Ajay Kumar Singh

Nibha Mishra
Department of Ophthalmology
NEWER IOLs King Georges Medical University,
Lucknow (INDIA)
WHAT IS AN IOL ???

An artificial lens that is implanted inside the eye

usually replacing natural crystalline lens during
cataract or refractive surgery to correct optical
power of the eye.
HISTORY

Italian scientist Tadini in mid 18th century first considered

intraocular lens implantation.

In 1795, Casamata implanted glass IOL which sank

posteriorly.

English ophthalmologist Sir Nicholas Harold Lloyd Ridley

is credited for first successful IOL implantation on
November 29th 1949, at St. Thomas hospital in London.

Sir Harold Ridley (1906-2001)

EVOLUTION AND DEVELOPMENT

Generation-I (1949-1954)

Biconvex PMMA PCIOL

Implanted behind iris after ECCE
Diameter 8.32 mm; Power 24 D

Complications:
Inferior decentration
Posterior dislocation
Inflammation
Secondary glaucoma
 EVOLUTION AND DEVELOPMENT

Generation-II (1952-1962)

Early Anterior Chamber IOLs

Fixation of lens in angle recess

Complications:
Advantages:
Less decenteration
Corneal decompensation
Decreased reaction Pseudophakic Bullous
keratopathy
Uveitis
Secondary glaucoma
 EVOLUTION AND DEVELOPMENT

Generation-III (1953 1975)

Iris supported or iris fixated IOLs

Advantages: Complications:
It is away from angle structures hence Iris chaffing
rate of complications like secondary Pupillary distortion
glaucoma is less.
Chronic inflammation
Rate of dislocation is less.

Less contact with corneal endothelium CME

hence lesser damage to it. Distortion on pupillary
dilatation
 EVOLUTION AND DEVELOPMENT

Iris clip lens (Binkhorst) Iris claw lens (Worst)

 EVOLUTION AND DEVELOPMENT

Binkhorsts another modification (1965)-

Iridocapsular Lens

Posterior haptics in capsular bag with anterior

loops removed.

In 1970 Binkhorst and Worst employed a trans-

iridectomy suture for fixation mechanism-
MEDALLION lens.
 EVOLUTION AND DEVELOPMENT

Generation-IV (1963-1990)
Intermediate ACIOLs
Made up of flexible loops with multiple point of fixation
More stable lesser complications
Choyce, Mark VIII, Mark IX, flexible ACIOL, Kelman, Kelman flexible
tripod, Kelman quadraflex, Kelman multiplex 4 point fixation

Choyce Mark IX Kelman

 EVOLUTION AND DEVELOPMENT

Generation-V (1975-1990)

Improved PCIOLs

Rigid tripod design (John Pierce)

J-looped PCIOL (Steven Shearing)

Modified J-looped PCIOL (Sinskey)

C-looped PCIOL (Simcoe)

One piece PCIOL (Eric Arnott)

Major advantage-POSITION
 EVOLUTION AND DEVELOPMENT

Generation VI (1990- present) (Modern IOLs)

Aspheric IOL Phakic IOL

Multifocal IOL Aniridia IOL

Accommodative IOL Scleral fixated IOL

Toric IOL Glued IOL

Adjustable IOL
Telescopic IOL
Electronic IOL
NEWER IOLs
DESIGN AND MATERIAL

Square-edge design

Surface Modifications

UV absorbing material

Chromophores are added.

Two classes-
Hydroxybenzophenones
Hydroxyphenylbenzotriazoles

Bio-compatible material
Uveal compatibility
Capsular compatibility
Bio-active material
ASPHERIC IOLs

Human eye- Aspheric Optics

+ -
Cornea- Positive spherical aberration
Young crystalline lens- Negative spherical
aberration

Ageing- Crystalline lens gains Positive

+
spherical aberration +
ASPHERIC IOLs
 ASPHERIC IOLs

CONVENTIONAL SPHERICAL IOLs:

A biconvex IOL exhibits positive

spherical aberration.

ADD positive spherical aberration to the

already positive corneal spherical
Conventional IOL increase
aberration the spherical aberration of the eye
 ASPHERIC IOLs

How to overcome this ???

Strategy 1:
Lens with negative spherical aberrations to balance the normally positive
corneal spherical aberrations

Strategy 2:
Lens with minimum spherical aberrations so that no additional spherical
aberration is added to the corneal spherical aberrations

Aspheric IOLs attempt to improve pseudophakic vision by controlling spherical aberrations.

 ASPHERIC IOLs

TYPES:

Anterior prolate surface

Tecnis, Advanced Medical Optics (AMO)

Posterior prolate surface Acrysof

TecnisAO
IQ
SofPort
Akreos
Acrysof IQ, Alcon Laboratories

Both Anterior and Posterior prolate surfaces

Akreos AO, SofPort AO and L161 AO, Bausch & Lomb
MULTIFOCAL IOLs

Restoration of accommodation in pseudophakia-

 MULTIFOCAL IOLs

Single IOL with two or more focal points.

Types
Refractive

Diffractive

Combination of both
REFRACTIVE MULTIFOCAL IOLs

Bulls eye lens

o Concentric rings of different powers
o Central addition surrounded by distance optical power

Annulus design
3-5 rings-
o Central for distance vision
o Near vision ring
o Distance vision ring
 REFRACTIVE MULTIFOCAL IOLs

Bright light/ Distance dominant zone

Large Near dominant zone

Low light/ Distance

dominant zone 5 4 3 2 1

Near zone Aspheric transition

Distance zone
 REFRACTIVE MULTIFOCAL IOLs

Multiple focal points of a refractive MIOL

 REFRACTIVE MULTIFOCAL IOLs

Silicone MIOLs
Array multifocal IOL (AMO)
First FDA approved foldable MIOL

Acrylic MIOLs
ReZoom multifocal IOL (AMO)

PREZIOL (Acrylic)(Care Group)

Manufactured by Indian company

Also available as non foldable PMMA lens

DIFFRACTIVE MULTIFOCAL IOLs
 DIFFRACTIVE MULTIFOCAL IOLs

Distance vision (white arrow) Near vision (blue arrow)

 DIFFRACTIVE MULTIFOCAL IOLs

Tecnis Multifocal IOLs (AMO)

ZM900 (Silicone)

ZA00 (Acrylic)

Optic Diameter 6.0 mm

Optic Type
Modified prolate anterior surface

Total diffractive posterior surface Tecnis ZM900 Tecnis ZA900

Diffractive Power +4.0 diopters of near addition (+3.0 Diopters at spectacle plane)
 DIFFRACTIVE MULTIFOCAL IOLs

Acrysof IQ ReSTOR (Alcon)

Acrylic diffractive multifocal IOL with apodized design
Optic diameter- 6 mm

Refractive for distance, and a diffractive lens for near.

16 rings distributed over central 3-6 mm

Peripheral rings placed closer to each other

Central rings are 1.3 m elevated are for near vision whereas
peripheral 0.2 m elevated and for distant vision
Anterior peripheral surface is modified to act as refractive design

Near Addition +3.0 D at IOL plane (+2.5 D at spectacle

plane)
 MULTIFOCAL IOLs

Refractive vs Diffractive
REFRACTIVE MULTIFOCAL IOLS DIFFRACTIVE MULTIFOCAL IOLS

Excellent intermediate and distance vision Excellent reading vision and very good
distance vision

Near vision fair but may not be sufficient to see Fair Intermediate vision
very small print

Patients who read for prolonged periods of time Patients who do lots of computer work may not
or in poor lighting may experience eye fatigue. accept it well

PUPIL DEPENDENT LESS DEPENDENT ON PUPIL

 MULTIFOCAL IOLs

Disadvantages
Reduction of contrast sensitivity

Glare, haloes

Less satisfactory visualization of fundus- difficulty in vitreo-retinal procedures

Requires Visual-Cortical Neuro-adaptation

Requires

Accurate biometry

Precise IOL implantation

Astigmatic reduction
 MULTIFOCAL IOLs

PATIENT SELECTION:
Recommended for most but NOT ALL patients.

Not recommended in:

Monofocal lens in the other eye Previous corneal transplantation
surgery
Pediatric patients
Keratoconus
Patient with high ametropia
Very small or fixed dilated pupils
Patients with unrealistic expectations
Where there is doubt about the
Moderate to severe macular
stability of IOL centration
degeneration
>83 years of age (Because age
Irregular astigmatism or high degrees
reduces contrast sensitivity)
of regular astigmatism
 ACCOMMODATIVE IOLs

Monofocal IOL

Changes position inside the eye as the eye's

focusing muscle contracts
1 mm of anterior movement of lens = 1.80 D of
accommodation
Mimicking the eye's natural ability to focus
 ACCOMMODATIVE IOLs

Silicone
Crystalens (Bausch & Lomb)
Only FDA approved IOL for correction of presbyopia

Hydrophilic Acrylic
BioComFold type 43E (Morcher GmbH)

1CU (HumanOptics AG)

Tetraflex (Lenstec Inc.)

ACCOMMODATIVE IOLs
 ACCOMMODATIVE IOLs
Working Mechanism of CrystaLens
 ACCOMMODATIVE IOLs

Akkolens IOL (Akkolens)

Anterior element with a spherical lens to correct

the overall refraction of the eye, and two cubic
optical surfaces for varifocal effect.

Cubic optical elements are fitted by spring-like

haptics fused at the rim to allow a movement
perpendicular to the optical axis.
 ACCOMMODATIVE IOLs

Synchrony Dual-Optic IOL (Visiogen)

One piece Silicon foldable IOL

Two optics with high plus anterior and

posterior minus lens that are connected by

spring like haptics.

When zonular tension is released resulting

compression of optic-spring haptic releases

anterior optic forward.

 ACCOMMODATIVE IOLs

SmartLENS (Medennium Inc.,Irvine, Calif.)

Manufactured from thermodynamic hydrophobic acrylic material which makes it a
stable, flexible, gel polymer.
2.0 mm rod and injected through a normally sized capsulorhexis
Reconfigures itself
High refractive index
Prevent PCO
 ACCOMMODATIVE IOLs

NuLens (NuLens Ltd., Israel)

Sulcus fixated lens

Composed of silicone gel between 2

rigid plates with an opening on the front
plate

With increased vitreous pressure, the

plate compress, the polymer bulges
through the anterior plate aperture,
resulting in increased curvature and in
increased curvature and increased power.

Accommodation +30 to +50 D

 ACCOMMODATIVE IOLs
FluidVision IOL (PowerVision, Belmont, Calif.)
The annular peripheral haptics- Fluid reservoir

The fluid moves back and forth naturally through this

pliable system (Microfluidic technology)

The channels in the lens are completely translucent

As the ciliary body and zonular apparatus contract and

expand, that fluid in the peripheral annular haptics is
forced radially through a channel into the centre of the
lens, causing it to increase its anterior posterior
curvature

Average accommodation +5 D
 ACCOMMODATIVE IOLs
LiquiLens (Vision Solutions)
A dual liquid IOL (two immiscible fluids of different refractive indices)
Gravity dependent
Lower 3/4th Lower refractive index- Distant vision (in straight gaze)
Upper 1/4th Higher refractive index- Near vision (in downgaze)
Disadvantages of Accommodative IOLs

Smaller optic-more aberrations

Failure of accommodation due to
Fibrosis

Capsular opacification

Anterior

Posterior

Costly
 TORIC IOLs

Vision with Cataract and Cataract corrected with IOL Cataract and Astigmatism
Astigmatism but Astigmatism remaining both corrected with Toric IOL
 TORIC IOLs

Designed to correct astigmatism

Axis of toric power is designed with 2 small hash-
marks
Pre-operative marking of steep axis (greater
curvature) of cornea (in sitting position)
Per-operative alignment of lens with corneal marking
1 misalignment ~ 3.3% loss of cylindrical power
Proper positioning of IOL is a must
 TORIC IOLs

Two Types
Silicone
STAAR Toric IOL (STAAR Surgicals)

Cylindrical powers: 2.0 D and 3.5 D

Acrylic
AcrySof Toric IOL and Acrysof IQ Toric IOL (Alcon Labs)
Cylindrical powers of 1.5 D, 2.25 D, and 3.0 D

T-flex (Rayner)

1.0 to 11.0 D in 0.25 D steps

Acri.Comfort (Zeiss)
 TORIC IOLs

Proposed incision is IOL is loaded into the IOL is implanted in the

marked at the steepest plus injection cartridge with capsular bag and axis is
meridian. the toric marks on the aligned
anterior surface
ROLLABLE IOLs
Ultrathin ~100
Hydrophilic material
Front surface curved
Back surface: series of steps with concentric
rings
Open up gradually
Implanted by phakonit technique

Acrismart
Thin Optx ultrachoice
Slimflex lens
PHAKIC IOLs
Implantation of IOL without removing natural
crystalline lens.
ADVANTAGE: Preserves natural accommodation
Mostly used in Myopic eyes: -5 to -20 DS
Also used in Hyperopic eyes
Concern in Hyperopes:
More chances of endothelial damage
Increased risk of angle closure glaucoma

Life-long regular follow up required.

 PHAKIC IOLs

Posterior
Chamber
Iris fixated
Angle
fixated
 PHAKIC IOLs

Posterior Chamber Phakic IOLs

Examples:

Implantable collamer lens (ICL) (VISIAN; STAAR)

Phakic refractive lens (Medennium)
Sticklens

COMPLICATIONS:
Endothelial cell damage
Inflammation
Pigment dispersal
Elevated IOP
Cataract
 PHAKIC IOLs

Implantable Collamer Lens (ICL)

Pre-crystalline lens made of silicone or collamer.

The length of the lens is calculated by subtracting
0.5 mm from the white-to-white limbal diameter.
Overall size- 11-13 mm
Otical zone - 4.5-5.5 mm
Toric model also available

COMPLICATIONS:
Constant contact pressure
Cataract
Ciliary body reactions
Prevent free passage of aqueous.- Iridectomy
required
SPINNAKER EFFECT: Blowing sail of a boat
 PHAKIC IOLs

Iris Fixated Phakic IOL

VERISYSE/ARTISAN (AMO/OPTECH)
Made of PMMA

convexo-concave

Length = 7.2 8.5 mm

Optic size = 5-6 mm

Haptics fixed to iris claws

 PHAKIC IOLs

Iris Fixated Phakic IOL

ADVANTAGES OVER ICL:

Customized smaller size possible

Can be examined from end-to-end under the slit lamp

microscope throughout the patient's life

COMPLICATIONS-
Early post op AC inflammation
Glaucoma
Iris atrophy on fixation sites
Implant dislocation
Decentration
Endothelial cell loss
 PHAKIC IOLs

Angle Fixated Phakic IOL

TWO TYPES
4 point fixation
Baikoffs modification of Kelman type haptic design

NuVita MA20 (Bausch and Lomb)

3 point fixation
Vivarte (IOL Tech)

Separate optic and haptic

 PHAKIC IOLs

COMPLICATIONS

Endothelial cell loss

Irregular pupil

Iris depigmentation

Post-op inflammation

Halos and glare

Surgical induced astigmatism

PIGGYBACK IOLs

An intraocular lens that piggybacks onto an

existing intraocular lens or two IOLs are
implanted simultaneously.

First IOL is placed in the capsular bag.

The second (piggyback) IOL is placed in the bag

or sulcus.
 PIGGYBACK IOLs

Advantages

Easier to place 2nd IOL than to explant IOL & replace it

Lesser risk

More predictable

Can change power with time-by adding IOL or explanting an IOL

Better image quality
Increased depth of focus
 PIGGYBACK IOLs

Disadvantages
COMPLICATIONS
Interlenticular opacification (Interpseudophakos Elshnigs pearls) (RED ROCK SYNDROME)
Unpredictable final IOL position
ADJUSTABLE IOLs
Lens works on the principle of a piston.

The haptic-optic junction is a piston such that the optic can be moved forwards or
backwards.

It allows multiple adjustments.

Useful for pediatric age group.

LIGHT ADJUSTABLE IOLs
A photosensitive adjustable foldable 3-piece IOL

Composed of subunits (macromers) embedded in a matrix. Focal UV irradiation (365 nm)

from a digital light delivery device (Carl Zeiss Meditec) causes polymerization of macromers.

Non-polymerised macromers diffuse and migrate into their radiated area causing a power
change

Irradiating the lens again locks in the desired configuration

Calhoun's light adjustable IOL.

ANIRIDIA IOLs

Various designs
Overall size = 12.5 to 14 mm
Optic diameter = 3.5 to 5 mm
Central clear optic
Surrounding colored diaphragm
SCLERAL SUPPORTED IOLs
PCIOLS sutured to the sclera through sulcus
Widely used technique if there is no capsule
or only sections of peripheral capsule.
No endothelial damage
Low risk of iris chaffing
Some risk of suture breaking
Some risk of suture erosion
 SCLERAL SUPPORTED IOLs

Techniques of fixation:
Ab-interno
Ab-externo

Single loop
Double loop

o Single haptic fixation

o Double haptic fixation
GLUED IOLs
Fibrin glue-assisted suture-less posterior chamber IOL implantation technique.

INDICATION: Eyes with a deficient posterior capsule.

The IOL is introduced through a limbal incision and both the IOL haptics are
externalized under the scleral flap with a 25-gauge MicroSurgical Technology
forceps.
IMPLANTABLE MINIATURE TELESCOPE

Miniature implantable Galiliean telescope

Implanted in posterior chamber
Held in position by haptics loops
Contain number of microlenses which
magnify objects in the central visual field.
Improves central vision in ARMD.
 IMPLANTABLE MINIATURE TELESCOPE

Acts as a telephoto system to enlarge images 2-3 times.

Telephoto effect allows images in the central visual field to not be focused directly
on the damaged macula, but over other healthy areas of the central and peripheral
retina

Diseased eye: Image focused on Implanted eye: Image focused on

damaged macula macula and periphery
 IMPLANTABLE MINIATURE TELESCOPE

DRAWBACKS:

Surgically more challenging

Difficulty due to the size and weight of the implant
Endothelial compromise
Blocked peripheral retinal visibility
Difficulty in future retinal laser treatments
Loss of peripheral vision
TELESCOPIC IOL
Next generation of implantable miniature telescopes.
Uses mirrors rather than glass lenses
25 X magnification of central images
The LMI (Lipshitz Macular Implant) optics is 6.5mm and only
slightly thicker than a standard IOL
Contains 2 miniature mirrors (a 2.8 mm posterior doughnut
shaped mirror that reflects light anteriorly onto a 1.4 mm central
retinafacing mirror which in turn focuses the light on retina).
Does not affect peripheral vision.
 TELESCOPIC IOL

Ray diagram showing the mirrored deflection of certain light rays that emerge
with magnification , the peripheral rays are not engaged by the mirror lens system and pass
through as they would in a standard lens implant thus helping to maintain a relatively normal
visual field .
SHAPE OF THINGS TO COME
ELECTRONIC IOL
World's first implantable lens with artificial intelligence.

CONCEPT: The pupil responds to accommodation by getting

smaller. The IOL includes sensors that detect very small changes in
pupil size. The pupillary response to accommodation is different
from the pupillary response to light in regard to amplitude and how
Electro-active switchable element
rapidly

it occurs in response to accommodation.
Change in the molecular configuration of the liquid crystal to alter the optical power of the
lens
Automatically adjusts focusing power electronically, in milliseconds
Maintains constant in-focus vision for various distances and light environments.
Controlled by a micro-sized power-cell with an expected >50 year rechargeable cycle life.
 ELECTRONIC IOL

AUTO FOCAL LENS: Electro-active liquid BATTERY:

LENS: Set to correct crystal centre for near vision (with small pupil) Rechargeable Li-ion
distant vision (with dilated battery
pupil)

FRONT (CUT-AWAY)
VIEW OF ELENZA
ELECTRONIC IOL

MICRO CHIP:
Regulates the auto-focal
lens

PHOTO SENSOR: Detects

the external light
 ELECTRONIC IOL

Remaining safety and

technological issues
What happens to the electronic

components if the lens is hit with a

YAG laser ???

Are any of the materials toxic ???

What if there's leakage ???

Thank you