Presentation by Detlev Breyer (MD) at ASCRS 2017 in Los Angeles. Title: Individualized Patient Care – Comparison of Different Variants of Blended Vision with Rotational Asymmetric Multifocal Intraocular Lenses (MIOL). This presentation discusses an innovative treatment of cataracts and presbyopia.

1. Individualized Patient Care - Comparison of Different Variants of Blended
Vision with Rotational Asymmetric Multifocal Intraocular Lenses (MIOL).
E. Taylor, D. Breyer, H. Kaymak, K. Klabe, P. Hagen, F. Kretz, G. Auffarth

2. Financial Disclosure
Breyer, Kaymak & Klabe Eye Surgery and Premium Eyes are Consulting, Study Center & MAB for:
Abott, Alcon, AlimeraSciences, Allergan, AMO, Bayer, Carl Zeiss Meditec, Ellex, Fluoron, Geuder, iOptics, LensAR,
Novartis, Oculentis, Oertli, Revision Optics, Santen, Staar Surgical, Thea, Topcon, Visufarma, Ziemer

3. • Rotationally asymmetric
• Purely refractive bifocal optic
 No diffractive ring structures
 High light transmission
• Anterior: Sector-shaped segment with
+1.5D (Comfort MF15) or
+2.0D (Mplus MF20) addition for
improved intermediate vision
• Posterior: Aspherical surface
• Optics and haptics with square edges
Pictures are used with the kind
permission of Oculentis
Theoretical Background:
Lentis Comfort MF15 and Lentis Mplus MF20

4. • Rotationally asymmetric
• Purely refractive bifocal optic
 No diffractive ring structures
 High light transmission
• Anterior: Sector-shaped segment with
+3.0D addition for improved near vision
Posterior: Aspherical surface
• Optics and haptics with square edges
• Small transition zones between additional segment
and the rest of the MIOL
Theoretical Background:
Lentis MplusX MF30

5. Distance [cm] 33 40 50 67 100 200
∞
Defocus [D] -3 -2.5 -2 -1.5 -1 -0.5
0
Comfort Emmetropic Vision:
• Bilateral: Comfort MF15 with +1.5D addition for improved intermediate vision
• Target refraction: Emmetropia in both eyes
Comfort Blended Vision:
• Dominant eye: Comfort MF15 with +1.5D addition, target refraction: Emmetropia
• Non-dominant eye: Lentis Comfort
Comfort MF15 with +1.5D addition, target refraction: -1.5D or
Mplus MF20 with +2.0D addition, target refraction: -1.25D
• Advantage: Increased range of high quality vision
• Stereoscopic vision in overlap region
Comfort Emmetropic / Blended Vision

6. Distance [cm] 33 40 50 67 100 200
∞
Defocus [D] -3 -2.5 -2 -1.5 -1 -0.5
0
Comfort + MplusX:
• Dominant eye: Lentis Comfort
• Non-dominant eye: Lentis MplusX (toric)
• Target refraction: Emmetropia in both eyes
• Advantage here: Reading fine print
• Brought overlap for stereoscopic vision
Compare all variants!
(Retrospective data analysis)
Further idea: Combine segmental MIOLs with different additions
Comfort + MplusX Blended Vision

7. • Idea 2013 Singapore APACRS – Laser blended vision
• First presentation 2014 London ISOP & ESCRS
• Science 2015 Barcelona ISOP & ESCRS
Blended Vision with Segmental MIOL = Duesseldorf Formula

8. Materials and Methods: Preoperative Patient Data
Lentis MIOL Comfort MF15 Mplus MF20 MplusX MF30
Number of Eyes 1281 71 61
M:F [%] 45:55 37:63 41:59
Age [years] 67±10 62±13 62±12
number of CAT-surgeries 1130 48 48
number of RLE 122 21 13
Spherical Equivalent [D] -0.9±4.3 -1.2±4.2 0.6±3.6
Cylinder [D] -0.9±0.8 -1.0±1.1 -0.9±0.9
CDVA [logMAR] 0.3±0.2 0.2±0.2 0.3±0.3
UDVA [logMAR] 0.7±0.4 0.7±0.5 0.6±0.3
IOL-Power [D] 19.6±5.0 20.2±5.5 21.8±4.5
Target refraction [D] -0.4±0.5 -1.0±0.5 -0.3±0.2

9. Postoperative examinations
(3 – 6 months):
• Manifest Refraction
(Phoropter)
• Visual Acuity
(ETDRS reading chart)
• Defocus curves
• Contrast sensitivity
(Ginsburg-Box, Revision Optics)
• Subjective photopsia
(Halo&Glare Simulator, CZM)
• Patient questionnaire
(Quality of Vision)
Materials und Methods: Postoperative Examinations

10. Results: Predictability
0%
25%
50%
75%
100%
(-oo, -1) [-1, -0.5) [-0.5, 0.5] (0.5, 1] (1, oo)
Percentageofeyes[%]
∆SE [D]
Predictability: SE(post) - SE(target)
Comfort MF15 (n=643)
Mplus MF20 (n=51)
MplusX MF30 (n=43)
• Small deviation from emmetropia
• Segment with additional power makes it harder to measure postoperative manifest
refraction precisely (especially in case of MplusX with +3.0D addition)

11. Monofocal IOL (mon, cc)
MplusX MF30 (mon, cc, n=12)
Mplus MF20 (mon, cc, n=17)
Comfort MF15 (mon, cc, n=63)
Reference Curve VA=1,0 (mon, sc)
0.00
0.25
0.50
0.75
1.00
1.25
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
DecimalVA
Defocus [D]
Results: Monocular Defocus Curves
n = number of eyes
mon = monocular
bin = binocular
sc = uncorrected
cc = distance corrected
EV = emmetropic vision
BV = blended vision
% = MIOL capacity
(area under curve)
72%
74%
43%
76%
100%

12. Monofocal IOL (mon, cc)
Comfort MF15 (mon, cc, n=63)
Comfort EV (bin, sc, n=36)
Comfort BV (bin, sc, n=56)
Reference Curve VA=1,0 (mon, sc)
0.00
0.25
0.50
0.75
1.00
1.25
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
DecimalVA
Defocus [D]
Results: Comfort MF15
n = number of eyes
mon = monocular
bin = binocular
sc = uncorrected
cc = distance corrected
EV = emmetropic vision
BV = blended vision
% = MIOL capacity
(area under curve)
85%
43%
100%
72%
95%
Binocular defocus curve as superposition of the monocular ones

13. Monofocal IOL (mon, cc)
Comfort MplusX (bin, sc, n=22)
Comfort EV (bin, sc, n=36)
Comfort Mplus BV (bin, sc, n=32)
Comfort BV (bin, sc, n=56)
Reference Curve VA=1,0 (mon, sc)
0.00
0.25
0.50
0.75
1.00
1.25
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
DecimalVA
Defocus [D]
Results: The Duesseldorf Formula
n = number of eyes
mon = monocular
bin = binocular
sc = uncorrected
cc = distance corrected
EV = emmetropic vision
BV = blended vision
% = MIOL capacity
(area under curve)
85%
43%
91%
100%
92%
95%
Binocular defocus curve as superposition of the
monocular ones

14. • Contrast sensitivity measured with Ginsburg box:
 Perceive orientation of tilted wavy patterns
 Contrast decreases, frequency increases
• Test performed monocularly and distance-corrected
• For high spatial frequencies: slightly better results for Comfort
(more data for MplusX needed) 1
10
100
1000
1.5 3.0 6.0 12.0 18.0
contrastsensitivity
spatial frequency [cpd]
mesopic light conditions
ref. area juvenile eyes
MplusX (n=3) Comfort (n=16)
1
10
100
1000
1.5 3 6 12 18
contrastsensitivity
spatial frequency [cpd]
photopic light conditions
ref. area juvenile eyes
MplusX (n=3) Comfort (n=16)
Results: Contrast Sensitivity with Ginsburg Box

15. Simulation software from CZM:
• Subjective matching of patients photopsia via a graphic user interface
• Binocular and uncorrected
• 4 categories:
„mild“„none“
„moderate“ „severe“
Halo and Glare Simulator

16. 0%
25%
50%
75%
100%
"none" "mild" "moderate" "severe"
PercentageofEyes[%]
Strength of Halo&Glare
Halo & Glare Simulator
Phakic Eyes (n=126)
Comfort EV (n=30)
Comfort BV (n=36)
Results: Halo and Glare - Phakic Eyes & Comfort MF15
n = Number of eyes
Phakic Eyes = Employees
(age: 16-60)
EV = Emmetropic Vision
BV = Blended Vision
No significant differences between phakic eyes and Comfort EV/BV

17. 0%
25%
50%
75%
100%
"none" "mild" "moderate" "severe"
PercentageofEyes[%]
Strength of Halo&Glare
Halo & Glare Simulator
Phakic Eyes (n=126)
Comfort EV (n=30)
Comfort BV (n=36)
Comfort Mplus BV (n=30)
Comfort MplusX (n=10)
Halo & Glare Simulator: Duesseldorf Formula
n = Number of eyes
Phakic Eyes = Employees
(age: 16-60)
EV = Emmetropic Vision
BV = Blended Vision
No significant differences between groups

18. 0%
25%
50%
75%
100%
"very good" "good" "moderate" "bad" "very bad"
PercentageofEyes[%]
"How satisfied are your with the quality of vision in the far?"
Quality of Vision Questionnaire
Comfort EV (n=30)
Comfort BV (n=38)
Comfort Mplus BV (n=22)
Comfort MplusX (n=12)
• Patient questionnaire shows high satisfaction with quality of far vision
• Single ”bad” answers from patients with postoperative deviation from emmetropia in
dominant eye (Comfort MF15)
Results: Patient Questionnaire - Far
Dominant eyes with
postop. SE ≈ -1.0D

19. 0%
25%
50%
75%
100%
"very good" "good" "moderate" "bad" "very bad"
PercentageofEyes[%]
"How satisfied are your with the quality of vision in the intermediate?"
Quality of Vision Questionnaire
Comfort EV (n=30)
Comfort BV (n=38)
Comfort Mplus BV (n=22)
Comfort MplusX (n=12)
• Patient questionnaire shows high satisfaction with quality of intermediate vision
• No significant difference between the groups
Results: Patient Questionnaire - Intermediate

20. 0%
25%
50%
75%
100%
"very good" "good" "moderate" "bad" "very bad"
PercentageofEyes[%]
"How satisfied are your with the quality of vision in the near?"
Quality of Vision Questionnaire
Comfort EV (n=30)
Comfort BV (n=38)
Comfort Mplus BV (n=22)
Comfort MplusX (n=12)
• Patient questionnaire shows high satisfaction with quality of near vision
• Not expected: Comfort BV slightly “better” than Comfort MPlusX
(however not significant, more data needed)
Results: Patient Questionnaire - Near

21. • Knowledge of defocus curves and MIOL capacities is essential to
meet patients visual needs
• MIOL capacities:
- Comfort MF 15 Blended Vision: 95%
 Very good binocular VA over broad range!
- Comfort MF 15 MplusX MF30: 92% & high near VA
- Comfort MF 15 Mplus MF20 Blended Vision: 91%
- Comfort MF 15 Emmetropic Vision: 85%
• Good contrast sensitivity for Lentis Comfort
• Photopsia such as Halo&Glare (though physically inevitable for
MIOLs) only moderately increased compared to phakic eyes
• Very satisfied patients: Our favorite = Comfort BV
• Cave: Postoperative period of 1 - 3 months for satisfying
neuroadaption needed
Conclusion and Outlook

22. Thank you very much for your attention!