Acta Ophthalmologica 2015

The importance of angle kappa evaluation for

implantation of diffractive multifocal intra-ocular
lenses using pseudophakic eye model
ın1 and Klára
Marta Karhanová,1 František Pluháček,2 Petr Mlčák,1 Ondrej Vláčil,1 Martin S
Maresová1
1
Department of Ophthalmology, Olomouc University Hospital and Faculty of Medicine and Dentistry, Palacky University,
Olomouc, Czech Republic
2
Department of Optics, Faculty of Science, Palacky University, Olomouc, Czech Republic

ABSTRACT. working distances (Blaylock et al. 2006;

Purpose: To determine the critical value of the angle kappa in connection with a Hütz et al. 2008), increased dysphotop-
higher risk of photic phenomena for the AcrySof ReSTOR and Tecnis multifocal sia compared to monofocal intra-ocular
intra-ocular lens (MIOL) on a standardized pseudophakic eye model. To analyse lenses (IOL) (Souza et al. 2006; Chiam
the impact of biometric value changes on the critical angle kappa. et al. 2006; Hofmann et al. 2009),
Methods: Geometrical optic rules applied to a suitable optical model of the decreased contrast sensitivity (Montes-
pseudophakic eye were used to calculate the critical value of the angle kappa for Micó & Alio 2003; Zhao et al. 2010) and
the Tecnis and three types of the AcrySof ReSTOR MIOLs. The angle kappa increased intra-ocular straylight (De
was defined as critical if the incident ray passed through the first ring’s edge area. Vries et al. 2008). Unfortunately, in
some cases, even an IOL exchange is
The influence of different positive optical corneal power (K), effective lens
required (Woodward et al. 2009). How-
position (ELP) and axial length (AL) on the critical angle kappa (jc) was
ever, the bag-in-the-lens could only be
investigated. The dependence of jc on one of the parameters was studied for implanted in 70% of the eyes (Tassignon
standardized values of the remaining parameters. et al. 2014). A lot of studies have
Results: The highest value of the critical angle kappa was evaluated for the focused directly on the analysis of the
Tecnis MIOL. The increase in ELP and K caused an increase in jc under the governing factors for patient satisfac-
given conditions. On the contrary, an increase in AL led to lower values of jc. tion or dissatisfaction after MIOL
Conclusion: We demonstrated the dependence of the critical angle kappa on the implantation and attempted to find
central part of the MIOL and on biometric parameters of the eye, especially on the criteria for patient selection (Walkow
effective lens position. According to these results, we conclude that shallow anterior & Klemen 2001; Blaylock et al. 2008;
chamber depth in connection with a higher angle kappa is an important risk factor Kohnen et al. 2008; Pepose 2008;
for pronounced photic phenomena after implantation of a diffractive MIOL. Woodward et al. 2009; De Vries et al.
2011). It has been confirmed that the
Key words: angle kappa – anterior chamber depth – effective lens position – multifocal intra- main complaints in dissatisfied patients
ocular lens – photic phenomena are blurred vision and photic phenom-
ena (Woodward et al. 2009; De Vries
et al. 2011). The causes associated with
Acta Ophthalmol. 2015: 93: e123–e128
ª 2014 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
disturbing photic phenomena have
included MIOL decentration, posterior
doi: 10.1111/aos.12521 capsular opacification, retained lens
fragment, dry eye syndrome, uncor-
rected visual acuity, use of spectacles
Introduction and demands regarding refractive out- for distance purposes, postoperative
In recent years, multifocal intra-ocular comes are still increasing. Although astigmatism and postoperative spheri-
lens (MIOL) implantation has become excellent results are reported in many cal equivalent (Walkow & Klemen 2001;
an increasingly common solution for recent studies after MIOL implantation, Woodward et al. 2009). In the last years,
cataract and presbyopic patients who there are also some limitations. The the angle kappa has also attracted
want to find a spectacle-free option after weaknesses of MIOLs are, in particular, interest in connection with a possible
surgery. However, patient expectations unsatisfactory visual acuity at specific higher risk of disturbing photic phe-

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Acta Ophthalmologica 2015

nomena after MIOL implantation. It is

assumed that, in patients with a higher
angle kappa, a MIOL may induce more
aberrations, glare and halo. To date,
only few studies in larger cohorts of
patients have been published concerning
this problem (De Vries et al. 2011;
Prakash et al. 2011; Karhanov a et al.
2013). Although Prakash et al. (2011)
found a statistically significant associa-
tion between the angle kappa and photic
phenomena, they also noted that many
patients with a high angle kappa were
asymptomatic. Up to now, there has
been no clear explanation of this fact.
None of the published papers addressed
the question regarding which value of
the angle kappa is already a risk when
implanting a MIOL. Only recommen-
dations based on experience from the
practice have been published.
The aim of this study was to deter-
mine the critical value of the angle kappa
in connection with a higher risk of
developing photic phenomena for four
diffractive MIOLs, the Tecnis (Abbot,
Illinois, USA) and three types of Acry-
Sof ReSTOR (Alcon, TX, USA), on a
standardized pseudophakic eye model.
The second aim was to analyse the
impact of biometric value changes in
the pseudophakic eye on the critical
angle kappa and to find out whether
angle kappa evaluation is necessary for
every patient before planned implanta-
tion of a diffractive-type MIOL.
Methods
For an explanation of the photic phe-
nomena, a geometrical construction of
the incident rays through the nodal
points is used. The ray passes through
the first nodal point, and the foveally
observed distant object defines the nodal
axis. The nodal axis is commonly
denoted as the visual axis. The angle
kappa (j) is the angle between the nodal
(visual) axis and the pupillary axis. The
pupillary axis is considered identical with
the optical axis of the eye (Tunnacliffe
1993). It is assumed that the photic
phenomena markedly increase if the
intersection of the nodal axis and the
MIOL moves from its central part to the
first ring of the MIOL. The relevant
border value of the angle kappa is
referred to as critical angle kappa jc
(Fig. 1).
The critical value jc of the angle
kappa can be calculated using the
geometrical optical rules applied to a
Fig. 1. The schema of the used optical model of the pseudophakic eye with an optical axial length
AL and an effective position ELP of a thin MIOL with the centre C of the MIOL on the eye
optical axis. R marks the border of the central part of the IOL of the diameter d. The points N and
N’ represent the first and second nodal points of the pseudophakic optical system, F’ is the second
focal point of this system. The critical angle kappa kc is marked.
suitable optical model of the pseud- The nodal visual axis corresponds to
ophakic eye. The optical model applied the ray passing from the observed object
in this text is based on the standardized to the fovea through the nodal points.
pseudophakic schematic eye (Holladay Moreover, it intersects the thin MIOL in
1997, 1998, 2007) with a thin IOL the border R of its central part and the
(Fig. 1). The distances used are ori- first ring for the critical angle kappa (see
ented according to Fig. 1 with the Fig. 1). According to the geometrical
positive values in the incident light construction in Fig. 1 and to the rect-
direction (i.e. from left to right) and angular triangle RCN’, the size |jc| of
negative values in the opposite direc- the jc can be computed by the relation
tion. The MIOL is perfectly centred to
the pupil centre. The model is repre- d=2
jjc j ¼ arctan ð2Þ
sented by a positive optical corneal AL  ELP þ F0 N0
power K, an optical axial length AL, a
thin MIOL effective optical power P F0 and N 0 are the second focal point
for distance correction, an effective and the second nodal point of the
position ELP of the thin MIOL and pseudophakic eye optical model, and
by a refractive index n of the aqueous C is the centre of the MIOL. It can be
and vitreous. The ELP means a dis- shown (Tunnacliffe 1993) that
tance of the MIOL optical centre from
the anterior corneal vertex. A zero 1
F0 N0 ¼ f ¼  ð3Þ
postoperative refraction of the pseud- F
ophakic eye is considered. Under these
conditions, the P is a dependent vari- The quantity f is the equivalent first focal
able. It can be shown that the relation length of this optical system, and F is its
n n equivalent optical power. The F can be
P¼ n ð1Þ obtained using a common equation for
AL  ELP
K  ELP the equivalent lens power in the form
holds for this eye optical model (Holl-
aday 1997, 1998). The central part of ELP
F¼KþP KP ð4Þ
the MIOL with the constant power has n
the diameter d.

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 Acta Ophthalmologica 2015

The formula (2) can be rewritten using

(3) and (4) to the form

d=2
jjc j ¼ arctan
AL  ELP  1
KþPELP
n KP
ð5Þ

The term (5) along with (1)

describe the influence of the pseud-
ophakic eye model parameters K, ELP,
AL and n on the critical value jc for the
given diameter d of the central MIOL
part.
For the calculation of the concrete
Fig. 2. Dependence of the critical angle kappa |kc| on the effective lens position ELP in the
value of critical angle kappa (jc), the
pseudophakic eye model for the standardized values K = 43.27 D and AL = 23.65 mm and for
standard parameters of the considered four values of d. The standardized value ELP = 5.25 mm is represented by the vertical dashed
pseudophakic eye model (Holladay line.
1997, 1998, 2007) K = 43.27 D, ELP =
5.25 mm, AL = 23.65 mm and n = 1.336
were applied to the relation (5). The
MIOL was modelled according to the
Tecnis ZMB00 (addition +4.0 D) and
AcrySof ReSTOR SV2STO (addition +
2.5 D), SB6AD1 (addition + 3.0 D)
and SN6AD3 (addition + 4.0 D) MIOLs
of the parameters d = 1.0 mm,
d = 0.938 mm, d = 0.86 mm and
d = 0.74 mm, respectively. All the data
relating to these MIOLs were obtained
from the manufacturers. Next, the influ-
ence of quantities K, ELP and AL on the
jc was analysed in the case of the above-
mentioned MIOL parameters by the
relation (5). In particular, the depen-
dence of the jc on one of the parameters
was studied for standardized values of
the remaining parameters.
Fig. 3. Dependence of the critical angle kappa |kc| on the optical corneal power K in the
Results pseudophakic eye model for the standardized values ELP = 5.25 mm and AL = 23.65 mm and
for four values of d. The standardized value K = 43.27 D is represented by the vertical dashed line.
The values of the critical angle kappa
were jc   15.48° for the Tecnis
ZMB00 (d = 1.0 mm), jc   14.56°
for the AcrySof ReSTOR SV2STO
(d = 0.938 mm), jc   13.39° for
the AcrySof ReSTOR SB6AD1
(d = 0.86) and jc   11.58° for the
AcrySof ReSTOR SB6AD3
(d = 0.74).
The results of the influence of
quantities K, ELP and AL on the jc
in the cases of these four multifocal
lenses are presented in Figs 2–4 in the
graphical form. The increase in ELP
and K caused an increase in jc under
the given conditions (Figs 2 and 3).
On the contrary, the increase in AL
led to lower values of jc (Fig. 4). The
Fig. 4. Dependence of the critical angle kappa |kc| on the optical axial length AL in the
impact of the MIOL characteristics is
pseudophakic eye model for the standardized values K = 43.27 D and ELP = 5.25 mm and for
evident, too – the higher d, the higher four values of d. The standardized value of AL = 23.65 mm is represented by the vertical dashed
jc. line.

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Acta Ophthalmologica 2015
Discussion
Angle kappa is defined as the angle
between the visual axis (connects the
point of fixation with the fovea) and
the pupillary axis (a line through the
centre of the pupil perpendicular to the
cornea). A positive angle kappa is
associated with an out-turning of the
eye (the pupillary axis is temporal
relative to the visual axis), while a
negative angle kappa is an inward
turning of the eye (the pupillary axis
is nasal relative to the visual axis).
Thus, when an eye fixates on a light
source, the reflection on the cornea
(Purkinje image) will not be centred
but will be located nasal (positive angle
kappa) or temporal (negative angle
kappa) to the pupillary centre. Accord-
ing to the published literature, a
positive kappa angle varies from 3.5
to 6° in emmetropic eyes and from 6.0
to 9.0° in hyperopic eyes. In myopic
eyes, the angle kappa is smaller, aver-
aging approximately 2.0°, and can even
be negative (Von Noorden & Campos
2002). Basmak et al. (2007a,b) also
reported the angle kappa to be higher
in hyperopes than in emmetropes and
myopes. Hashemi et al. (2010) found
mean angle kappa values of 5.52 
1.19° in hyperopic eyes, 5.72  1.10°
in emmetropic eyes and 5.13  1.5° in
myopic eyes.
With the development of new types
of intra-ocular lenses, angle kappa is
coming to the forefront of interest of
cataract surgeons. Kottler et al. (2004)
reported a hyperopic patient with a
large angle kappa in whom the residual
refractive error after toric phakic intra-
ocular lens implantation was improved
by displacement of the lens according
to the visual axis. De Vries et al. (2011)
suggested that three major causes of
discomfort after MIOL implantation
(ReSTOR, Alcon Laboratories; Re-
zoom, Abbott Medical Optics; Tecnis,
Abbott Medical, Optics) were residual
refractive error, posterior capsule opac-
ification and large pupil size. However,
a large angle kappa and MIOL decen-
tration from the visual axis should also
be considered. Soda & Yaguchi (2012)
evaluated the influence of horizontal
decentration on optical performance in
different MIOLs using an eye model.
He found that clinically relevant effects
are not to be expected up to a decen-
tration of 0.75 mm. But a possible
influence of angle kappa on these
e126
results was not taken into account.
We confirmed in our previous study
(Karhanová et al. 2013) that temporal
decentration of the ReSTOR multifo-
cal IOL (in cases of a positive angle
kappa) was associated with the greatest
risk of photic phenomena. By contrast,
nasal decentration (in cases of a posi-
tive angle kappa) did not cause pro-
nounced photic phenomena. Prakash
et al. (2011) evaluated the role of angle
kappa in the occurrence of photic
phenomena after MIOL implantation
(Rezoom). They reported that patient
complaints about glare and halo
showed positive correlation with the
preoperative values of angle kappa. On
the other hand, they found that many
patients with a high angle kappa were
asymptomatic.
The assumed cause of pronounced
photic phenomena after implantation
of diffractive-design MIOLs in patients
with a higher angle kappa is that the
fovea centric ray would pass closer to
the edge of the rings and not through
the central area of the MIOL (Fig. 5A
and B). To date, several MIOLs of this
design have been available and com-
monly used in practice. For the pur-
pose of our study, we evaluated the
AcrySof ReSTOR (Alcon Laborato-
ries, Inc., Fort Worth, Texas) and the
Tecnis (Abbot Illinois, USA) MIOLs.
The AcrySof ReSTOR is designed to
provide quality near and distance
vision by combining apodized diffrac-
tive and refractive technologies. The
centre of the lens consists of apodized
diffractive optic that focuses light for
near through distance vision. Apodiza-
tion is the gradual tapering of diffrac-
tive steps from the centre to the outside
edge of the lens. It helps to create a
smooth transition of the light between
distant, intermediate and near focal
points. The refractive zone surrounds
the apodized diffractive region. To
date, three types of the AcrySof
ReSTOR IOL have been introduced
in the market – AcrySof ReSTOR
SN6AD3 (addition + 4.0 D), SB6AD1
(addition + 3.0 D) and SV2STO (addi-
tion + 2.5 D). They vary not only in
add power, but also in central zone
diameter and in the number of diffrac-
tive rings. The Tecnis MIOL is a full
diffractive optic. The diffraction pat-
tern of this lens is on the posterior
surface of the lens (as compared to the
AcrySof ReSTOR lens on the anterior
surface of the lens), and the lens has the
aspheric prolate technology. We evalu-
ated these four lenses in our study
because of their different central diam-
eters (d). The mentioned differences in
MIOL design did not influence our
analysis because the MIOL was
replaced with a thin lens in our model
and was represented only by its equiv-
alent optical power P and central zone
diameter d. By comparing these four
MIOLs on the pseudophakic eye
model, we confirmed that the higher
the central zone diameter, the higher
must be the angle kappa to reach the
edge of the first ring of the IOL. In all
four types of MIOLs, the critical angle
kappa (reaching the edge of the ring)
calculated was higher than that found
in normal population.
On this theoretical model, we also
confirmed the influence of K, AL and
ELP on the critical angle kappa. For
better illustration, we calculated the
border values of parameters K, AL and
ELP corresponding to the critical angle
kappa jc = 7° (which can be found in
normal population) for all four types of
the MIOL as a model case (Table 1).
Two of the eye model parameters
always have standard values and one
of them was calculated. The values of K
and AL for this particular model case
are out of normal range, but the border
values of ELP achieve a realistic size.
According to these results, we suggest
that the most important biometric
value that can influence the possible
occurrence of photic phenomena after
MIOL implantation in connection with
a higher angle kappa be ELP. When
the interdependence of ELP and pre-
operative anterior chamber depth are
taken into account (Olsen et al. 1990;
Holladay 1993; Olsen 2006), it can be
established that patients with preoper-
ative shallow anterior chamber depth
are at a higher risk.
In our study, we presumed the
MIOL to be perfectly centred to the
pupil centre. In the case of a decentred
MIOL, the considered border point R
(see Fig. 1) shifts according to the
direction and size of the decentration.
Thus, the term d/2 in the equation (2)
as well as (5) must be corrected – it
must be increased for the decentration
towards the visual axis or decreased for
the opposite direction. In the simplest
approximation, the term d/2 can be
replaced by the term d/2 + D or d/2 –
D, where D represents the decentration
size (in length units). The resultant
 Acta Ophthalmologica 2015

et al. 1990; Holladay 1993; Olsen 2006)

and a lower jc (see Fig. 2). Thus, the
effect of the opposite decentration on
the risk of photic phenomena should be
taken into account particularly for
shallow preoperative anterior cham-
bers.
This study also has some limitations.
The optical model of pseudophakic eye
used simplifies the situation in a real
eye. In a real eye, all three observed
parameters (K, AL and ELP) vary.
Also, the ELP is influenced by several
factors, not only by preoperative axial
(A) length, anterior chamber depth and
curvature of the cornea, but also by
lens thickness and refraction (Olsen
et al. 1990). The principal limitation is
the simplifying presumption that pho-
tic phenomena are induced by the
interaction of the central ray (corre-
sponding to the nodal axis in our
model) with the first MIOL ring. This
approach, also considered in another
study (Prakash et al. 2011), enables to
derive a relation between the critical
angle kappa and other parameters of
the eye and MIOL based on geometri-
cal optics and the thin MIOL approx-
imation (see above), but does not take
(B) into account other optical effects
caused by diffraction, etc. Thus, this
Fig. 5. Schematic ray diagram showing that in eyes with a small angle kappa, a fovea centric ray approach does not allow a detailed
may pass through the central area of the MIOL (A), while in those with a higher angle kappa, a
analysis of the influence of the angle
fovea centric ray may pass close to the edge of the ring, thus causing photic phenomena (B).
kappa on the photic phenomena, and
the real values of the critical angle
kappa can differ from our results based
Table 1. The results of values of optical corneal power K, effective position ELP of the thin IOL
and optical axial length AL corresponding to the critical angle kappa jc = 7° for four different
on simplified computations. Neverthe-
diameters d of the central part of the MIOL and for the refractive index n = 1.336. Two of the eye less, according to the aim of this study,
model parameters always have standard values, and one is changed in each combination. Only the the relationships obtained show which
values of ELP achieve a realistic size. parameters should be considered for
angle kappa evaluation with regard to
K [D] (ELP = 5.25 mm, ELP [mm] (K = 43.27 D, AL [mm] (K = 43.27 D, the risk of photic phenomena and how
d [mm] AL = 23.65 mm) AL = 23.65 mm) ELP = 5.25 mm)
their values can influence this risk.
0.74 26.70 3.66 35.95 Despite these limitations, we think
0.86 19.22 3.04 40.93 that the results of our study, especially
0.938 14.10 2.63 44.17 the dependence on biometrical param-
1.0 9.86 2.31 46.74 eters of the eye, can help to find a
possible explanation for the contradic-
tion why some patients with a higher
curves presented in Figs 2–4 shift ory of the haptics, contraction of the angle kappa are asymptomatic while
upwards or downwards in this case. It capsule, and IOL rotation, it is uncer- others complain of disturbing photic
means that the decentration towards tain whether the lens would stay in the phenomena. Further studies on real
the visual axis causes an increase in the decentred position (Prakash et al. eyes will be required to confirm this
jc and the risk of photic phenomena 2011). Conversely, the opposite decen- hypothesis.
evoked by a large angle kappa should tration causes a decrease of the jc and In conclusion, the perception of
be reduced. In the practice, different can heighten the risk of photic phe- photic phenomena is multifactorial.
methods for compensating for a large nomena. These results are in accor- Our study suggests that angle kappa
angle kappa (decentration of the dance with the study by Karhanov a may also play a role. We confirmed the
MIOL towards the visual axis) have et al. (2013). Moreover, as mentioned dependence of critical angle kappa on
been described (Melki & Harissi- above, a shallow preoperative anterior the central zone diameter of the multi-
Dagher 2011). However, due to mem- chamber leads to a lower ELP (Olsen focal IOL and on biometric parameters

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Acta Ophthalmologica 2015
of the eye, especially on the effective
lens position. According to these
results, it can be concluded that espe-
cially shallow anterior chamber depth
in connection with a higher angle
kappa could be an important risk
factor for pronounced photic phenom-
ena after multifocal IOL implantation.
We incorporated this conclusion in
our daily practice. We recommend to
evaluate the angle kappa in all patients
with preoperative shallow anterior
chamber depth before planned implan-
tation of a diffractive-design MIOL. In
cases when a larger angle kappa is
confirmed, we prefer to implant
another type of presbyopia-correcting
IOLs. By contrast, in patients with
normal or deeper anterior chamber,
we do not require angle kappa evalu-
ation before diffractive-design MIOL
implantation.
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Received on February 14th, 2014.
Accepted on July 3rd, 2014.
Correspondence
Martin Šı́n, MD, PhD, FEBO
Department of Ophthalmology
University Hospital Olomouc
I. P. Pavlova 6
77900 Olomouc, Czech Republic
Tel: +420 588 444 202
Fax: +420 588 422 530
Email: sin.martin@seznam.cz
This research was supported by Grant No.
PrF_2013_021 from the Faculty of Science of
Palacky University, Olomouc, Czech Republic.
The authors have no financial interest in any
product mentioned in the text and no potential
conflict of interest in this article.
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