Longterm results of 1 CU® accommodative intraocular lens implantation: 2-year follow-up study

Real-World Clinical Results with the Hoya Vivinex Impress Intraocular Lens with Enhanced Depth of Focus

BACKGROUND

In cataract surgery, intraocular lenses (IOLs) with enhanced depth of focus are an option to correct presbyopia. The purpose of this quality assurance analysis was to evaluate visual acuity and patient satisfaction after implantation of the Hoya Vivinex Impress IOL.

METHODS

The Hoya Vivinex Impress IOL was implanted in patients undergoing cataract surgery at the Pallas Klinik, Olten, Switzerland. Five weeks postoperatively, a clinical examination and a survey on patient satisfaction were conducted.

RESULTS

A total of 17 eyes (9 patients; mean age 64 years) underwent cataract surgery with implantation of a Hoya Vivinex Impress IOL. Five weeks postoperatively, mean uncorrected distance visual acuity (UDVA) was 0.2 logMAR, uncorrected intermediate visual acuity (UIVA) was 0.0 logMAR, and uncorrected near visual acuity (UNVA) was 0.2 logMAR. The mean distance-corrected visual acuity results were 0.0 logMAR, 0.1 logMAR, and 0.3 logMAR, respectively. Reading the newspaper without glasses was possible for 33.4% of patients. Visual disturbances such as halos and glares were not reported.

CONCLUSION

Cataract surgery with Hoya Vivinex Impress IOL implantation revealed good distance and intermediate vision and, in some patients, functional near vision as well as a high patient satisfaction.

Future Intraocular Lens Technologies

The future of intraocular lens (IOL) technology has already begun with a number of recent innovations. The postoperative change of refractive power will lead to a customized fine-tuning that provides patients with the individual vision they expect and with as much spectacle independence as possible. The latest-generation (2.0) Light-Adjustable Lens (RxSight) was recently introduced into clinical practice, with the first results being very encouraging. Other methods of altering the power of an already implanted IOL are under development. The same can be said about the correction of presbyopia, the so-called last frontier in refractive surgery. Extended depth-of-focus IOLs have been introduced, as has the technology of the pinhole IOL. The latter has therapeutic potential beyond the refractive aspect and has already proven helpful in cases of iris defects and irregular corneas. Several technologies are currently being tested to achieve-finally-an accommodative IOL. One such concept uses the (remaining) strength of the ciliary muscle, whereas another is triggered by the pupil reaction when shifting focus from far to near. Not an IOL itself, but rather a high-tech innovation that so far has mostly been implanted during cataract surgery, is a microelectronic sensor that measures habitual intraocular pressure (IOP) at any given time and promises to revolutionize the management of glaucoma patients. The last generation of this device (Eyemate; Implandata Opthalmics Products GmbH) is implanted during small-incision cataract surgery; the latest development is an even smaller sensor that will be inserted suprachoroidally before, in the near future, such a device will be part of a capsular ring. These IOP sensors are a prime example that IOL technology will continue to be a driving force in ophthalmology, with a positive impact far beyond cataract surgery.

Clinical application of accommodating intraocular lens

The present review describes recent advances in application of accommodating intraocular lenses (AIOLs). Standard monofocal intraocular lenses (MIOLs) only correct distance vision, while AIOLs are designed to allow both good distance vision and near vision, which is achieved through the contraction and relaxation of ciliary muscles by providing transformation of the axial movement or curvature of the lens. Thus, AIOLs may be a better choice for those patients who demand a higher level of visual performance. Since techniques to analyze the performance of AIOLs have not been standardized, and there is a variety of both subjective and objective methods, it is hard to measure the performance of these intraocular lenses. By evaluating advantages and disadvantages of various AIOLs, and introducing techniques for measurement the performance postoperative, this paper can provide some relative information on choosing the type of AIOLs in the clinic.

Premium intraocular lenses: The past, present and future

Purpose

To present potential benefits as well as limitations of premium intraocular lens (IOL) use, and provide insight in future of premium cataract surgery.

Methods

Bibliographic research was performed in PubMed/Medline database, and the most recently updated papers were evaluated. Keywords used were: premium intraocular lens, multifocal intraocular lens, toric intraocular lens, toric multifocal intraocular lens, accommodative intraocular lens, and the respective brand names.

Results

Multifocal IOLs provide uncorrected distance visual acuity (UDVA) of 0.03 logMAR in 82.3%–95.7% of patients and overall spectacle independence in 81%–85% of patients. Toric IOLs provide UDVA of 0.3 logMAR in 70%–95% of patients, residual astigmatism of 1 D or less is noted in 67%–88% of patients, and spectacle independence is reported in 60%–85% of patients. Toric multifocal IOLs provide UDVA of 0.3 logMAR in 92%–97% of patients, and spectacle independence is reported in 79%–90% of patients. Accommodative IOLs represent intensively developing field in ophthalmology, and the results are still variable depending on the IOL model.

Conclusions

Premium IOL technology and advanced surgical techniques have significantly improved postoperative visual outcomes. Future developments will potentiate development of new premium IOL designs that will provide spectacle independence and excellent visual outcomes after cataract surgery.

Accommodating Intraocular Lenses

With an explosive increase in the worldwide prevalence of presbyopia, development of an accommodating intraocular lens (IOL) with expansive accommodative amplitude remains the holy grail in lens-based refractive surgery. A dynamic change in the dioptric power of the eye can be accomplished by various strategies alone or in combination, including changes in the position, shape, or refractive index of a single- or dual- optic IOL. This article reviews the cumulative advances in these various lens designs, along with clinical outcomes and complications of those that have been implanted. The challenges that remain in each cat-egory are also highlighted.

Accommodative intraocular lenses: where are we and where we are going

Presbyopia still remains the last frontier of refractive surgery. Its surgical management is under constant evolution due to the limitations that exist today with respect to its management, which is probably in relation with the multifactorial basis in which presbyopia is clinically developed in the human. Until currently, virtually all surgical techniques that have been proposed for its correction are based on the induction of pseudoaccommodation in the presbyopic eye, including multifocality. However, the real restoration of accommodation is more complex, and it has been tried by the use of different, so called, “accommodative” pseudophakic intraocular lenses (AIOL). Overall, the reported results with these lenses by independent authors have been modest in relation with the restoration of the accommodative power of the eye and these modest benefits are usually lost with time due to the long term changes in the capsular bag. This fact made these lenses to be almost abandoned in the last few years, but there are currently other AIOL models being used with innovative mechanisms of action and different anatomical support outside the capsular bag that offer encouraging preliminary results that could bring a new potential of application to these types of lenses.

In this article, we will update the modern refractive surgeon about the fundamentals and provide updated information about the outcomes of AIOLs by reviewing the concept of accommodation, the different attempts that have been accomplished in the past, their demonstrated published results in human clinical trials, and the future alternatives that may arrive in the near future.

Comparison of visual outcomes, spectacles dependence and patient satisfaction of multifocal and accommodative intraocular lenses: innovative perspectives for maximal refractive-oriented cataract surgery

Background

The aim of this study was to evaluate visual outcomes for different working distances (far, 60 cm and 33 cm) and impact on vision quality of multifocal IOLs AcrySof ResTOR SN6AD1 and SN6AD3 (Alcon, Inc., Fort Worth, Texas, USA) as well as REVIEW FIL611PV multifocal and OPTOFLEX FIL618 accommodative IOLs (Soleko, Ltd., Rome, Italy) in patients undergoing bilateral phacoemulsification.

Methods

In this observational prospective study 63 patients undergoing binocular cataract surgery were divided into four groups for implantation of one of the IOLs under evaluation. Visual outcomes were evaluated at 1 day, 7 days, 1 month, 3 months and 6 months after surgery. Patients’ satisfaction and spectacle independence were evaluated with questionnaires administered at the 6-months follow-up.

Results

Improvements in visual acuity for the three working distances were statistically significant in all cases compared to the preoperative status, especially after binocular implantation. The AcrySof ReSTOR SN6AD1 multifocal IOL provided the best visual acuity results and tolerability for all working distances. While performing worse than SN6AD1, FIL611PV and FIL618 provided better uncorrected visual acuity and spectacles independence for intermediate/close-up and far distances respectively, in comparison with the SN6AD3 group.

Conclusions

SN6AD1 was confirmed the best choice for all working distances. However, FIL611PV IOL may represent a valid and more cost-effective alternative, especially if surgeons intend to prioritize spectacle independence and patient autonomy at intermediate and close-up distances, in accordance to specific needs and requests.

Trial registration

Trial retrospectively registered in ISRCTN Registry on 02/02/2017. TRN: ISRCTN14145737.

A review of the surgical options for the correction of presbyopia

Presbyopia is an age-related eye condition where one of the signs is the reduction in the amplitude of accommodation, resulting in the loss of ability to change the eye's focus from far to near. It is the most common age-related ailments affecting everyone around their mid-40s. Methods for the correction of presbyopia include contact lens and spectacle options but the surgical correction of presbyopia still remains a significant challenge for refractive surgeons. Surgical strategies for dealing with presbyopia may be extraocular (corneal or scleral) or intraocular (removal and replacement of the crystalline lens or some type of treatment on the crystalline lens itself). There are however a number of limitations and considerations that have limited the widespread acceptance of surgical correction of presbyopia. Each surgical strategy presents its own unique set of advantages and disadvantages. For example, lens removal and replacement with an intraocular lens may not be preferable in a young patient with presbyopia without a refractive error. Similarly treatment on the crystalline lens may not be a suitable choice for a patient with early signs of cataract. This article is a review of the options available and those that are in development stages and are likely to be available in the near future for the surgical correction of presbyopia.

Comparison of Visual Performance after Implantation of 3 Types of Intraocular Lenses: Accommodative, Multifocal, and Monofocal

Purpose

To compare the performance of accommodative, multifocal, and monofocal intraocular lenses (IOLs).

Methods

In this clinical control study, 3 types of IOL were implanted in 128 eyes of 86 patients with age-related cataract who underwent phacoemulsification. Accommodative (Tetraflex), multifocal (ZMA00), and monofocal (Akreos Advanced Optics [AO]) IOLs were implanted into 43, 40, and 45 eyes, respectively. The uncorrected, best-corrected distance, contrast sensitivity, and distance-corrected intermediate and near visual acuity (UCDVA, BCDVA, CSVA, DCIVA, and DCNVA, respectively), amplitude of pseudoaccommodation, and patient satisfaction were measured at 1, 3, and 12 months after surgery.

Results

Differences in CSVA at all contrast degrees, UCDVA, and BCDVA among the 3 groups were not significant. Patients in the Akreos AO group exhibited a poorer DCIVA and DCNVA and experienced less pseudoaccommodation compared to patients in the other 2 groups at 3 and 12 months after surgery (p<0.01). Patients in the ZMA00 group exhibited a better DCIVA and experienced more pseudoaccommodation than patients in the Tetraflex group (3 months: p<0.05, 12 months: p<0.01 for both outcomes). Three months after surgery, total spectacle independence was achieved by 84.4%, 60.7%, and 17.2% of the ZMA00, Tetraflex, and Akreos AO group patients, respectively.

Conclusions

All 3 types of IOLs allowed greater distance visual acuity; however, multifocal IOLs produced better DCIVA and DCNVA and more pseudoaccommodation and spectacle independence. Accommodative IOLs ranked second. Neither accommodative nor multifocal IOLs reduced CSVA.

Diffractive multifocal intraocular lens compared to pseudo-accommodative intraocular lens implant for unilateral cataracts in pre-presbyopic patients

Purpose:

To evaluate the efficacy of diffractive multifocal and pseudo-accommodative IOLs in pre-presbyopes with cataract.

Materials and Methods:

A prospective randomized control study was performed on patients with cataract in the pre-presbyopic age group. Patients were randomly allocated to 2 groups: Group 1 comprised 12 patients who underwent implantation of a diffractive multifocal IOL and Group 2 comprised 13 patients who underwent implantation of a pseudo-accommodative IOL after standard phacoemulsification. Efficacy was measured by postoperative distance and near uncorrected visual acuity, contrast sensitivity, spectacle independence, and glare and halo.

Results:

The study patients were aged 22–35 years and included 14 females and 11 males. All examinations were performed 6 months postoperatively by a second observer unaware of the study objectives. Mean uncorrected distance visual acuity was 0.125 ± 0.1 LogMAR in Group 1 and 0.1385 ± 0.1 in Group 2 (P = 0.7993). Near visual acuity was 0.0917 ± 0.1 in Group 1 and 0.386 ± 0.2 in Group 2 (P < 0.0001). Contrast sensitivity was good in both groups based on the Pelli-Robson chart (P = 0.3919). Night-time glare was present in 3 (25%) patients in Group 1 and in 2 (15.4%) patients in Group 2. No patients in either group had difficulty driving during the day or night. Ten patients in Group 1 (83.3%) and 7 patients in Group 2 (53.85%) had spectacle independence (P = 0.1249).

Conclusion:

Greater proportions of patients who underwent diffractive multifocal implantation achieved functional distance and near vision as compared to those in the pseudo-accommodative IOL group. There was greater variability in near vision in patients who received the pseudo-accommodative IOL as compared to those in the multifocal IOLs. Contrast sensitivity remained adequate in both the groups. There were more glare and halos in the multifocal group as compared to those in the pseudo-accommodative group. More patients achieved spectacle independence with multifocal IOLs.

Reading ability and stereoacuity with combined implantation of refractive and diffractive multifocal intraocular lenses

PURPOSE

To evaluate reading ability and stereoscopic vision with combined implantation of refractive and diffractive multifocal intraocular lenses (IOLs).

METHODS

Thirty-one cataract patients (62 eyes) were assigned to receive either a ReZoom NXG1 IOL in the dominant eye and a Tecnis ZM900 IOL in the fellow eye (MIOL group), or Sensar AR40e IOLs bilaterally (SIOL group). The uncorrected visual acuity (UCVA) at 500 cm, best spectacle-corrected visual acuity (BSCVA) at 500 cm, reading acuity, reading speed, near stereoacuity and questionnaire were assessed 3 months postoperatively.

RESULTS

Three months postoperatively, monocular and binocular UCVA and BSCVA at 500 cm showed no significant differences in both groups. The uncorrected reading acuity and reading speed in the MIOL group were significantly better than those in the SIOL group and were similar to that with correction in the SIOL group. The uncorrected mean near stereoacuity in the MIOL group was significantly better than that in the SIOL group (69 ± 50 seconds of arc in the MIOL group versus 180 ± 160 seconds of arc in the SIOL group). Patients in the MIOL group had a high level of satisfaction and more than 80% of them had an increased independence from spectacles for brief reading.

CONCLUSION

The combined implantation of refractive and diffractive multifocal IOLs was effective in improving reading ability and near stereoacuity with a good visual quality.

[Alkylphosphocholines inhibit lens epithelial cell proliferation and attachment]

BACKGROUND

Posterior capsule opacification (PCO) is one of the major concerns in modern cataract surgery. Ten years after successful surgery, Nd:YAG capsulotomy is required in up to 42% of patients with an acrylic sharp-edged intraocular lens (IOL). Some accommodative and multifocal IOLs display even higher capsulotomy rates. Pharmacologic prophylaxis with alkylphosphocholines (APCs) could be a novel option in PCO prevention.

METHODS

The human lens epithelial cell line HLE-B3 served as an in-vitro model. After incubation with APCs in different concentrations (0.01, 0.1, and 1 mM), the trypan blue exclusion assay and the live/dead test were performed at serum concentrations of only 5%. Cell proliferation was assessed with the MTT test. Evaluation of cell attachment was done with fibronectin- and laminin-coated wells.

RESULTS

APCs can inhibit the proliferation of human lens epithelial cells in the presence of only 5% serum in a dose-dependent manner. Proliferation inhibition of 60% and attachment inhibition of about 50% were reached at concentrations of 0.1 µM.

CONCLUSION

APCs inhibit proliferation and attachment of human lens epithelial cells in nontoxic concentrations in vitro. The substance can be applied topically, and an intraoperative application for pharmacologic PCO prophylaxis is feasible.

Comparison of clinical outcomes with three different aspheric intraocular lenses

PURPOSE

To compare the quality of vision achieved with different aspheric intraocular lens (IOL) implants.

METHODS

This prospective, comparative and randomized study included 90 eyes that underwent phacoemulsification and implantation with one of three different aspheric IOLs. Patients were assigned randomly to receive one type of aspheric IOL: Tecnis Z9003(®) (Advanced Medical Optics, Santa Ana, California, USA) (Group A), Acrysof IQ SN60WF(®) (Alcon Laboratories, Fort Worth, Texas, USA) (Group B) or Akreos ADAPT-AO(®) (Bausch & Lomb, Rochester, New York, USA) (Group C). Ophthalmic examinations, including uncorrected visual acuity, best spectacle-corrected visual acuity (BCVA), refractive error, wavefront analysis, contrast sensitivity under mesopic and photopic conditions, and a subjective questionnaire, were performed postoperatively.

RESULTS

The mean BCVA, mean refractive error and high-order aberrations were not significantly different among the three groups. The spherical aberrations were 0.0021 ± 0.096 for group A, 0.048 ± 0.071 for group B and 0.11 ± 0.089 for group C, indicating a significantly lower magnitude in group A (p = 0.012). In addition, group A showed significantly better results in contrast sensitivity under mesopic (p = 0.042) and photopic (p = 0.047, 0.049) conditions at low spatial frequencies. Nevertheless, postoperative patient satisfaction was not different among the three groups.

CONCLUSION

The Tecnis Z9003(®) IOL reduced spherical aberrations and improved contrast sensitivity under mesopic and photopic conditions at low spatial frequencies. Nevertheless, the final visual quality was not different among the three groups.

Biconvex posterior chamber accommodating intraocular lens implantation after cataract surgery: long-term outcomes

PURPOSE

To evaluate the long-term efficacy of a biconvex accommodating intraocular lens (IOL) to restore near visual performance.

SETTING

Department of Ophthalmology, Keio University Hospital, Tokyo, Japan.

METHODS

This 4-year study comprised eyes that had cataract surgery with implantation of a 1CU accommodating IOL. At all postoperative visits, the following were assessed: subjective spherical equivalent (SE) refraction; uncorrected (UDVA) and corrected (CDVA) distance visual acuities; uncorrected (UNVA), distance-corrected (DCNVA), and corrected (CNVA) near visual acuities; change in minimum additional (add) power (diopters) to attain CNVA; and accommodation amplitude. A questionnaire was administered at the last visit.

RESULTS

Twelve eyes of 8 cataract patients (mean age 59.0 years +/- 18.4 [SD]) were evaluated. Postoperatively, the mean SE at 1 year and 4 years was significantly more hyperopic than at 1 month (P<.05). The mean UDVA increased significantly at 4 years compared with 1 month (P<.05). There were no significant changes in CDVA, UNVA, CNVA, and DCNVA throughout the follow-up period. The change in the minimum add power to attain CNVA and in the subjective and objective accommodation amplitudes also did not change significantly over time. Eighty-three percent of patients reported being satisfied with the results.

CONCLUSION

Four years after implantation of an accommodating IOL, most patients had good vision and were satisfied, although the accommodation amplitude for near vision was not sufficient throughout the follow-up.

Mechanism of action of the tetraflex accommodative intraocular lens

PURPOSE

To investigate the mechanism of action of the Tetraflex (Lenstec Kellen KH-3500) accommodative intraocular lens (IOL).

METHODS

Thirteen eyes of eight patients implanted with the Tetraflex accommodating IOL for at least 2 years underwent assessment of their objective amplitude-of-accommodation by autorefraction, anterior chamber depth and pupil size with optical coherence tomography, and IOL flexure with aberrometry, each viewing a target at 0.0 to 4.00 diopters of accommodative demand.

RESULTS

Pupil size decreased by 0.62 ± 0.41 mm on increasing accommodative demand, but the Tetraflex IOL was relatively fixed in position within the eye. The ocular aberrations of the eye changed with increased accommodative demand, but not in a consistent manner among individuals. Those aberrations that appeared to be most affected were defocus, vertical primary and secondary astigmatism, vertical coma, horizontal and vertical primary and secondary trefoil, and spherical aberration.

CONCLUSIONS

Some of the reported near vision benefits of the Tetraflex accommodating IOL appear to be due to changes in the optical aberrations because of the flexure of the IOL on accommodative effort rather than forward movement within the capsular bag.

Alkylphosphocholines as a potential pharmacologic prophylaxis for posterior capsule opacification

PURPOSE

To evaluate the effect of alkylphosphocholines (APCs) on human lens epithelial cell (LEC) proliferation, attachment, and migration in a well-established in vitro model.

SETTING

Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany.

METHODS

The immortalized human LEC line HLE-B3 was incubated for 24 hours with APC in different concentrations in the presence of Eagle's modified essential medium supplemented with fetal calf serum under standard cell-culture conditions. The trypan blue exclusion test and live-dead assay were performed to exclude toxic concentrations. To determine cell proliferation, cells were incubated with APCs at the maximum slope of the growth curve for 24 hours before the tetrazolium dye-reduction assay (MTT test) was performed. After cells were seeded on coated 24-well plates, incubated with APCs, and rinsed with phosphate-buffered saline, cell attachment was assessed by the MTT test. Migration was determined by a modified Boyden chamber method after incubation of LECs with APCs.

RESULTS

Alkylphosphocholines were effective inhibitors of human LEC proliferation, attachment, and migration at nontoxic concentrations in vitro. The 50% inhibitory concentration was close to 0.1 mM. An APC concentration of 1.0 mM accounted for the following: inhibition of cell proliferation of more than 80%, reduction in cell attachment to 66.5%, and inhibition of cell migration of more than 90%. All effects were dose dependent. No toxic effects were detected compared with controls.

CONCLUSIONS

Alkylphosphocholines might have the potential for topical application as a single-dose agent to prevent posterior capsule opacification formation. However, further studies are needed before a clinical application can be considered.

Time course of accommodation after implantable collamer lens implantation

PURPOSE

To assess the time course of accommodative function after Implantable Collamer Lens (ICL) implantation and to investigate the relationship between patient age and accommodation in ICL-implanted eyes.

DESIGN

Prospective, nonrandomized clinical trial.

METHODS

We prospectively examined 69 eyes of 40 consecutive patients with myopic refractive errors of -3.25 to -22.75 diopters (D) who were undergoing ICL implantation. We assessed the amplitude of accommodation using an accommodometer before and one, three, six, and 12 months after surgery. We also investigated its relationship with patient age.

RESULTS

The accommodation was 6.36 +/- 3.94 D (mean +/- standard deviation) before surgery and 4.89 +/- 2.72 D, 4.98 +/- 2.67 D, 5.16 +/- 2.72 D, and 5.72 +/- 2.85 D at one, three, six, and 12 months after surgery, respectively. The variance of data was statistically significant (P = .02, repeated-measures analysis of variance). Multiple comparisons demonstrated significant differences between measurements made before surgery and at one month after (P = .004, Fisher least significant difference test), before surgery and at three months after (P = .007), and before surgery and at six months after (P = .01). There was a significant correlation between patient age and accommodation before (Pearson correlation coefficient, r = -0.665; P < .001) and one year after (r = -0.803; P < .001) ICL implantation.

CONCLUSIONS

Accommodation was impaired transiently in the early postoperative periods, and then recovered gradually over time, indicating that transient dysfunction of the ciliary muscles by ICL fixation may occur after ICL implantation even if the crystalline lens remained intact. As patients aged, the amplitude of accommodation became significantly smaller not only in normal eyes but also in ICL-implanted eyes.