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Dr. Jason E. Compton O.D.
The Right Contact, Inc.
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Vision Changes
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Major Age Related Diseases
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Structural Changes
◦ Presbyopia
◦ Cataracts
◦ Macular Degeneration
◦ Glaucoma
◦ Diabetic Retinopathy
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Pupil Size
Dry Eyes
Lid laxity
Loss of peripheral vision
Decrease Color Vision
Vitreous Detachments
TREAT
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During cataract surgery, your eye's natural
lens is removed and replaced with an IOL.
Standard monofocal IOLs probably will give
you great distance vision
Many times… patients require glasses after the procedure
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Available IOL Technology:
◦ Toric IOLs
◦ Presbyopic IOLs
 Multifocal
 Accommodating
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These options are considered PREMIUM
because they can provide a better visual
outcome after cataract surgery than a
standard IOL.
◦ Staar Toric IOL (Staar Surgical)
Available in two powers
 Silicone Material
 Up to 3.5D.
Staar Toric IOL
FDA Approval – 1998
◦ Acrysof Toric IOL (Alcon)
Corrects 1.5D to 3.0D astigmatism
 Acrylic Single Piece Lens
 Increased Stability
Acrysof Toric IOL
FDA Approval – 2005
◦ Acrysof IQ Toric IOL (Alcon)
Corrects 1.5D to 6.0D astigmatism
 Enhanced Aspheric optics
 UV blocker
Acrysof IQ Toric IOL
FDA Approval – 2009
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Powers Range
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Effective Power
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Accurate Measurements
◦ -1.50D to -6.00D
◦ up to -4.11D
◦ Lenticular / Refractive / Corneal
cylinder measurements
 Keratometry
 Topography
 Toric Calculator
The AcrySof® Toric IOL Calculator is an easy-to-use,
highly accurate tool that helps surgeons to select the
appropriate IOL model and provides recommended axis
placement of the IOL in the capsular bag
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Stability of the bag is in question
◦ An unstable capsular bag with pseudoexfoliation.
◦ In these patients, the lens may rotate once implanted,
altering the patient’s vision.
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Corneal topography shows anything other than the "bow-tie"
pattern of regular astigmatism
◦ A toric IOL will probably not treat astigmatism successfully if the cornea is
irregular
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Toric
◦ Staar
◦ Acrysoft
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Presbyopia
◦ Multifocal IOLs
 ReZoom (Abbott Medical Optics)
 AcrySof ReSTOR (Alcon)
 Tecnis (Abbott Medical Optics).
◦ Accommodating IOLs
 Crystalens (Bausch + Lomb)
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Since the mid 1980s, dozens
of FDA trials have examined
the efficacy and safety of
presbyopia-correcting IOLs.
Many early lenses
demonstrated only moderate
patient satisfaction.
Today’s advanced and
extensively tested technologies
are yielding outstanding
postoperative outcomes.
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Multifocal IOLs
Use technology called diffractive and refractive optics.
This design provides both a distance and near focus
at all times. Your brain will learn to automatically
select the focus that is required at that time.
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Accommodating IOLs
This design mimics the movement of the natural crystalline
lens of the eye. Accommodating IOLs are able to move
and/or change shape inside the eye to allow focus at
multiple distances.
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Second-generation, refractive
multifocal lens.
Aspheric transitions between
zones provide intermediate
vision
+3.50D at IOL plane
+2.85D at the spectacle
plane
Previously the ReZoom was
considered the strongest
multifocal IOL for enhancing
intermediate vision, but now
it has competition…
FDA approval in March 2005
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Uses an aspheric optic
design to offset the
spherical aberration of the
cornea.
+4.00 at the IOL plane
According to FDA data,
the Tecnis Multifocal IOL
provides both good near
and distance vision.1
 Study found patients’ reading
speeds to be 175 words per
minute in bright light and
142 words per minute in low
light.
FDA approval in January 2009
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Most frequently implanted
presbyopia-correcting IOL for
cataract patients worldwide
since 2005
Its design is based on the
optical principle of
apodization—a series of
graduated steps that result in
diffraction of light
ReSTOR 4.0
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ReSTOR 3.0
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◦ +4.00 Add at the IOL plane
◦ +3.00 Add at the IOL plane
◦ +2.50 Add at the spectacle plane
The result is ability to focus on
items at distance, intermediate,
and near.
FDA approval in March 2005
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Multifocal IOLs
1.ReZoom (Abbott Medical Optics)
2.AcrySof ReSTOR (Alcon)
3.Tecnis (Abbott Medical Optics).
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Accommodating IOLs
1.Crystalens (Bausch + Lomb)
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First and only FDA-approved
accommodating IOL
Designed to move within the
eye, to provide focusing at
all distances.
Crystalens HD’s haptic acts
as “hinge” that allows the
lens to move forward and
flex secondary to vitreous
pressure during
accommodation.
Aberration Free
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Multifocal IOLs
• These designs work because the brain learns to select the appropriate zone to
"look" through to provide sight at near, intermediate or far ranges.
• Diffractive multifocal IOLs, are great for distance and near vision, but are not
optimal for intermediate distance and may cause minor amounts of distortion.
• Major drawback is low contrast sensitivity.
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Accommodating IOLs
• With one focusing zone it is less likely than multifocal IOLs to produce visual side
effects for distance vision such as night vision problems including glare and halos.
• At long distance, it is possible that vision may be crisper with accommodating IOLs.
• May not provide as much of a range of focus (near to far) as multifocal IOLs, and
this might lead to the need for reading glasses.
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Toric
◦ Staar
◦ Acrysoft
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Presbyopia
◦ Multifocal IOLs
 ReZoom (Abbott Medical Optics)
 AcrySof ReSTOR (Alcon)
 Tecnis (Abbott Medical Optics).
◦ Accommodating IOLs
 Crystalens HD (Bausch + Lomb)
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Getting involved in
cataract procedure
presents a great
opportunity for the
doctor/patient relationship
Layout the options but
make a recommendation
Who knows more about
the refractive status, eye
health and complete eye
care of the patient than
the optometrist?
A patient who reads a lot of
paperback novels may be a
better candidate for the ReSTOR,
while a heavy computer user
might be best served with a
Crystalens.
Standard vs Premium IOL
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The final decision should
be made between the
patient and the
optometrist, and then that
decision should be
communicated to the
surgeon.
◦ Obviously this may be altered
by the surgeons
recommendations but having
the patient already informed
about their options is always
welcome.
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Good candidates are generally
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Patient must be aware of the cost of cataract surgery
involving premium lenses.
◦ Easy-going
◦ Realistic in their expectations
◦ Willing to accept a few tradeoffs
◦ While most Medicare and private insurance will cover basic
cataract surgery costs, you still will need to pay out-of-pocket the
extra price of "premium" IOLs that are considered cosmetic and
not medically necessary. These costs can be as high as $2,500 per
eye.
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Several factors determine the IOL that best suits each
patient. These include the patient’s occupation, hobbies,
daily activities, pupil size and retinal health.
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Clean Ocular Surface
◦ All of these common conditions must be addressed prior to multifocal IOL
implantation to maximize patient outcomes.
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Dry eye
Blepharitis
Allergies
Pathology
◦ Anterior segment
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Pterygium
Corneal Abnormalities
Chalazion
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Epiretinal membrane
Macular Degeneration
Glaucoma
Etc.
◦ Posterior segment
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Understanding Astigmatism
◦ Keratometry
◦ Topography
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Always mention glare and halos.
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Nothing’s ever going to work as well as
the natural accommodation system
◦ Remind them of their current cataract
symptoms of glare and halos, and that they
may continue to see halos at night postsurgically, but to a much lesser extent.
◦ Remind them this is the best available
technology at this time.
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They may occasionally need a pair of
glasses from time to time.
◦ Especially when reading for long periods of
time or in dim illumination
• The Optometrist should be able to recognize potential problems
and be prepared for the possibility of other necessary surgeries.
• These extra procedures should not be viewed as a complication of
cataract surgery but as part of the process in obtaining good vision.
• An Optometrist who is vigilant before and after surgery plays a
major role in IOL surgery success!
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LRI (Limbal Relaxing Incision)
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LASIK or PRK
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Piggyback IOLs
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IOL exchange
◦ This performed by making a pair of deep incisions at the corneal limbus, anterior to
the vascular arcade. The length and placement of the incision is dependent upon the
axis and amount of astigmatism. LRIs work well if the spherical equivalent is close to
plano, and the astigmatism is under two diopters.
◦ Postoperatively, if the patient has residual myopia, hyperopia or astigmatism—may
be a candidate for a touch-up LASIK or touch-up PRK.
◦ This procedure can correct small or large spherical refractive errors after cataract
surgery, but they are rarely utilized.
◦ Replacement of the IOL is always the last resort
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AcrySof IQ ReSTOR Multifocal Toric The company has said that it plans to
file a pre-market application with the FDA in early 2012 for possible U.S.
approval.
The At Lisa Toric Multifocal IOL. An aspheric, toric, diffractive bifocal IOL that
corrects combined refractive errors.
Synchrony Dual-Optic Accommodating IOL. This is a dual-optic system.
When the ciliary body is relaxed, the optics remain close together for
distance vision. When the ciliary body contracts, the optics move apart, which
increases lens power and provides optimum near acuity.
Tetraflex Accommodating IOL. Tetraflex (Lenstec, Inc) has two haptics and
moves anteriorly secondary to vitreous pressure. This action, in turn,
enhances near acuity.
The NuLens Accommodating IOL (NuLens Ltd.) Stated as having potentially
up to 10 diopters of accommodation for a wider range of focus, compared to
only about two diopters provided by currently approved IOLs.
FluidVision Accommodating IOL (PowerVision) uses fluid-based mechanics to
change its shape in response to the movement of eye muscles. The lens is in
the early stages of human clinical trials, but so far appears capable of
providing more than 5 diopters of accommodation.
The Light Adjustable Lens. The Light Adjustable Lens is comprised of a
photosensitive silicone material that can be postoperatively reshaped with
ultraviolet light to correct any residual refractive error.
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Vision Changes
◦ Cataracts
◦ Presbyopia
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Historically, multifocal contact lenses have
been perceived as complex and providing
limited success.
But the truth is, they are relatively easy to fit,
enjoy higher—if not much higher—success
rates compared to 10 to 20 years ago
Multifocal lenses represent the best option
for the majority of presbyopic patients who
are interested in contact lens wear.
Alternating
Simultaneous
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Diffractive
Aspheric
Concentric
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Diffractive designs
◦ Diffractive lenses utilize concentric phase plates to
diffract light.
◦ This lens design induces significant ghosting of
images.
Due to these limitations, there are no current diffractive multifocal
contact lenses on the market
The Hydron Echelon lens [CooperVision] was discontinued in March 2006
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Aspheric designs offer a gradual change in
power from the center to the periphery.
◦ Anterior surface
◦ Posterior surface
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Aspheric multifocal lenses in general provide
a smooth progressive vision effect that
simulates pre-presbyopic vision function.
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Anterior Aspheric
◦ Plus power is greatest in the center of the lens progressing
to more minus in the periphery.
 For very small pupils, the near power will be emphasized and
distance vision will be compromised.
 For very large pupils the near vision will be compromised
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Posterior Aspheric
◦ Plus power increases toward the periphery.
 For very small pupils, the distance power will be emphasized and
near vision will be compromised.
 For very large pupil the distance vision will be compromised
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This design uses a distance or near optical
zone, which makes pupil size and lens
centration critical for the fit.
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Distance-centered
Near-centered
Pupil-intelligent
Aspheric-blended varieties.
This design incorporates distinct annular
zones of power to create their multifocal
effect.
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Simultaneous vs Alternating
Simultaneous Types
◦ Diffractive
◦ Aspheric
 Anterior
 Posterior
◦ Concentric (Annular)
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Alternating or translating designs have the
advantage of distinct and separate areas
dedicated to vision for distance and for near.
The positioning of the line of sight in
alternating multifocals is entirely dependent
on lens positioning in primary gaze and
translation upon inferior gaze.
The distance and near portions of the lens are
never used simultaneously.
Lens stability controlled by either prism or
truncation.
With appropriate base curve selection and
proper lid interaction, the lens will translate
up during downward gaze allowing the
patient to utilize the add in the lens
During primary gaze, the segment is
positioned below the pupil allowing the
patient to utilize only the distance portion
of the lens
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Most GP multifocal lenses utilize alternating
vision effects to some degree because they
move with the blink and will translate to
varying degrees with inferior gaze.
With isolated exceptions, soft and hybrid
multifocal lens designs are simultaneous
designs because they do not move
significantly with the blink or translate with
inferior gaze.
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Advantages
◦ Offers intermediate vision
◦ Near can be viewed without using downward gaze
◦ Lens design is thinner and more comfortable to wear
◦ Stereopsis is maintained
◦ Lid positioning is not as important to the success
Disadvantages
◦ Pupil size is a consideration to success
◦ Patients may experience flare and ghosting
◦ May experience reduced night vision
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Advantages
◦ Gives sharp distance and near vision
◦ Not as dependent on pupil size
◦ Interferes less with night vision
Cons
◦ Less comfortable due to edge thickness
◦ No intermediate vision
◦ Lid tension and position must be
appropriate for design to work
◦ Can only view near on downward gaze
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The soft multifocal contact lens market is
dominated by the silicone hydrogel designs
from the major manufacturers.
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#1
Back of your mind
◦ Distance
◦ Intermediate
◦ Near
#2 ◦ High Light (small pupil)
◦ Low Light (large pupil)
Anterior Aspheric
Posterior Aspheric
Distance Center Concentric
Baseball Player
Lawyer
Mechanic
Drive at night
Waiter in restaurant
Security Guard
Photographer
Near Center Concentric
Alternating
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The key to fitting success is to appropriately
match an individual patient's vision demands
and with the proper design.
Success is based on the realization that no
one lens design is superior to another.
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Motivation
Expectations
Cost and patient compliance
Physical considerations
If a patient is not motivated psychologically…
it is going to make your job that much harder.
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Appearance - Patients wear contact
lenses because they want to lose the
glasses.
◦ Multifocal lenses psychologically hide this
aging process.
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Convenience -Presbyopia is especially
frustrating when its new. These
patients never had a problem to read
a menu, sign a check, etc.
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What are the patients' vision expectations?
How and when do they want to wear
multifocal lenses?
Does the patient want to wear contact lenses
full time, daily yet limited hours, or
occasionally?
What specific activities are most important?
Consider the vision demands of those
responses and how the various designs
might perform under those circumstances.
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Discuss
◦ Comfort
◦ Cost
◦ Acceptance
If you are able to discover
that a given patient is not
able to afford multifocal
lenses, or that he would not
accept the vision outcomes
available, or would not be
able to tolerate physical lens
adaptation, then you could
avoid wasting his time and
yours.
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There are certain anatomical factors that will
help you choose an appropriate lens design
◦ Corneal Abnormalities
◦ Tear film quality and quantity.
◦ Lid margins
 Anterior and/or posterior blepharitis.
◦ Allergic conditions
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Also be aware of all prescribed that can affect
the corneal surface.
Pupil size is important, especially in
extremes.
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Highly Motivated
Dislikes Wearing Glasses
Presently Wearing Contact Lenses
Realistic Expectations
Distance Rx >.75D
Goal
20 / HaPpY
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