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Financial disclosure
Alcon, Zeiss, J&J AMO, Physiol, Thea, Allergan, Santen, Dompe, Cutting Edge)
Race
for
Progress
!

What is new : to pay for progress ?
4 properties
 Asphericity (Q factor)
• correlated to Spherical aberration
• AS – or AS free / improve quality of vision
• Integrated on optic by manufacter (no extracost)
 Toricity : access to cylindrical correction > 1
D
 Presbyopia
• Correction : accommodative (the ideal …still
awaited)
• Compensation : Multifocaux …EDOF

Thanks to surgical progress
 Mini and micro-incision : no induced astigmatism +
Sutureless
 Fast recovery + safety increase
 Emmetropia can be targeted
 LRI combinable on a femtocataract ?? platform
Thanks to better understanding and control of
optics
 Toric IOLs for sphero-cylindrical correction
…asfor long-lasting glasses and contact lenses
 Asphericity linked to spherical aberrations : vision
quality
 Why not spectacles independence ? : Multifocal
…EDOF

« True »
Cataract
 BCVA < 0.6 ? Official but outdated criterian
 Loss of quality of vision to integrate (constrast, halos, glare)
 LOCS III
 New indices : OSI (OQAS) / DLI (i.Tracey) / densitometry
(Pentacam, OCT)
 > 65 years old
« PRELEX » : Refractive Clear lens
exchange
 Demand for spectacle independance
 « Prevent » cataract occurrence
 Increase retinal risk ? < 56 years old+ LA >
24 mm
Patient selection
and
information +++
Raise the level of ambition : create
demand
High expectations : benefit / risk = > 55
years When Presbylasik and
monovision insufficient
IO solution = the
winner
of presbyopia
correction

Poor candidate selection
 No respect of ocular and general contraindications
 No assessment of expectation and needs
Inadequate measurements :
 No refined evaluation of ocular structures (lens, retina…)
 No optical biometry
 No topography
 …Neither aberrometry
 Binocular vision, Kappa angle
Insufficient patient Information
 Decision tree of available strategies not described
 Limits and benefits not listed

Intraoperative complications
?
 Risk = those of a cataract surgery
 If capsular rupture …nomultifocal implantation (decentration,
tilt)
 …Thenbinocular balance ?
Secondary cataract =
PCO
 Not acomplication ….butearlier visual penalization than monofocal
 Y
AGnever <6 months, wider …respectthe optic of IOL(carefulfocus)
Quid …ifan ocular disease occurs ?
 RD : no surgical problem
 Glaucoma : neuropathy alters visual field whatever the
correction
 Maculopathy : more delicate surgery
= loss of the ability to use multifocality (as
spectacles) but probably no exchange
In case of multifocal
IOLs
Multifocal IOLs
or EDOF (included
Pinhole)

Hogan JC, Kutryb MJ – Mo Med 2009 – Jan-Feb 106(1) : 78-
82
Objective measurements
 UDVA(4m) + UNVA(30 - 40 cm) +UIVA (60-70 cm)
 Refraction
 BDCVA + UNVA with BCVA (fordistance)
 Defocus curve, amplitude of accommodation
 Capacity for near : reading speed
 Quality of vision
• Contrast sensitivity +/- glare
• MTF
• Aberrometry (spherical aberrations) (no reliability of H.Shack WF)
Mystery of dysphotopsia
Questionnaire of life +++ : satisfaction rate

• Incomparable / predecessors (halos, VP??)
• Thanks to optical refinements
o Asphericity, toricity
o Apodization, smoothing
• If patient informed....over 90%
happy without glasses
o Light-dependent visual performances
o No restoration of the 20-year-old eye
o Just compensate for the loss of accommodation
• Marques EF - JCRS 2015 feb 41(2) 354-63
Comparison of visual outcomes of 2 diffractive trifocal IOLs (indépendances lunettes 100%, comparables
)
• Cochener B – JRS 2015

 Refractiv
e Better respect of vision
quality
 Often limited in near vision
 Diffractive : bi or
trifocal
 Thefavorites
…hydrophilic,hydrophobic
 Optics in constant refinements
 Refractive or diffractive toric : a true
benefit
 ½ patient have an astigmatism > 1D
 Used to represent THE cause for ReTt : PRK,
LRI…
 Piggy back ? In
expansion
 In front of a monofocal , in
sulcus
 Additive surgery …..reversible !
Benefited
of added
asphericity
Trifocal : « smart
concepts »
• No more light loss / bi
• gain in intermediate
vision
Toric : allowed
access
to emmetropia
Can be « tried »
or 2ary
implanted

AT 839 – Zeiss
• Hydrophylic
• 2X C loop for
toric Pod F
• Plate
• Toric version
• Hydrophylic (PCO)
• 2 add : 1.66 + 3.33
D
• + smoothing
• Quadrifocal (2
far)
• « enlighten »
• Hydrophobic ,
GF ?
No more loss of light (15%) /
bifocal
But gain in intermediate vision
Ev
i
dence based : efficacy +
safety Target =
emmetropia
MicroF Fine
Vision
Physiol
PanOptix -
Alcon
VI 70
cm
VI 60
cm

0,
0
0,
1
0,
2
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0,
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5
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6
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4,0
-
3,0
-
2,0
-
1,0
0,
0
1,
0
2,
0
FineVisio
n
Acrilisa
Tecnis
FineVisi
o
n Dr
Gautier

Various Principles for one
Objective
 No light division on multiple focal
points
 Better vision quality than multifocal
 Better sensitivity to contrasts
 Less photic phenomena
On the other hand
 VA by far well preserved
 Optimized intermediate
AV
 Near vision less efficient
Current elective
indications
• Elderly patients
• Patients with retinal risk
• Surgeon ...concerned
about multifocality

Focal (diffractive)
zones
Asphericity
modulation
Pinhol
e
Symfony ®, AT Lara
®
MiniWell ®
IC8 ®
Compromise
• Monofocal /
MF
• Minimonovisio
n

Micro-Monovision recommanded : - 0.5 to -0.75D
 On non dominant eye
 Below : dependance of glasses for near
 Beyond : halos induced
Higher tolerance to remaining error
 Cylinder and /or sphere up -0.75 D
 Less demanding of emmetropia achievement than
Multifocal
Quality of vision
 Comparative study with diffractive trifocal IOLs
 Comparable level of functional symptoms (6 to 10%)

First dare one....
Then let yourself be convinced of the results
Then refine your choice
 According to his conviction: materials, drawing
 According to the needs of the custom match patient
 Combine them " mix match " (dominant :far / dominated:
near ?)
Watch for evolutions...full explosion
 For increasing accuracy
 ...IOL with "increased depth of field"?
 including the integration of the femtocataract: what gain?
Toric :
• ≽ 0.75 D MF

A complete
range :
• AT Lisa : Bi (809)(2006) / tri (839) +/-toric
(939)
(2013)
• AT Lara +/- toric (2017)
One piece / 4 haptics design :
• Refractive /
diffractive
• Concept LISA
• L : Light distributed asymmetrically (between Fand N: ↓halos and
glare)
• I : Independency from pupil size
• S : SMP technology no right angles for reduced light scattering
• A : Aberration correcting optimized aspheric optic
(↑contrast sensitivity, depth offield and sharper vision)
square edgedesign
+ 360° anti-PCObarrier
= for doublePCO
protection

First 1.8 mm
MICS
First bitoric
MICS
First
multifocal
1.8 mm
MICS
First toric
multifocal
MICS
First trifocal
preloaded
MICS
200
1
200
6
200
7
201
2
201
7
First trifocal
toric
Preloaded
MICS
200
5
201
3
Next
generation
EDoF
CT
ASPHINA
CT
SPHERIS
AT TORBI AT LISA AT LISA toric BLUEMIXS
(2010)
AT LISA tri AT LISA tri
toric
AT LARA
Easy and
save
preloaded
MICS
injector
201
0
A continuous track of
INNOVATION

Bifocal : Phase zones equal in all zones, which contributes to
near vision
Trifocal : Phase zones different in even (near vision) and
uneven (intermediate) zones
True living vision : additional
value of intermediate vision (fills
the gap)
5 German multicentric clinical data collection / n = 60; 1 month follow-up
6 Prospective case series, Peter Mojzis, MD, Ph. D, FEBO / n = 26; 6 month
follow-up

3 Detlev Breyer, Introducing trifocal AT LISA tri 839MP. Presentation given at APACRS symposium, Singapore, 2013 / n = 38 patients; 3
months follow-up
6 Prospective case series, Peter Mojzis, MD, Ph. D, FEBO (HavlíčkůvBrod, Czech Republic) / 6 month follow-up
6
3

• Mean EPCO score for the central 4,3mm zone of 0,26 ±
0,35 and a Nd:YAG laser capsulotomy rate of 2% at 1
year follow-up
Prospective case series, Peter Mojzis, MD, Ph. D, FEBO / n = 50; 12 month
follow-up0
Prospective case series, Patrick Versace, MD (Sydney, Australia) R² = 0,94
0
3
2
1
4
5
6
y =-10,9-11x0 4 5 6
VGAUSTRALIA
mean 0.21 D (from 0.00 to 0.68)
Achieved
change
in
CYL
[D]
1 2 3
Attempted Cyl [D]
7 eyes - 1 m postOP
overcorrected
undercorrected
• AT Lisa Bi : 90% < 7° rotation
• AT Lisa tri : same encouraging
outcome

AT LARA 829 (MP) : (cf Frank Goes)
for less side effect than multifocal , but no loss of BNV than
Monovision
 4 haptics
 Hydrophilic acrylic IOL (hydrophobic surface properties)
 Optical « light bridge » on ant surface (continuous
extends the range of focus )
 Aberration neutral aspheric design optic
 Advanced chromatic aberrations correction (better contrast
sensitivity)
 « Smooth microphase » (minimize light scattering)

Whereas for users who are convinced up to 40% of their
IOLs
Probably
 Frightened by the unpopularity of their
past
 Fear of their complications
• Wrong patient selection
• Non respect of the operating conditions (integrity bag,
axis...)
 More refractive approach
 Requires an exploration platform
 Requires discussion, selection,
information
 ....Pb of cost
Education +
Information of
MD
ESCRS 2016 survey:
40% tri / 34% Bi / 18%
EDOF

If there’s no restoration …Progress in Optics allow an
efficient compensation of accommodation loss.
Multifocal IOLs of yesterday have no comparison with
those of today…neither to those of tomorrow ?!
EDOF IOLs : an interesting compromise that may
extend the
number of patients and surgeons ?

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