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New Motor Driven Adjustable IOL

New Motor Driven Adjustable IOL

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Published by Dennis Murphy
A significant problem for both patients and the cataract surgeon today is the difference between the desired and the actual post-operative refraction achieved after cataract surgery. The new IOL design will allow the first generation of these lenses to have their axial position in the eye adjusted multiple times without requiring further surgery
A significant problem for both patients and the cataract surgeon today is the difference between the desired and the actual post-operative refraction achieved after cataract surgery. The new IOL design will allow the first generation of these lenses to have their axial position in the eye adjusted multiple times without requiring further surgery

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Published by: Dennis Murphy on Jan 31, 2011
Copyright:Attribution Non-commercial


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New Motor-drivenAdjustable IOL Design
A significant problem for both patients and thecataract surgeon today is the difference between thedesired and the actual post-operative refractionachieved after cataract surgery. The new IOLdesign will allow the first generation of these lensesto have their axial position in the eye adjustedmultiple times without requiring further surgery.This will adjust the effective insitu refraction.Later generations will allow astigmatic errors to becorrected as well as providing very effectiveaccommodative IOLsDennis Murphy 28 Jan 2011
New Motor-driven Adjustable IOL Design
The causes of refractive errors
There are many variables that determine the final refractive outcome for any patient. Someimportant parameters include the preoperative biometry
measurements of the anterior corneasurface curvature and the axial length of the eye
These measurements are then used in aregression equation to estimate the IOL power required to produce emmetropia in that eye.The anterior cornea measurements rely on Keratometry to measure the curvature of the frontsurface of the cornea. This measurement however is only part of the optical path through theentire eye. The path must also include the posterior curvature of the cornea as well as thecornea thickness and its refractive index. The Keratometer gives an estimate of the totalcorneal power based on the anterior surface curvature it measured and a posterior radius thatis estimated as a percentage of the anterior radius according to a “standard cornea” model. Italso uses a standardized corneal thickness as well as an assumed refractive index. Problemscan arise due to the fact that the dimensions of each cornea are not exactly same the same asthe “standard cornea”. In addition, if the patient has undergone any previous cornealrefractive surgery such as radial keratotomy, photorefractive keratectomy, LASEK or LASIK  procedures then these operations can change the assumed relationship between the anterior and posterior corneal surface curvatures. The end result is that the estimated total corneal power may be a little different to the real power.The other major measurement needed is the axial length of the eye from the front of thecornea to the retina. This is usually done using A-scan biometry. This technique usesultrasound and the measurement is based on knowing how long the sound wave takes totravel from one point to the next in various tissues. As the sound pulse travels through theeye, a certain amount of energy from the wave is reflected back to the probe at each interfacein the eye (e.g. cornea/aqueous/lens/vitreous/retina). The various spikes returned to the probeare then used to calculate the distances through the cornea, the anterior chamber, the lens andthe vitreous body.There are many structures (including the cataract itself) within the eye that reflect theultrasound energy. To get an accurate axial depth measurement the operator has to knowwhich of the many returned echo spikes represent the required points along the optic path.These spikes are then tagged and the instrument applies the appropriate sound velocities between each of the spikes of interest in order to accurately measure the cornea thickness, theanterior chamber depth, the lens thickness and the vitreous chamber depth. In addition, theultrasound probe must be held exactly parallel to the optical axis of the eye, otherwise theultrasound path through the eye will not follow the actual path whose measurement isrequired. Also if the probe is pressed too hard against the cornea it will cause the cornea todeflect inwards and hence shorten the measured path. The end result of any errors inidentifying the correct return echo spikes, or any alignment or probe application force errors,will mean that the measured total axial eye length will be different to the actual length.There are various formulas used to calculate the required IOL power. Which one is useddepends on whether the patient’s eye length is close to the average length, or is shorter or 
3longer. The actual calculation is generally done internally in the instrument based on the datafed to it by the surgeon. While the actual forms of the various equations within the instrumentare complex, the general form for an average axial length eye (approx. 22mm to 24.5mm) isshown below
P = A – 2.5L – 0.9K 
= IOL power in diopters required to produce emmetropia
= the “A” position constant supplied by the manufacturer 
= axial length of eye (mm)
= estimated total corneal power (diopters) from the keratometry measurementsAll of the equations used to predict what IOL power is required to produce emmetropia in the patient’s eye are examples of multiple regression analysis where we have several independentinput parameters (A, L & K). The object of regression analysis is to predict the “average”value of the dependent output variable – which in this case is the required IOL power.Several problems can arise from using a regression formula to predict the required IOL power as opposed to doing an impractical (but much more accurate) ray-trace through the eye. Thefirst of these are the uncertainties in the measurement of both the true axial length of the eyeand the actual total corneal power as discussed at the start of this article.Second, is the assumption in the various equations that the dimensions of the anterior and posterior segments in the eye are always proportional to each other as per the standard modeleye. This is almost never exactly true and in some cases can be significantly different to the“standard model”The third potential problem arises because of uncertainty in exactly where the implanted lenswill actually sit in the capsular bag in the eye. The axial position of the implanted lens has amajor effect on the effective insitu power of the IOL. Any unexpected changes in this position can lead to large refractive errors. There are two issues here.The A-constant that is supplied by the manufacturer for eachof their IOL models is only an estimate of where they believetheir particular IOL will sit within the capsular bag after implantation. As can be seen in FIG. 1, the axial position of the optic body of the IOL will be influenced by a number of factors such as the haptic angulation – the maximum diameter of the capsular bag (e.g. larger haptic angles with a smaller capsule diameter will push the lens closer to the retina) – and the actual axial position of themaximum diameter of the capsular bag along the optic axis of the eye.To some extent the actual position of the implanted lens will also depend on each surgeon’soperating technique. Depending on the actual circumstances of each eye and operation, theaxial position of the lens may vary from what the surgeon expects.

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