Refractive Lens Surgery

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2 CORE MESSAGES Refractive Lens Exchange as a Refractive Surgery Modality Richard S. Hoffman, I. Howard Fine, Mark Packer 2 New multifocal and accommodative lens technology should enhance patient satisfaction. 2 Newer lens extraction techniques using microincisions and new phacoemulsification technology will enhance the safety of this procedure. 2 Ultimately, refractive lens exchange will be performed through two microincisions as future lens technologies become available. 2 Attention to detail with regard to proper patient selection, preoperative measurements, intraoperative technique, and postoperative management has resulted in excellent outcomes and improved patient acceptance of this effective technique. Advances in small incision surgery have enabled cataract surgery to evolve from a procedure concerned primarily with the safe removal of the cataractous lens to a procedure refined to yield the best possible postoperative refractive result. As the outcomes of cataract surgery have improved, the use of lens surgery as a refractive modality in patients without cataracts has increased in popularity. Removal of the crystalline lens for refractive purposes or refractive lens exchange (RLE) offers many advantages over corneal refractive surgery. Patients with high degrees of myopia, hyperopia, and astigmatism are poor candidates for excimer laser surgery. In addition, presbyopia can only be addressed currently with monovision or reading glasses. RLE with multifocal or accommodating intraocular lenses (IOLs) in combination with corneal astigmatic procedures could theoretically address all refractive errors including presbyopia, while simultaneously eliminating the need for cataract surgery in the future. Current attempts to enhance refractive results and improve functional vision with customized corneal ablations with the excimer laser expose another advantage of RLE. The overall spherical aberration of the human eye tends to increase with increasing age [1–4]. This is not the result of significant changes in corneal spherical aberration but rather increasing lenticular spherical aberration [5–7].
4 R.S. Hoffman · I.H. Fine · M. Packer This implies that attempts to enhance visual function by addressing higher-order optical aberrations with corneal refractive surgery will be sabotaged at a later date by lenticular changes. Addressing both lower-order and higher-order aberrations with lenticular surgery would theoretically create a more stable ideal optical system that could not be altered by lenticular changes, since the crystalline lens would be removed and exchanged with a stable pseudophakic lens. The availability of new IOL and lens extraction technology should hopefully allow RLEs to be performed with added safety and increased patient satisfaction. 2.1 Intraocular Lens Technology 2.1.1 Multifocal IOLs Perhaps the greatest catalyst for the resurgence of RLE has been the development of multifocal lens technology. High hyperopes, presbyopes, and patients with borderline cataracts who have presented for refractive surgery have been ideal candidates for this new technology. Historically, multifocal IOLs have been developed and investigated for decades. Newer multifocal IOLs are currently under investigation within the USA. The 3M diffractive multifocal IOL (3M, St. Paul, Minnesota), has been acquired, redesigned, and formatted for the three-piece foldable Acrysof acrylic IOL (Alcon Laboratories, Dallas, Texas). Pharmacia previously designed a diffractive multifocal IOL, the CeeOn 811 E (AMO, Groningen, The Netherlands), which has been combined with the wavefront-adjusted optics of the Tecnis Z9000 with the expectation of improved quality of vision [8] in addition to multifocal optics. The only multifocal IOL currently approved for general use in the USA is the Array (AMO, Advanced Medical Optics; Santa Ana, California). The Array is a zonal progressive IOL with five concentric zones on the anterior surface. Zones 1, 3, and 5 are distancedominant zones, while zones 2 and 4 are near dominant. The lens has an aspheric design and each zone repeats the entire refractive sequence corresponding to distance,intermediate, and near foci. This results in vision over a range of distances [9]. A small recent study reviewed the clinical results of bilaterally implanted Array multifocal lens implants in RLE patients [10]. A total of 68 eyes were evaluated, comprising 32 bilateral and four unilateral Array implantations. One hundred per cent of patients undergoing bilateral RLE achieved binocular visual acuity of 20/40 and J5 or better, measured 1–3 months postoperatively. Over 90% achieved uncorrected binocular visual acuity of 20/30 and J4 or better, and nearly 60% achieved uncorrected binocular visual acuity of 20/25 and J3 or better. This study included patients with preoperative spherical equivalents between 7 D of myopia and 7 D of hyperopia, with the majority of patients having preoperative spherical equivalents between plano and +2.50. Excellent lens power determinations and refractive results were achieved. Another recent study by Dick et al. evaluated the safety, efficacy, predictability, stability, complications, and patient satisfaction after bilateral RLE with the Array IOL [11]. In their study, all patients achieved uncorrected binocular visual acuity of 20/30 and J4 or better. High patient satisfaction and no intraoperative or postoperative complications in this group of 25 patients confirmed the excellent results that can be achieved with this procedure. 2.1.2 Accommodative IOLs The potential for utilizing a monofocal IOL with accommodative ability may allow for RLEs without the potential photic phenome-
Page 2 and 3: Refractive Lens Surgery I. H. Fine
Page 4 and 5: Editors I. Howard Fine, MD Mark Pac
Page 6 and 7: Preface The first recorded time a h
Page 8 and 9: X Contents Chapter 14 AcrySof ReSTO
Page 10 and 11: Contributors Jorge L. Alio, MD, PhD
Page 12 and 13: 1 The Crystalline Lens as a Target
Page 16 and 17: na that have been observed with som
Page 18 and 19: piration through two separate incis
Page 20 and 21: 6 R.S. Hoffman · I.H. Fine · M. P
Page 22 and 23: 8 R.S. Hoffman · I.H. Fine · M. P
Page 24 and 25: 10 R.S. Hoffman · I.H. Fine · M.
Page 26 and 27: 12 M. Packer · I.H. Fine · R.S. H
Page 36 and 37: 22 J.T. Holladay 4.1 Introduction T
Page 38 and 39: 24 J.T. Holladay but only seven pre
Page 40 and 41: 26 J.T. Holladay from morning to ni
Page 42 and 43: 28 J.T. Holladay 4.3.2.2.3 Corneal
Page 44 and 45: 30 J.T. Holladay rienced this condi
Page 46 and 47: 32 J.T. Holladay many of these pati
Page 48 and 49: 34 J.T. Holladay IOL eRx V 1336 =
Page 50 and 51: 36 J.T. Holladay raised. A more tho
Page 52 and 53: 38 J.T. Holladay rior segment laser
Page 54 and 55: 40 D.D. Koch · L.Wang corneal refr
Page 56 and 57: 42 D.D. Koch · L.Wang Table 5.1. M
Page 58 and 59: 44 D.D. Koch · L.Wang Fig. 5.4. Nu
Page 60 and 61: 46 D.D. Koch · L.Wang Fig. 5.5. Ce
Page 62 and 63: 48 D.D. Koch · L.Wang ∑ Double-K
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50 L.D. Nichamin surgeon the abilit
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52 L.D. Nichamin Table 6.1. The Nic
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54 L.D. Nichamin 3.2 mm, its neglig
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56 L.D. Nichamin Fig. 6.4. The Nich
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58 L.D. Nichamin References 1. Anon
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60 S. Bylsma aphakic state. In cont
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62 S. Bylsma length),underwent full
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64 S. Bylsma K-Astigmatism
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66 S. Bylsma STIOL in the reversed
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68 S. Bylsma about the dynamics at
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8 Correction of Keratometric Astigm
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Fig. 8.2. AcrySof toric IOL implant
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Fig. 8.3. Mean absolute residual cy
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References 1. Hoffer KJ (1980) Biom
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80 M. Packer · I.H. Fine · R.S. H
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10 The Eyeonics Crystalens Steven J
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Fig. 10.3. Under binocular conditio
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Fig. 10.6. Anterior movement of the
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Fig. 10.7. One- and 3-year data fro
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10.6 Postoperative Considerations C
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10. Dell SJ (2004) Objective eviden
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100 N.X. Nguyen · A. Langenbucher
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12 CORE MESSAGES Synchrony IOL H. B
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Fig. 12.1. The single-piece silicon
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12.5 Clinical Results Clinical tria
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Fig. 12.6. Retroillumination photog
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References 1. Fisher RF (1973) Pres
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124 F.M. Sarfarazi 13.1 The Nature
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126 F.M. Sarfarazi Fig. 13.4. Lens
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128 F.M. Sarfarazi Fig. 13.5. Mecha
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130 F.M. Sarfarazi Fig. 13.9. Secon
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132 F.M. Sarfarazi Fig. 13.14. Sche
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134 F.M. Sarfarazi Fig. 13.18. Work
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136 F.M. Sarfarazi References 1. Ma
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138 A. Mirshahi · E.Terzi · T. Ko
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15 The Tecnis Multifocal IOL Mark P
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Fig. 15.1. The Alcon AcrySof multif
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Fig. 15.4. Multifocal vs. monofocal
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16 Blue-Light-Filtering Intraocular
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Fig. 16.2. Cultured human RPE cells
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tion to benefiting from less exposu
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16.7 Blue-Light-Filtering IOLs and
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15. Marshall J, Mellerio J, Palmer
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17 CORE MESSAGES The Light-Adjustab
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Fig. 17.2 a-c. Cross-sectional sche
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17.4 Animal Studies Dr. Nick Mamali
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Fig. 17.8. A laser interferogram (l
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enhanced visual function that remai
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13. Mather R, Karenchak LM, Romanow
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174 S. Norrby Fig. 18.1. Small cale
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176 S. Norrby Fig. 18.3. Scheimpflu
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178 S. Norrby Fig. 18.4. Schematic
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180 S. Norrby there was fibrin form
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182 S. Norrby material had a Young
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184 S. Norrby Koopmans et al. [28]
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186 S. Norrby 40. De Groot JH, Zuru
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188 L. Nordan · M. Morris regular
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190 L. Nordan · M. Morris produce
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20 CORE MESSAGES Bimanual Ultrasoun
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for an irrigating manipulator or ch
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5. Tsuneoka H, Shiba T, Takahashi Y
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200 J.L. Alio · A. Galal · J.-L.R
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22 CORE MESSAGES The Infiniti Visio
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Fig. 22.3. The AquaLase handpiece u
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23 CORE MESSAGES The Millennium Ros
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Fig. 23.1. Bausch & Lomb’s new cu
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Fig. 23.2. Advanced flow system car
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Fig. 23.5. Pulse or burst mode with
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24 CORE MESSAGES The Staar Sonic Wa
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Fig. 24.2. The tip undergoes compre
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the sonic tip moves back and forth
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25 CORE MESSAGES AMO Sovereign with
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Fig. 25.3. Schematic diagram of cav
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the Sovereign Compact (see Fig. 25.
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234 M. Packer · R.S. Hoffman · I.
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27 Conclusion: The Future of Refrac
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240 Subject Index Contrast sensitiv
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242 Subject Index P Pachymetry 53,
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Refractive Lens Surgery

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