Unilateral Implantation of Presbyopic Correcting IOLs

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Unilateral Implantation of Presbyopic
Correcting IOLs A Comparison of ReZoom,
ReSTOR, Crystalens 5.0, and Crystalens HD

• Frank A. Bucci, Jr, MD
• Bucci Laser Vision Institute
• Wilkes Barre, PA - USA

No Financial Interest
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• Purpose To evaluate pt. satisfaction the
  visual outcome of
• 295 pts. having received either 1 ReZoom
  (RZ), 1 ReSTOR (RS),
• 1 Crystalens-5.0 (CR-5.0), or 1 Crystalens
  HD (CR-HD) for the
• correction of presbyopia

Methods
KPE RL Hyperopic Myopic Emmetopia
ReZoom 80 58 25 39 36
ReSTOR 21 25 39 26 35
CR-5.0 35 12 40 45 15
CR-HD 47 17 23 47 30
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Results Unilateral Presbyopic
IOLs
ReZoom ReSTOR CR 5.0 CR HD
n 138 n 46 n 47 n 64
Mean Age 57 59 60 61
SCVA (preop) 20 / 315 20 / 126 20 / 279 20 / 329
SCVA (post op) 20 / 28 20 / 29 20 / 43 20 / 37
Sph.Equiv. (postop) - 0.21 0.19 - 0.52 - 0.66
Near mean J 2.0 1.6 3.2 2.7
Intermediate 3.6 4.0 3.0 2.8
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• June 05 -- December 05
  46 ReSTOR implanted
• Subjective Response of Patients - High
  of pts. Very Disappointed
• poor inter. (no computer vision)
  perceived near focal point too close
• generalized waxy vision at all focal
  points
• SUBTLE, but distinct loss of UDVA
  BCDVA dist. acuity

Poor Patient Satisfaction - Vaseline Vision
Dysphotopsia 3/46 Eyes (6.52)
3 emmetropic lensectomy pts. mean age
50 years 3 explantations (exchanged for
3 ReZoom)
Overall Outcomes
Consistent objective data
Very poor subjective responses
Final Outcome
Use of ReSTOR 4.0 as
unilateral IOL Abandoned

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• January 06 January 08
  138 ReZoom Implanted
• Subjective Response of Patients
• High of patients very satisfied
• pleased with distance vision (esp.
  during the day)
• pleased with enhanced intermediate
  vision
• gained substantial amounts of reading
• non haloed image in opposite eye at
  night with CL or emmetropia

Pearls for Success Careful Pre op
Counseling avoided disappointments re
need for reading glasses for fine print
avoided disappointments re need of
neuroadaptation for halos at night
Less halos and more rapid neuroadaptation
observed with ReZoom vs. Array
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Discussion

• Success is dependent upon 3 key factors
• as observed with bilateral presbyopic
  IOLs
• Knowledge of and efficient placement
  of PC IOL
• Strong Dr. Communication skills to
  facilitate
• ? proper pt. selection
• ? effective pre op counseling
• ? management of post op
  expectations
• Aggressive reduction in residual
  refractive errors

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Discussion ReZoom

• ReZoom was successful as a unilateral
• Broad range of vision
• ? distance ? intermediate ?
  near
• Pre op counseling was provided on
  the need for
• patience with neuroadaptation for
  halos
• Unilaterally, need for neuroadaptation
  much less
• because of the non-haloed image in
  opposite eye
• Conversion to bilateral with TMF
  diffractive has
• been shown to be very successful,
  if necessary

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Discussion TECNIS Multifocal

• TMF may be successful as a unilateral
  diffractive
• multifocal IOL, even though the ReSTOR
  failed
• European data 1,2,3 has shown superior
  intermediate
• vision for TMF vs. RS
• Outstanding near vision in both moderate
  and
• bright light
• Wider near focal range vs. RS
• No waxy vision
• 1 Scheider A., et al, European Society of
  Cataract and Refractive Surgery, 2006
• 2 Toto, L., et al, Journal of Cataract and
  Refractive Surgery, 2007
• 3 Hutz, W., et al, Journal of Cataract and
  Refractive Surgery, March 2008

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Discussion Crystalens

• Excellent distance with no halos at
  night
• the only lens with entirely no light
  phenomenon at night
• Excellent intermediate in high percentage
• note that the mean J intermediate
  for CR-HD is better than RZ
• but it has a higher variance and
  some patients may lack minimal
• intermediate
• Improved near
• note that the CR-HD has one half J
  line improved near
• vision compared to the CR-5.0
  without influencing quality
• of distance

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Discussion Crystalens
Unfortunately, even with the improved
near (J2.7 vs. 3.2) and intermediate
(J2.8 vs. 3.0) vision of the CR-HD
compared to the CR-5.0 A
significant of patients would still be less
than satisfied at near unless
some degree of monovision was
pursued with sacrificing of distance
vision There is also significantly
less predictability with all
Crystalens for both distance and near
targets which would be more
accentuated when used unilaterally
Conversion to bilateral with TMF would
likely be very successful
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Discussion ReSTOR

• One would expect the ReSTOR 3.0 with
  improved
• intermediate and a more comfortable focal
  point to
• function better than the ReSTOR 4.0.
  However, the
• ReSTOR 3.0 still reads poorly in dim
  light. Thus if a
• surgeon is considering a diffractive IOL,
  the TECNIS
• multifocal with excellent near vision at
  all levels of
• light (and pupil size) should be the lens of
  choice.

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Conclusions / Final Comments

• 1. With proper preop counseling and surgical
  planning all of the current presbyopic IOLs
• (except the ReSTOR 4.0) can work well for
  reducing the patients dependency on glasses
• or contact lenses.
• 2. Strengths and weaknesses of each IOL are
  obviously similar to what is
• observed in bilateral circumstances. The
  RZ has the broadest range of vision
• which is an important unilateral
  characteristic, but less halos would be
• ideal. Conversion to RZ/TMF is
  synergistic, and powerful.
• 3. On average, unilateral results for the
  CR-HD are encouraging with no halos
• being a plus. Conversion to bilateral
  with TMF is very synergistic and a solution to
• the 30 that are J4 at near because
  of a wide variance in results.
• 4. Even though RS 3.0 will be an
  improvement to RS 4.0, the TMF will be the
• diffractive lens of choice with
  excellent near vision in all lighting
  conditions.
• TMF could likely become the unilateral
  presbyopic lens of choice.

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• Thank You