coma,
trefoil and spherical aberration, but
many more of them are identified
only by mathematical expressions
(Zernike polynomials). They make
up about 15 percent of the total
number of aberrations in an eye.
•Order refers to the complexity of
the shape of the wavefront
emerging through the pupil — the
more complex the shape, the
higher the order of aberration.

12. Light ScatterLight Scatter
Earlier Cataract Operations(4)Earlier Cataract Operations(4) There are two kinds of light—the glow thatThere are two kinds of light—the glow that
illuminates and the glare that obscures.illuminates and the glare that obscures. James ThurberJames Thurber

13. 15

14. The ageing eye- spherical aberration
Increased higher
order aberrations-
mainly 3rd
– coma
4th
order- spherical
aberration
If an aberration
can be measured it
can be corrected
Positive spherical aberration is
produced when peripheral rays deviate
and cross in front of the retinal plane.

15. Wavefront Aberrometer

16. Spherical aberration with age
as lens ages its positive aberration increases and total optical
system aberration increases ; contrast decreases;
PUPIL DEPENDENT the fix = use aspherical IOL
The crystalline lens before age 20 (in
blue) generates little SA due to a flat
anterior surface and thin optic. Beyond age
20 (in red), the anterior surface becomes
more spherical (oblate) and induces
increasing amounts of SA

17. • Using aspheric IOL
improves driving
particularly
evident on
nighttime
simulation testing,
in which up to a
45-foot advantage
in stopping
distance at 55
mph (88.51 km/hr)
can be achieved.

18. Different IOLs can be used to offset different
amounts of spherical aberration

19. Refractive cataract surgery
1.Restore transparency of ocular media i.e remove
opaque lens
2.Accurately correct any refractive aberrations of the
eye - myopia,hyperopia
3.Correct astigmatism
4.Reduce spec dependence
5. 1+2+3+4 = predictable stable visual outcome
6.WHAT ABOUT NEAR VISION

20. MULTIFOCAL IOLs
refractive,diffractive,bifocal optics

21. What To Tell
Multifocal IOLs – we have the technology to
somewhat turn the clock back !
Spectacle free distance and near vision
•94% spectacles free (3 mnths)
•6% used glasses for specific dim light tasks
•8% c/o visual disturbances in the 1st
week.
•40% noticed some visual symptoms when asked –
not intolerable
•None of the symptoms were severe enough to
explant IOL
•All of pts would recommend IOL

22. WHAT TO TELL – more important to tell
THE DISADVANTAGES OF MULTIFOCALS
• All MF have some optical disadvantages
• Light entering the eye through a MF is split into
more then one focal point
• Halos , glare, decreased contrast sensitivity at
night,negative and positive dysphotopsia
• MF not suitable for night drivers
• Pt with any other ocular comorbidities will notice
these more readily – dry eye,AMD
• Intermediate distance va (computer) poor

24. What To Tell
The New Multifocal Family- “Multifocal Light”
for the active elderly
• Good distance va
• Less halos,glare
• Contrast sensitivity
effected less
• Intermediate distance
va better
• Still have acceptable
near va
• But need glasses for
reading fine print
• Oculentis comfort ReStore +2.5
• Zeiss Lisa
Trifocal

25. Multifocal “Light”
Refractive Diffractive( ReStor +2.5) ;
Bifocal (Oculentis Comfort)
• 50 pts=57-87yrs(65-87)
• All wanted to spectacle free for distance ,driving,golf,sailing,touring
• Wanted some reading vision (computer work) , willing to wear glasses for
fine print reading
• UCDVA= 6/9-6/4(94%6/6 or better)
• UCNVA= N8-N5 (44%N8)
• All were Toric IOLs except 8 eyes
• 10% noticed visual disturbance in 1st
week
• 6% noticed halos,glare (at night) but not intolerable
• No explants

26. What To Tell –
Contraindications of Multifocal IOL s
Ocular Co Morbidities
• Dry eye condition
• AMD- wet or dry or pre AMD (drusen)
• Diabetic macular oedema and retinopathy
• Irregular astigmatism
• Previous corneal surgery (Lasik)

27. ACRYSOF ReSTOR +2.5
• 50 pts=57-87yrs(65-87)
• All wanted to spectacle free for distance ,driving,golf,sailing,touring
• Wanted some reading vision (computer work) , willing to wear glasses for
fine print reading
• UCDVA= 6/9-6/4(94%6/6 or better)
• UCNVA= N8-N5 (44%N8)
• All were Toric IOLs except 2 eyes
• 10% noticed visual disturbance in 1st
week
• 8% noticed halos,glare (at night) but not intolerable
• No explants

28. Continual quest for high quality correction
Ophthalmologists and their patients are continually striving for high quality
vision correction. Perhaps the television industry and Apple has set the
bar even higher with the successful introduction of HDTV and retinal
image IPad, which has verified patients’ (and their visual cortex’s) strong
desire for a level of correction beyond lower order sphere and cylinder.
This patient desire along with the increasing role of wavefront science in
vision and eye care have produced a growing understanding and clinical
awareness of the role of HOAs, specifically fourth order SA and its
relationship to the pupil.
SA is the most prevalent HOA in human vision and thus must be
addressed in any efforts toward high quality vision correction. Its objective
magnitude and subjective effects on vision are directly related to pupil
diameter and, thus, that relationship must be addressed in the
measurement and correction of SA. While such measurements have been
effectively achieved and will continue to advance through the ever
increasing sophistication of wavefront aberrometry, the correction of SA
and its relationship to the pupil will present unique challenges, some of
which have already been addressed with developing

29. Continual Quest for high quality vision by
Ophthalomolgist and the patient
• Perphaps introduction of HDTV ,iPad with retina
display are setting the bar even higher for vision
correction
• This has verified pts (and their visual cortex) strong
desire for correction beyond lower order sphere and
cylinder
• Increasing role of wavefront science in identifying
HOAs that can be corrected (SA) to achieve high
quality vision.
• This playing increasing part in IOL design and use

30. Cataract Surgery With Implantation of an Artificial Lens
Thomas Kohnen, Prof. Dr. med.,1,2,*
Martin Baumeister, Dr. med.,1
Daniel
Kook, Dr. med.,3
Oliver K. Klaproth, Dipl.-Ing. (FH),1
and Christian Ohrloff,
Prof. Dr. med.
• The main criterion for the success of cataract surgery, aside for an
uncomplicated course of the procedure itself, is the long-term visual
result. The most commonly evaluated endpoints are high-contrast visual
acuity and the residual refraction deficit at the visual distances for which
the implanted lens is intended (6, 21). The expression “quality of vision”
has been coined in view of the fact that high-contrast visual acuity,
though it can be measured simply and quickly, is not a fully adequate
measure of the complex phenomenon of visual perception (e33, e34).
Quality of vision is the patient’s ability to see well in the context of his or
her own individual visual requirements (e35). Various objective and
subjective measures are used to determine the quality of vision (6, 22).