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Aspheric Iol

Aspheric Iol

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Intraocular lens centration and stability: efficacy of currenttechnique and technology
Robert Monte´s-Mico´, Alejandro Cervin ˜o and Teresa Ferrer-Blasco
Introduction
Intraocular lens (IOL) technology has been at the fore-front of ophthalmology research for many years nowbecause of the high social impact that any improvementhas on the population. Pseudophakic implants haveincreased the interest because of the inclusion of clearlens extraction procedures. Further, the increaseddemands for high quality retinal image due to currentlifestyles implies that there is a considerable effort ingetting one step closer to the perfect optics for thepseudophakic eye, in both monofocal and multifocalIOL designs.The lens design is, obviously, an important issue to reachthat target, but not less important are lens centration andstability over time. Conventional pseudophakic IOLimplantation consists of inserting the IOL in the capsularbag,implyingthatthereisacloseinteractionbetweenthelens and the capsular tissue and therefore the selection of the biomaterial is critical to avoid capsule opacification oralteration in the capsule-healing process that could affectthe surgical outcomes.There are a number of studies evaluating centration andstability of IOLs atdifferent times after implantation, butthe methodologies used for this assessment differ con-sistently between studies. There is no current gold stan-dard and the present review aims to summarize thedifferent techniques used.
Importance of lens centration and stability
The advantages of IOLs design could be limited, can-celled, or even turned into disadvantages by decentra-tion. The advantages of asphericity, for instance, are lostwhen decentration is more than 0.50mm[1,2]. Holladay
et al 
.[3]reported that measurements of optical qualityprovided evidence that if an aspheric IOL was centeredwithin 0.4mm and tilted less than 7
8
, it would exceed theoptical performance of a conventional spherical IOL.Dietze and Cox[4], after model eye simulations, indi-cated that the image quality with either aspherical orspherical designs deteriorates at a similar rate when thelens is tilted, spherical IOL performed much morerobustly when the lens was displaced. If tilt and decen-tration occur in combination then the performanceof aspherical designs strongly depends on the directionof the offset. With increasing decentration, the modeleye of Dietze and Cox[4]with aspheric IOL showed anincrease of asymmetrical third-order aberrations at amuch faster rate than the spherical lens, whereas sym-metrical fourth-order aberrations remained constant
Optometry Research Group, Optics Department,University of Valencia, Valencia, SpainCorrespondence to Robert Monte´s-Mico´, PhD,Optometry Research Group, Optics Department,Faculty of Physics, University of Valencia, C/Dr Moliner50, 46100, Burjassot, Valencia, SpainE-mail:robert.montes@uv.es
Current Opinion in Ophthalmology
2009, 20:33–36
Purpose of review
The manuscript presents a review of recently published studies analyzing differentmethodologiestoassesscentrationandstabilityofintraocularlensesafterimplantation.
Recent findings
Considering that there is no current gold standard for centration and stability ofintraocularlensesafterimplantation,wehavesummarizedthedifferenttechniquesusedclinically for intraocular lenses centration and stability estimation. We have describedthe use of Scheimpflug imaging, the anterior segment optical coherence tomographyandphotography analysis used forlens position estimation. Techniques used toassesslens rotation are based on image analysis on digital retroillumination images.
Summary
Centration and stability of intraocular lenses are a matter of most importance and manymethodshavebeendeveloped.Itseemsthatthebestmethodfortheassessmentoflensposition considers Scheimpflug imaging and for stability the use of retroilluminationimages.
Keywords
anterior segment optical coherence tomography, photography analysis,retroillumination images, Scheimpflug imaging
Curr Opin Ophthalmol 20:33–36
ß
2009 Wolters Kluwer Health | Lippincott Williams & Wilkins1040-8738
1040-8738
ß
2009 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/ICU.0b013e328318591c
 
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
(spherical IOL) or nearly constant (aspheric IOL). Thisstudy[4]shows the main limitations to correct ocularspherical aberration using aspheric IOLs. From a clinicalpoint of view, it has been reported that with continuouscurvilinear capsulorrhexis and in-the-bag IOL place-ment, mean IOL centration is within 0.1–0.3mm[57]. Wang and Koch[8]have recently concluded that with current surgical techniques, implantation of asphericaland monochromatic wavefront-corrected IOLs wouldreduce total ocular higher-order aberrations below cor-nealhigher-orderaberrationsinabout45and86%ofeyes,respectively (for a 6-mm pupil). The performance of anystatic correcting method is limited by residual aberrationsarising from misalignments. To obtain the optimalbenefit, the IOL should be centered on the visual axis[9]. The visual axis does not generally pass through thecenter of the pupil[10]and it should be thereforemeasured. In addition, some capsular fibrosis and otherbiomechanical events that modify the permanently fixedpositionoftheIOL mayalsoplayaroleinthefinalopticalquality of the eye. One should consider that one of themain sources to obtain the same visual and optical qualityoutcomes in eyes implanted with asphericorsphericalIOLs are the centration and tilt of the lens [11

].In the case of toric IOLs, the importance of lens rotationis extremely high. It has been estimated that approxi-mately 1
8
of off-axis rotation results in a loss of up to 3.3%of the lens cylinder power. Rotations more than 10
8
implies a reduction of the astigmatic effect intended inmore thanone-third, implying clinically significant con-sequences [12,13
].
Assessment of lens position
In the different studies available in the literature, severalmethods were used for the assessment of lens position.Although there is a very reasonable explanation behindthe methodology in most cases, very few methods havebeen assessed in terms of variance, reliability or both. Weare going to describe the use of Scheimpflug imaging, theanterior segment optical coherence tomography (OCT)and photography analysis.
Scheimpflug imaging
Slit-lamp images are normally distorted by both theoblique viewing with the instrument and the refractiveproperties of the eye. Clinical Scheimpflug systems aredesigned to minimize distortion due to the instrumentand, as stated by Coppens
et al 
.[14], distortion of theimage due to the eye optics must be compensated byimage processing. This study[14]shows one of the bestmethods to estimate IOL centration using Scheimpflugimaging.Kim and Shyn[15]used Scheimpflug imaging to com-pare decentration and tilt after successful cataractsurgery between three types of IOLs. The tilted filmplane and objective maintain the entire slit image infocus. Scheimpflug image processing confirms the pos-ition of implanted IOLs
in vivo
throughout the post-operative period. It also allows measurement of anteriorchamber depth (ACD) and thus observation of the pos-itional change of IOLs along the globe’s longitudinalaxis.
Anterior segment optical coherence tomography 
Anterior segment OCT has improved very considerablyover the last few years. The implementation of spectralOCT in the consulting room has considerably reducedexamination time and notably increased resolution ascompared with time-based devices. For IOL assessment,OCT systems can provide very useful evaluation of lensposition through resolutions up to 3
m
m. This level of resolution should allow the assessment of centration, tilt,vault and axial position within a very high level of accuracy.
Photography analysis
Verbruggen
et al 
.[16]used an image analysis tool throughanterior segment digital photography using a MathLab-implemented application to determine centration fromboth dilated pupil center and limbus. This techniqueimplied the location of the lens optical zone and then thepupil or limbal margins. The software tool then calcu-lated the shift between both geometrical centers. Mutlu
et al 
.[17,18]used photographs of Purkinje images toassess decentration and tilt.
Assessment of lens rotation
Obviously, analysis of lens rotation is of the most interestin toric IOLs. Tomographic techniques are not suitablefor this purpose, and the techniques described are basedon image analysis on digital retroillumination pictures inwhich the pupil is dilated and reference marks can beobservedonthelens.Caremustbetakenthough,assomemethods do not take into account cyclotorsion, forinstance. The differences between the methods appearon the image analysis and the reference marks. Weinand
et al 
.[19]used, as reference axis, the line between twoclearly identifiable points on the eye sufficiently separ-ated such as the Axenfeld loops, so that subsequentimages over time are referred to the same reference.Then, they used the insertion of the loops on the IOLas reference for the IOL position joining them with astraight line. The resulting angle between the referenceaxis and the reference on the IOL was compared atdifferent periods after surgery to determine rotationalstability. Viestenz
et al 
.[20]used a Heidelberg retinaangiograph to image the anterior and posterior segments.Methodology was repeated after 3 months and the anglebetween the fundus reference axis (axis between twocharacteristic points on the fundus) and the axis of the
34
Cataract surgery and lens implantation
 
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
toric IOL was measured. The difference between theangles measured at baseline and after 3 months would bethen the angle of rotation.The method used by Patel
et al 
.[21]was somehowdifferent. They used a computerized system to capturea retroillumination image and then the processing wasperformed. A software tool within the capture systemmapped the optic zone and located its center. Thenanother cursor marks a peripheral point on the opticand, along with the center, defines a line. The subtendedangle between this line and the vertical is then comparedwith assess rotation. Repeatability values obtainedintraobserver for loop and plate haptic IOLs were 0.35
8
and
À
0.28
8
, respectively. This study[21]shows one of the best methods to estimate IOL stability usingretroillumination images.
Centration and stability of pseudophakic intraocularlenses
Using Scheimpflug imaging Hayashi and Hayashi[22]compared stability of one-piece and three-piece acrylicIOLs (with soft acrylic loops and rigid polymethilmetha-crilate loops, respectively), reporting that there is nodifference between the two IOL types in tilt and centra-tion nor was there a difference throughout the follow-upperiod. Verbruggen
et al 
.[16]reported predictable cen-tration with the bag-in-lens implantation technique,which was stable over time. They used digital photogra-phy analysis in which the position of the optical zone of the IOL with respect to both the dilated pupil center andlimbus was measured to assess centration.With regards to rotational stability, Weinand
et al 
.[19]used retroillumination digital photography and sub-sequent image analysis to assess the rotational stabilityof a single-piece hydrophobic IOL finding a rotationbetween 0.5
8
and 1.0
8
in 47% of the patients studied(ranging from 0.1 to 1.8
8
). Till
et al 
.[23]found clinicallysignificant levels of rotation with toric plate-haptic IOLsin 11% of the patients.
Conclusion
Centration and stability of IOLs are a matter of mostimportance and reliable methods of determination are amust. Up to now, many methodologies have been devel-oped to determine centration and rotation of the IOL,andadifferentmethodisdescribedinalmosteverystudy.Although the reasoning behind all these methods offers aclever approach, it would be desirable to establish thebest one, doing appropriate performance assessment stu-diesandusingitasagoldstandardforthenewmethodstocome. To the authors’ knowledge, the best documentedmethod for the assessment of lens position would be thatdescribed by Coppens
et a
.[14]using Scheimpflugimaging, and, for rotational stability, that described byPatel
et al 
.[21]. Both methods proved to be repeatable,but the fact that they are the best documented ones doesnot imply necessarily that they are the best methodsto use.Beforeamethodisdevelopedfordeterminingtheclinicalimpact or the magnitude of lens position and stability,appropriate assessment of the methodology used shouldbe done. Then, both the author and the reader can assessthe full extent of the conclusion reached from the clinicalapplication of the methodology, to compare those resultswith other methods described, and to know its limita-tions.
Acknowledgements
This research has been supported in part by Red Tema´tica Optometrı´aMinisterio de Ciencia e Innovacio´n (Acciones ComplementariasSAF2008-01114-E).There are no conflicts of interest.
References and recommended reading
Papers of particular interest, published within the annual period of review, havebeen highlighted as:
of special interest

of outstanding interestAdditional references related to this topic can also be found in the CurrentWorld Literature section in this issue (p. 72).
1
Atchison DA. Design of aspheric intraocular lenses. Ophthalmic Physiol Opt1991; 11:137–146.
2
Altmann GE, Nichamin LD, Lane SS, Pepose JS. Optical performance of 3intraocular lens designs in the presence of decentration. J Cataract RefractSurg 2005; 31:574–585.
3
HolladayJT,PiersPA,KoranyiG,
etal.
Anewintraocularlensdesigntoreducespherical aberration of pseudophakic eyes. J Refract Surg 2002; 18:683–691.
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et al.
Update on fixation of rigid and foldableposterior chamber intraocular lenses. Part I: elimination of fixation-induceddecentration to achieve precise optical correction and visual rehabilitation.Ophthalmology 1999; 106:883–890.
6
JungCK,ChungSK,BaekNH.Decentrationandtilt:siliconemultifocalversusacrylic soft intraocular lenses. J Cataract Refract Surg 2000; 26:582–585.
7
Wallin TR, Hinckley M, Nilson C, Olson RJ. A clinical comparison of single-piece and three-piece truncated hydrophobic acrylic intraocular lenses. Am JOphthalmol 2003; 136:614–619.
8
Wang L, Koch DD. Effect of decentration of wavefront-corrected intraocularlenses on the higher-order aberrations of the eye. Arch Ophthalmol 2005;123:1226–1230.
9
Lo´pez-Gil N, Monte´s-Mico´R. New intraocular lens for achromatizing thehuman eye. J Cataract Refract Surg 2007; 33:1296–1302.
10
RyndersM,LidkeaB,ChisholmW,ThibosLN.Statisticaldistributionoffovealtransverse chromatic aberration, pupil centration, and angle psi in a popula-tionofyoungadulteyes.JOptSocAmAOptImageSciVis1995;12:2348–2357.
11

Monte´s-Mico´R, Ferrer-Blasco T, Cervin ˜ o A. Is there a benefit to asphericintraocular lenses? A review of the literature. J Cataract Refract Surg (inpress).This study shows a full review of visual and optical quality outcomes found indifferent articles in which aspheric IOLs were implanted.
12
Viestenz A, Seitz B, Langenbucher A. Evaluating the eye’s rotational stabilityduring standard photography: effect on determining the axial orientation oftoric intraocular lenses. J Cataract Refract Surg 2005; 31:557–561.
Intraocular lens centration and stability
Monte´s-Mico´
et al 
. 35

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