INTRAOCULAR LENS

EVOLUTION, TYPES & USES

Guide : Dr. Sagun Narayan Joshi

Dr. Triptesh Raj Pandey

1st year Resident
BPKLCOS 8th May, 2013
 Presentation Layout
• Introduction
• History & Evolution
• Parts & Features
• Types & Uses of IOL
• Complications
 Intraocular lens
• An artificial lens made of plastic, silicone,
acrylic or other material
• Implanted lens in the eye
• Replace/Along the existing crystalline lens

Cataract

Refractive correction
 History
• Tadini : 18th century
– Considered intraocular lens (IOL) implantation

• Casamata, 1795
– First attempt of IOL implantaion
– Glass IOL sank posteriorly
 Generation I
1949-1954

Sir Harold Ridley

• First person to successfully

implant an intraocular lens

• November 29, 1949, St.

Thomas’ Hospital,London

• First intraocular lens :

Polymethylmethacrylate
(PMMA)
• Idea of IOL implantation
– An intern’s question
– Replacing the lens removed during cataract
surgery

• Acrylic plastic material

– Royal Air Force pilots sustaining eye injuries during
WW II involving PMMA windshield material
– Splinters of the Plexiglas domes in the cockpits
– No rejection or foreign body reaction
– Splinters remained relatively inert in internal eye
Complications:
Foresight in 3 important areas:

• PMMA in biconvex
– Inferior design
decentration
– Posterior dislocation
• Extracapsular surgery
– Inflammation
– Secondary
• Posterior glaucoma
chamber placement

– Power error of 16
diopters
Generation II (1952-1962)
Early Anterior Chamber Lenses

• Anterior chamber
• Fixation of the lens : Angle recess
• Narrow confines: Less dislocation
• After either an (ICCE) or an ECCE
• Considered a simpler technical
procedure

Baron : First designer & implanter

of an anterior chamber lens
– May 13, 1952
 Angle-supported lens
Complications:
• –By Strampelli
Corneal decompensation
• –Used from 1950bullous
Pseudophakic to 1955
keratopathy
– Uveitis
Mark VIII lens
• –By
Secondary
Choyce glaucoma
• –Either
Uveitis-glaucoma-hyphema
as a secondary lens
(UGH) syndrome
implant or primarily after
intracapsular cataract surgery

Azar 91Z lens

• Rounded haptic in inferior
chamber angle
• Notched haptic in superior
chamber angle, with lens
vaulted anteriorly
 Generation III (1953-1975)
Iris-Supported Lenses

•Soon
• Binkhorst’s
Frequent change of
dislocation
noted that
from
the ICCE
Ridleyto
ECCE
lens
– Iris chafing, pupillary abn
– Early dislocation
• • Introduction
High rate of corneal
of his two-loop
decompensation:
iridocapsular
Made anteriorIOL ACIOL
: 1965
loops (early 1950s)
of four-loop lens
longer
• Iris-supported/fixated IOLs
Increased corneal decompensation
• Almost immediate reduction in
Cornelius Binkhorst
• Peripheral : Early advocate of
touch
the incidence
iris-supported IOLsof many of these
complications
• Four-loop, iris-clip IOL
IOL
ECCEstyles
in early for intracapsular
1950s : surgery
• Crude by modern standard
•• Epstein lens
Retained lens(Copeland)
cortex
• Fibrosis & adhesions betw iris & capsule

ICCE eliminated residual cortical material

•IOLs
Medallion lens with
of that period platinum
featured clipwith
optics (Worst)
• loops,
• struts, or
• holes for sutures
 fixation
• Original to the iris
iris-fixated lensfor(Fyodorov)
support
 Generation IV (1963-1990)
Intermediate Anterior Chamber
Lenses
Advantages
Major disadvantages of earlier
anterior chamber IOL
• Excellent finish with highly
• Close proximity of the haptics &
polished smooth surfaces
loops to delicate tissues  
• Difficulty in IOL sizing
• Tissue contact less likely to result
in chafing damage
Various rigid & flexible, open-loop, Modern ACIOL
one-piece PMMA designs
• Sizing less critical   
• Point fixation possible  
• Three- and four-point fixation
• Much easier to remove, when
Kelman IOLs
necessary
Generation V (1975-1990)
Improved Posterior Chamber Lenses

Return to Harold Ridley’s original concept of IOL

implantation

– 1975: John Pierce implanted 1st

uniplanar PCIOL-Rigid tripod design

– Steven Shearing:Two J shaped loops

PCIOL(Major design)

– William Simcoae: C-looped PCIOL

– Eric Arnott: One piece PMMA PCIOL

– Major Advantage : Position

Generation VI (1990-Present)
Modern ACIOL
Many changes in surgical – Various kelman-Choyce
techniques after 1980-1990s designs
• Introduction of OVDs – Modifications by Baikoff &
Clemente
• In-the-bag fixation
• Continuous curvilinear Modern capsular lenses:
capsulorrhexis, hydrodissection – Rigid PMMA
& phacoemulsification – Soft foldable
• Safer surgery, implantation – Multifocal IOL
through a smaller incision – Phakic IOL
– Toric IOL
– Aspheric IOL
– Accomodative IOL
Gentn Date Description
I 1949-1954 Original Ridley posterior chamber
lens
II 1952-1962 Early anterior chamber lenses
III 1953-1975 Iris-supported lenses
IV 1963-1990 Intermediate anterior chamber
lenses
V 1975-1990 Improved posterior chamber lenses
VI 1990- Modern capsular posterior chamber
Present lenses & modern anterior chamber
lenses
 Classification
I Method of fixation III Focussing ability

A Anterior chamber IOL A Monofocal IOL

B Iris supported IOL B Multifocal IOL
C Accomodative IOL
C Posterior chamber IOL

IV Aphakic vs Phakic IOL

II Optic material
V Special function IOL
A PMMA IOL
B Silicon IOL A Toric lens
C Acrylic IOL B Aspheric lens
D Hydrogel IOL C Spheric lens
Edge finish ( Ridge, square, or sharp )

Foldable/Non-foldable

Power ( Plus, minus, plano )

Haptic style ( Plate or loop )

Wavelength feature ( UV or blue-light blocking )

 Parts of IOL
Optic
– Central part overlying the optic axis
– Focuses light on the retina

Haptics
– Filaments/Plate connected to optics
– Holds lens in the place in the eye
 Features of IOL
Rigidity Edge
– flexible or rigid Square or rounded

Holes
Optic size
To keep IOL in position
– 5-7mm Easy manipulation and dialing
Nidus for inflammation
Shape Haloes, Diplopia
• Round or oval
• Spheric or aspheric
• Plano convex or biconvex
Haptic angulation
– relative to the plane of optic

For posterior chamber lens

• 100 anterior angulation
– Keep the optic part away
from pupil
– PCO formation
– Pupillary capture
– Post operative inflammation.
For anterior chamber lens
• Posteriorly angulated lens
– Vault the intraocular lens
away from the pupil
Materials used for intraocular lenses

Optic materials Haptic materials

• Non-foldable • Polypropylene
– Polymethylmethacrylate • PMMA
• Acrylic
• Foldable • Polyamide
– Silicone • Polyvinylidene fluoride
– Hydrophobic acrylic (PVDF)
– Hydrophilic acrylic
Non-foldable IOL
Polymethylmethacrylate (PMMA)

• 1st material used

• Acrylic of ethacrylic & methacrylic
acid

• Rigid, inert, non-autoclavable

• Chemically stable

• Excellent optical properties

• Refractive index-1.4913
• Inexpensive

• Disadvantage
– Rigid & require larger incision
 • Polyhydroxyethylmethacrylate
•• Copolymer
Crossed of phenylethacrylate
linked polysiloxane &
chains
Foldable IOL (pHEMA)
phenylethylmethacrylate
•• Differ in index-1.47
Refractive
Silicone •• Water
– refractive index-1.41-1.47
Refractive indices
• Refractive content-38%
Hydrophobic acrylic index-1.55
– water content
– Smaller in dry state
•• Advantages:
– surface properties
– Swell on hydration
Advantages
Hydrophilic acrylic – clarity and mechanical strength
–
– Reduced rates of
Heat resistant, PCO
Autoclavable
–
– Higher
•• Advantage
Advantage refractive index
Moldable, Compressible,
– Less
– Thinner lens to&corneal
harmful
Highly
– Smaller flexible transparent
incision: self sealing wound
• Disadvantages
endothelium
–– Lesser
Excellent tensile & tear strength
astigmatism
– Fold
Tacky&nature:
–– Quicker Unfold faster
visual rehabilitaion
• stick to forceps
•• Disadvantage
Disadvantage
– • between
– Extreme
• Disadvantages 2 parts
flexibility of IOL on
Lower refractive index
– insertion
–– More
Reduced
Can be tensile strength
expensive
pitted
– High
Susceptible todecentration
mechanical damage
–– rates
– Decentration
Slippery of
–– Pitting
Lack adhesive
of IOL property
Multifocal IOLs
– Simultaneous viewing
• both distance vision and near vision
– Glare and halos at night time

• Bifocal IOL
– Centre zone:Near power
– Outer zone :Distance power
– Fairly satisfactory in bright light
– Performs poorly for near vision in
dim illumination
• Depth of focus
• Multiple-zone IOL

– Central & Outer zone: Distance

vision
– Inner Annulus : Near vision

Diameters selected:
• Near correction : Moderately
small pupil
• Distance correction for both
AMO Array™
large & small pupil
Diffractive multifocal IOL

• Overall spherical shape : Distance

vision

• Posterior surface: stepped

structure

• Diffraction from the multiple rings

produce a second image, with an
effective add power

• Optical aberration

AcryoSof ReSTOR AMO ReZoom

Accommodating IOLs

– For both distance vision and midrange near

vision

– Not as strong for closer vision as the

multifocal IOLs

• Interact with ciliary muscles and zonules

Crystalens
– Hinge in each flang

– Anteriorly: Accommodative effort

– Posteriorly:Accommodation relaxed

Akkommodative® 1CU
“Mix and Match"

• Incorporating the strengths of both type of IOL

• Multifocal IOL in one eye to emphasize close reading vision

• Accommodating IOL in the other eye for further midrange

vision

• Distance vision not compromised with this approach, while

near vision is optimized
Toric Lenses

• Designed to reduce preexisting

astigmatism in patients with cataracts

• Cylindrical correction
– Posterior optic surface
• Spherical correction
– Anterior optic surface

• Rotation of these IOLs within the Acrysof Toric IOL

capsular bag after implantation, esp
plate haptic IOL
Aspheric Intraocular Lenses

• Spherical aberrations vary with age

• Cornea : +ve spherical aberration

• Crystalline lens -ve spherical aberration
– Shift toward positive spherical
aberration. Tecnis™ IOL

– Approaches zero ~ 40 years of age

– Increasingly positive as aging continues

– Adds to positive spherical aberration of

the cornea
– Glare and reduced contrast sensitivity
Scleral Fixation IOL

• Sutures passed through haptics

• Supported to the sclera

• Devoid of posterior capsular

support PMMA Scleral Fixation IOL Lens

• Anterior chamber IOL cannot

be implanted
UV / Blue Light Filtering IOLs

– Chromophores

– Filter
• UV
• High-energy blue light

– Too much filtering of blue light

• Depression, especially winter months (SAD)

– Blue light-filtering IOLs

• approximately equal to that of UV light-filtering
IOLs color vision
• some compromise in the blue light spectrum
under mesopic light condition
Piggyback Lens

• High hyperopia

• In short axial lengths reduces

optical aberrations

• Acrylic folding lenses

Thinner
Interlenticular opacification
Aniridia Intraocular Lenses

• Posterior chamber aniridia IOLs

• Within the capsular bag
• Black PMMA Morcher GmbH
• Two basic models
– Ring with one black segment
– Multisegmented ring

Aniridic Ring
For Very Small Incisions

• Clear corneal incisions

– 1.1 to 1.6 mm
• Hydrophilic acrylic
• Water content 18%

Fresnel-like ring
• Correct for spherical
aberration UltraChoice 1.0 Rollable™ ThinLens
Adjustable-power Pseudophakic Intraocular Lenses

Calhoun Vision : Three-piece silicone IOL

Refractive power
• Adjusted noninvasively after implantation
Implantable Miniature Telescope (IMT™)

Late-stage AMD & other maculopathies

Functions in conjunction with dioptric

power of cornea
Secured inside capsular bag

Anterior window of the optic extends

through the pupil
Clearance ~ 2.0 - 2.5 mm to corneal
endothelium

Implanted in one eye to improve central

vision,
Other eye remains as is to continue to
provide peripheral vision
Phakic IOLS (PIOLs)

– Natural lens left untouched

– Preserves accommodation
• Angle-supported NuVita AC phakic IOL
• Iris-fixated
• Sulcus-Supported

• Indication
– High refractive errors(-5 to -20 D)
Artisan phakic IOL with iris enclavation
– Laser & surgical correction (LASIK
and PRK) contraindicated
– Hyperopia

Visian ICL
 Power of IOL

Importa To be calculated carefully to

●

meet the visual requirements

nce:- of individual patient.

Widely used formula

• Modified Sanders-Retzlaff-Kraff
formula (SRK)
 Modified Sanders-Retzlaff-Kraff formula

Based on
• Statistical correlation between calculated and
observed refractive error after ocular implantation

E: A:
• E=A - 2.5L - 0.9K Emmetropic power Predetermined
of eye constant of IOL

K:
L: Average of
Axial length in mm keratometry
readings
• Parameters estimated by
– A-scan USG
– Keratometry
• Axial lengths betw 22mm - 24.5mm

SRK II formula
– Addition of a correction factor
– Increases the lens power in short eyes E=A - 2.5L - 0.9K
– Decreases it in long eyes
Other formulas

• Binkhorst
• Hoffer
• Shammas
• Holladay
• SRK/T
Suitable position for implanting IOL
• Best placed in posterior chamber in the
In the ciliary • Zonular dialysis
capsular
sulcus bag.
supported
by the anterior • Posterior capsule tear
capsule

In anterior
implanting a lens
chamber not feasible for
supported by the • If posterior chamber is
angle structure
 Uses

• Cataract

• Refractive correction
Intraocular lens selection in special
circumstances

• Diabetes
• Uveitis
• Subluxed lenses & Zonular instability
• Capsular tear
• Vitrectomised eyes
• Paediatric cataract
Diabetes

• Surgical technique & the choice of IOL

– postoperative fundus visualisation

• Rigid, large optic diameter PMMA lenses

– permit peripheral retinal visualisation
– panretinal photocoagulation
– vitreoretinal surgery
– wide posterior capsulotomy

• Accumulate surface deposits

• Large incision, delay refractive stabilisation
• Exacerbate postoperative inflammation
• Foldable silicone lenses
– small incision
– Less CME
– Disadvantage if vitrectomy
surgery required
– Silicone oil

• Square edged acrylic

lenses
– Small incision
– Appear stable
– Show less adherence of
silicone oil
Uveitis

Hydrophilic acrylic material

– good uveal but worse capsular biocompatibility

• Heparin surface modification of PMMA lenses

– reduces the number and extent of deposits
– but not completely prevent their formation

• Acrylic & hydrogel lens implants

– fewer surface deposits than unmodified PMMA
lenses

• PCO lesser tendency

– Acrylic lenses
– Square edge
Subluxated lenses and abnormal zonules

• Risk of capsule contraction

– IOL with rigid haptic material better
– larger overall diameter

• Plate haptic implants avoided

• Use of a capsular ring or rings

– may reduce the risk of capsule contraction,
particularly prevalent in pseudoexfoliation

• Capsule retained but zonule integrity in doubt

– lOL can be placed in the ciliary sulcus
Capsular tear

• Unfolding of a silicone lens may extend any pre-

existing capsule tear

• Implantation of silicone plate haptic lenses

contraindicated unless the rhexis and capsular bag
are intact

• Loop haptic foldable lens

– can often be successfully inserted by careful positioning of
the haptics despite a capsule tear
Vitrectomised eyes

• Biometry altered by silicone oil tamponade

• Silicon Lenses should be avoided

• Ability to visualize the fundus fully

• An unstable capsular bag or damaged zonules

– may dictate IOL selection

• Large optic IOL with a low rate of PCO &

anterior capsule opacification highly desirable
Paediatric cataract

• Long term complications of anterior chamber lenses

preclude their use

• Ideal site IOL : Capsular bag in the posterior chamber

• PMMA allow safe implantation in infants

• Lenses designed specifically for paediatic eye available

• Adult lenses can also be used, providing their overall

diameter not greater than 12 mm
 COMPLICATIONS
1. Intraocular Lens Model Selection Error

2. Procedural Problems

3. Intraocular Lens Location Problems

4. Intrinsic Intraocular Lens Problems

5. Inflammation-mediated Complications
1. IOL Model Selection Error

• Wrong Optic Material

Acrylic IOLs
– Diabetes
– Pseudoexfoliation
– History of uveitis; patients
– Undergoing combined procedures
– blood—aqueous barrier compromise

• Silicone Oil Adherence to Intraocular Lenses

• Aniridia Intraocular Lens Misapplication

• Wrong Power Selection

– Penetrating keratoplasty
– Silicone oil in the vitreous cavity
– Prior refractive surgery
2. Procedural Problems

• Endothelial Touch
– corneal endothelial decompensation

• IOL flip

• Iris Damage
– Iris prolapse through incision site
– Hyperopia
– Overfilled AC

• Haptic Damage
– poor memory of polypropylene
– optic decentration

• Optic Damage
– PMMA scratch
– Silicone optics torn
– Acrylic optics crack
3. Intraocular Lens Location Problems

Capsular Tears

Sunset Syndrome

Rotation of Toric IOL

Pupillary Capture

Capsular Block Syndrome

UGH Syndrome
4. Intrinsic Intraocular Lens Problems

• Sterility, Haptic & Optic Defects

• Acrylic Glistenings
– water vacuoles drawn in from aqueous
– can also occur in silicone IOLs

• Optic Calcification :
– Hydrophilic acrylic IOLs

• Pseudophakic Dysphotopsia
– Positive: Brightness, streaks, rays, glare
– Negative: Subjective darkness or
shadowing
5. Inflammation-mediated Complication

• Long-Term Endothelial Cell Loss

• Optic Precipitates
– Fuchs' heterochromic uveitis, diabetes,, glaucoma
– Acrylic IOL had fewer giant cell deposits
– 2nd Gen Silicon IOL even lesser

• Posterior Capsule Opacification

1. Hydrodissection-enhanced cortical cleanup
2. In-the-bag (capsular) fixation
3. Capsulorrhexis edge on IOL surface
4. IOL biocompatibility
5. Maximal IOL optic-posterior capsule contact
—”shrink-wrap”
6. Barrier effect of the IOL optic
7. Suppression of postoperative inflammation
• Lactocrumenasia

• Anterior Capsule Opacification

• Capsule Fibrosis
– fibrous metaplasia of the anterior capsular cells
– cannot migrate, but they develop contractile
ability
– Silicon IOL

• Capsular Contraction
– Pseudoexfoliation
– Advanced age
– Diabetes
– Chronic uveitis

• Optic Decentration
References

• Fundamentals of Clinical Ophthalmology, Cataract Surgery :Andrew Coombes and David Gartry, BMJ
Publishing Group 2003

• Duanes’ Ophthalmology, 6th Ed

• Yanoff’s

• Cataract Surgery and its complications : Jaffe 6th Ed

• AAO Clinical Optics,2011-2012

• AAO Lens & Cataract,2011-2012

• Principle & Practice of Ophthalmology, Albert & Jackobiec’s

• Clinical Ophthalmology : A Systematic Approach:Jack J Kanski 7th Ed

THANK YOU