Sir Harold Ridley was the first to successfully implant an intraocular lens in 1949 using polymethylmethacrylate (PMMA). Early intraocular lenses had high complication rates of dislocation and glaucoma. The evolution of intraocular lens design led to foldable lenses made of silicone and acrylic materials that are implanted in the capsular bag for better stability and lower complication rates. Modern multifocal and toric intraocular lenses provide patients with independence from glasses by correcting presbyopia and astigmatism. Precise biometry and surgical technique are important for optimal outcomes with premium intraocular lenses.

1. Dr. Neeraj Agarwal

2. History:-
 Sir Harold Ridley was the
first to successfully implant
an intraocular lens on
November 29, 1949, at St
Thomas' Hospital ,
London.
 That first intraocular lens
was manufactured from
Polymethylmethacrylate
(PMMA.).

3.  INSPIRATION
 Inertness of intraocular plexiglass shards
 A medical student, Steve Perry questioned him why was he not
replacing the lens after removal
 Approximately 1000 Ridley IOLs implanted in the next 12
years
 Complications
 Disclocation : approx 20%
 Glaucoma : 10 %
 Uveitis
 Went into disrepute
 Strongly opposed by Sir Duke-Elders

4. First IOL

5. Structure of IOL
ACIOL PCIOL

6. The Evolution of Intraocular Lenses

7. EVOLUTION OF IOLs
1. First generation IOLs
 Ridley lenses
 Disadvantages – posterior dislocation
poor surgical technique
2. Second generation IOLs
 Rigid and semi-rigid anterior chamber IOLs
 Advantages – reduce posterior dislocation
 Disadvantage – corneal decompensation
UGH syndrome

8. 3. Third generation IOLs
 Iris supported lens
 Advantages- less corneal decompensation
 Disadvantages – iris chaffing
pupillary distortion
inflammation

9. 4. Fourth generation IOLs
 Modern anterior chamber lens
 Flexible loops and multiple point fixation
 Advantages – more stable, better design, less
complications
 Disadvantages – anterior chamber is not the
physiological site for IOL

10. 5. Fifth generation IOLs
 PMMA lenses
 Rigid posterior chamber iol

11. 6. Sixth generation IOLs
Foldable IOL
7. Seventh generation IOLs
Multifocal IOL

12. 8. Eighth generation
Accomodative IOL
Phakic refractive IOL

13. POSITIONING OF IOL
1. Posterior chamber
implantation
 Ciliary sulcus fixation
 In the bag fixation
Eg:- modified C loop type
IOL

14. Ciliary sulcus fixation

15. In-the-bag fixation

16. 2. Anterior chamber
implantation
 angle supported IOLs

17. 3. Iris- fixated lens
 Fixed on the iris with
claws,loops or sutures
 Eg- Singh and Worst’s
iris claw lens

19. ADVANTAGES OF IN-THE-BAG
PLACEMENT
 Proper anatomical site
 Symmetrical loop placement
 Intraoperative stretching or tearing of zonules is avoided
 Minimimal magnification (<2%); (20-30% aphakic glasses, 7-12% aphakic contact
lens, ACIOL 2-5% )
 Low incidence of lens decentration and dislocation
 Maximal distance from the posterior iris pigment epithelium, iris root, and ciliary
processes
 Loop material alteration is less likely
 Safer for children and young individuals
 Reduced posterior capsular opacification

20. Parts of an IOL
 OPTIC
Part of the lens that focuses
light on the retina.
 HAPTIC
Small filaments connected to
the optic that hold the lens in
place in the eye
HAPTE
N
OPTIC

21. HAPTIC DESIGN
 Plate haptic
 Loop haptic
 C-loop
 J-loop
 Modifies C-loop
 Plate-loop

22. Different types of haptic angulation relative to the
plane of optic:-
For posterior chamber lens:-
 100 anterior angulation to keep the optic part
away from the pupil.
For anterior chamber lens:-
 Posteriorly angulated lens to vault the
intraocular lens away from the pupil

23. ANGULATED HAPTICS ALLOW FOR ADEQUATE PUPILLARY
CLEARANCE AND ADHESION TO THE POSTERIOR CAPSULE

24. LENS CHEMISTRY
(Optic Materials)
 RIGID MATERIALS
 PMMA
(Polymethylmethacrylate)
 Water content <1%
 Refractive index 1.49
 Usually single piece
 FLEXIBLE MATERIALS
 Silicones
 Acrylics
 Hydrophilic
 Hydrophobic

25. FLEXIBLE MATERIALS
 Silicone
 Polymers of silicone and oxygen
 Since 1984; first material for foldable IOLs
 Hydrophobic (contact angle with water of 99°)
 1.41 to 1.46
 3 piece
 Thick optics (need larger incisons)
 Handling is difficult; loading into injector
 Bacterial adhesion
 Anterior capsule rim opacifies quickly
 Low PCO
 Lowest threshold for YAG laser damage
 Glistenings
 Adherence of silicone droplets

26. HYDROPHOBIC ACRYLIC
 Copolymers of acrylate and methacrylate
 1993 (Acrysof 3-piece lens)
 Most successful IOLs today
 Angle of contact with water is 73°
 3-piece or 1-piece designs
 1.44 to 1.55
 Easy handling; prone to mechanical damage
 At least a 2.2-mm incision
 Low PCO rates
 Good resistance to YAG laser
 Photopsias
 Glistenings
 BSS packaging (reach 4% water content before implantation)

27. HYDROPHILIC ACRYLIC
 Mixture of hydroxyethylmethacrylate (poly- HEMA) and
hydrophilic acrylic monomer
 End of the 1980s
 1.43
 18 -26% water content
 Contact angle with water is lower than 50°
 Single piece
 Easiest to handle; less mechanical/YAG laser damage
 Sub-2-mm incisions
 Higher PCO rate
 Low resistance to capsular contraction
 Calcium deposits

28. LENS CHEMISTRY
(Haptic Material)
 PMMA
 Polyimide (Elastimide)
 Polyvinylidene fluoride (PVDF)

29. PREMIUM IOLs
 MULTIFOCAL
 ACCOMODATIVE
 TORIC IOLs

30. Mindset of the Presbyopic Refractive
Patient
 Patients are interested in lifestyle, not pathology and
are happy to pay for the enhanced quality of life
 Old paradigm: Patient want to see better than they did
with their cataracts
 New paradigm: Patients want to see better than they
did before they developed cataracts

31. MULTIFOCAL IOLs
 Single IOL with two or more focal points
 Types
 Refractive
 Diffractive
 Combination of both

33. REFRACTIVE MULTIFOCAL IOLs
 Bull’s eye lens
 Concentric rings of different
powers
 Central addition surrounded by
distance optical power
 Annulus design
 3-5 rings
 Central for distance vision
 Near vision ring
 Distance vision ring

34. 12345
Bright light/ Distance dominant zone
Large Near dominant zone
Low light/ Distance
dominant zone
Distance zone
Near zone Aspheric transition
REFRACTIVE MULTIFOCAL IOLs

35.  Silicone MIOLs
 Array multifocal IOL (AMO)
 First FDA approved foldable MIOL
 5 concentric zones on its anterior surface
 50% distance, 37% near, 15% for intermediate vision
 Acrylic MIOLs
 ReZoom multifocal IOL (AMO)
 Zone 1,3 and 5 : distance
 Zone 2 and 4 : near
 60% distance, 40% near and intermediate
 PREZIOL (Acrylic)(Care Group)
 Manufactured by Indian company
 Also available as non foldable PMMA lens

36. Multiple focal points of a refractive multifocal IOL

37. DIFFRACTIVE MULTIFOCAL IOLs
 Anterior aspheric surface : basic
refractive power
 Multiple grooves on posterior surface
: diffractive power
 41% of light : distance
 41% : near vision
 Pupil independent

38. DIFFRACTIVE MULTIFOCAL IOLs

39. Multiple focal points of a diffractive multifocal IOL

40. Based on the average
corneal-surface
wavefront-derived
spherical aberration

41.  Tecnis Multifocal IOLs (AMO)
 ZM900 (Silicone)
 ZA00 (Acrylic)
 Optic Diameter 6.0 mm
 Optic Type
 Modified prolate anterior surface
 Total diffractive posterior surface

42.  Acrysof IQ ReSTOR (Alcon)
 Acrylic diffractive multifocal IOL with apodized design
 Optic diameter- 6 mm
 Refractive for distance, and a diffractive lens for near.
 16 rings distributed over central 3.6 mm
 Peripheral rings placed closer to each other
 Central rings : 1.3 µm elevated, near vision
 Peripheral 0.2 µm elevated, distant vision
 Anterior peripheral surface is modified to act as refractive
design

43. Apodization literally means "removing the foot“
To remove or smooth a discontinuity at the edges

44. INTRAOPERATIVE EXCLUSION
 Significant vitreous loss during surgery
 Pupil trauma during surgery
 Zonular damage
 Capsulorhexis tear
 Capsular rupture
 Eccentric CCC

45. SPECIAL CONSIDERATIONS FOR
MfIOLS
 Counselling (most important)
 Accurate Biometry
 Power Calculation
 Surgical Technique
 Round, centered CCC completely overlapping the lens
optic
 Removal of all viscoelastic from behind the lens

46.  Loss of contrast sensitivity
 Glare and halos
 scattering of light at the dividing line of the different zones
 improves with bilateral implantation, because of “a bilateral
summation” effect
 Less satisfactory visualization of fundus- difficulty in vitreo-
retinal procedures
 Requires adaptation

47. ACCOMMODATIVE IOLs
 Monofocal IOL
 Changes position inside the eye as the eye's focusing
muscle contracts
 1 mm of anterior movement of lens = 1.80 D of
accommodation
 Mimicking the eye's natural ability to focus

48.  It is still not known whether the ability of
these new IOL design will not be impair by
long-term postoperative fibrosis/
opacification within the capsular bag

49.  CrystaLens
 The lens is hinged adjacent to the
optic
 with accommodative effort
▪redistribution of ciliary body mass
▪result in increased vitreous pressure
▪move the optic forward anteriorly
within the visual axis
▪creating a more plus powered lens

51.  synchrony IOL (Visiogen Inc.)
 One-piece silicone lens
 The anterior lens has a high plus power beyond that required to produce
emmetropia(30-35 D)
 the posterior lens has a minus power to return the eye to emmetropia
 The distance between the two optics
•minimum in the un-accommodated state
•maximum in the accommodated state
 No long term data

52.  Silicone
 Crystalens (Bausch & Lomb)
 Only FDA approved IOL for correction of presbyopia
 Hydrophilic Acrylic
 BioComFold type 43E (Morcher GmbH)
 1CU (HumanOptics AG)
 Tetraflex (Lenstec Inc.)

54.  Modern cataract surgery is more of refractive
surgery.
 Myopia & hypermetropia can be corrected using
appropriate spherical powers of IOL’s.
 However approximately 20% of patients who
undergo cataract surgery have 1.25D of corneal
astigmatism or more.
 It can be corrected with Toric IOL’s.

55.  Other options for correction of co-existent
cataract and astigmatism
 LRI during cataract surgery( upredictable results)
 Laser procedures postoperatively (are associated with
new set of complications).

56.  First introduced by Shimizu et al in 1994.
 It was nonfoldable 3 piece toric IOL made from
PMMA.
 It had oval optic with loop haptics ,available in
cylinder power 2-3 D.
 Postoperatively 20% IOL’s rotated > 30 degrees and
50% IOL rotated about 10 degrees.

58. Factor Affecting Rotation of Toric
IOL
(1) IOL Material-
Hydrophobic Acrylic < Hydrophilic Acrylic < PMMA < Silicon
(2) Overall IOL diameter - Larger diameter prevents rotation .
Toric IOL’s are available nowadays in 11-13 mm overall
diameter.
(3) Haptic Design-
Initial concept
- Loop haptics prevent early rotation .
- Plate haptics prevent late rotation.
Recent concept – No difference in incidence of post operative
rotation between plate and loop haptics provided material of
both loop and plate is same.

59. Patient selection
 Regular corneal astigmatism > 1.5 D
 Vision compromising cataract
 Patient wants spectacle independence

60. Facts
 20% of patients with cataract have astigmatism >1.25
D
 Every incision on cornea induces additonal
astigmatism (SIA).
 Implantation of monofocal lens will require
distance and near correction both in these cases.
 B/L Toric IOL’s give high level of spectacle
independence(97%).
 Requirement of near correction can be overcome by
multifocal toric IOL(AcriLisa multifocal toric IOL)

61. Vision with
cataract
Vision with
normal IOL
Vision with Toric
IOL

62. TORIC IOL POWER CALCULATION
 Precise keratometry
 Surgically induced astgmatism [SIA].

63. Keratometry
 Can be done with
 Manual keratometer
 Automated keratometer
 Corneal topography
 K readings from all the three show high repeatability
and are comparable.
 Manual keratometer should be calibrated regularly.

64.  Corneal topography is required in case of unusual
reading & poor quality mires.
 Precautions
 Reading must be quick to avoid drying of cornea.
 Don’t rub on the cornea.
 Centration must be proper.

65. Surgically Induced Astigmatism
 Every incision changes the cornea.
 Closer to the centre & larger the incision more effect
on corneal curvature.
 Other factors affecting it are preoprative corneal
astigmatism, suture use and patient’s age.
 In addition there is variability from patient to patient.
 Overall effect can be summed up with vector analysis.

66. SIA Calculation
 Obtain SIA calculator
 Fill it for 20-30 cases minimum
 Be precise about axis and incision
 Calculator auto calculates SIA

67. AcrySof Toric IOL Calculator
Data input
 Patient data
 Keratometry
 IOL spherical power
 Surgically induced
astigmatism
 Incision location
67

68. Output screen
 Recommended IOL model
and spherical equivalent
power
 Optimal axis placement
 Magnitude and axis of
anticipated residual
astigmatism
68

69. Marking of Eye
Instruments
• Bubble marker
• Gravity marker

70. STEPS
A) Reference marking
- Done prior to surgery with patient upright
- Two reference markers placed at limbus 180 degree apart
- Used to align marking instuments for placement of axis
marks
B) Axis marking : Using reference marks as a guide the
patient eye is marked accurately at two positions 180
degree apart
TIPS:-
- Dry the conjunctiva with a swab
- Enhance marking at 3-9 o clock
- It lasts throughout surgery

71. Surgery
• Standard phacoemulsification
• Incision size 1.5 – 3.4 mm
• Well centered rhexis with diameter 5- 5.5 mm with 360
degrees overlap of IOL margin
• Marks on IOL indicate flat meridian or plus cylinder axis
of toric IOL
• Cohesive viscoelastics are preferred.

72. • IOL alignment
 Tap (“nudge”) IOL down into capsular bag to seat
lens onto the posterior capsule.
Gross alignment
OVD removal
Final alignment
If overshoots

73.  If any compromise of zonular integrity or capsule
occurs please switch to standard non toric IOL
POST OP XIS ALIGNMENT-
 Slit Lamp with dilated pupil
 Wavefront aberrometry in undilated pupil
 Realignment should be done in < 2 wks

74. Complications
 Rotational stability is critical
to effectiveness of toric IOLs.
 1° rotation results in 3.3 %
IOL power loss
 30° rotation negates
cylindrical correction of toric
IOL
 Further rotation induces more
astigmatism
74

75. IOL IMPLANTAION IN SPECIAL
SITUATIONS
 ABSENCE OF CAPSULAR SUPPORT
 Scleral fixation (suture/glue)
 Iris fixated
 ACIOLs
 PEDIATRIC AGE GROUP
 Heparin coated
 Multifocal IOLs
 DRUG ELUTING IOLs
 Triamcinolone acetonide
 Dexamethsone
 Antibiotic
 Diclofenac sodium (0.2 mg/mL)
 Mitomicin C (0.2 mg/mL)
 Colchicine (12.5 mg/mL) and 5-fluorouracile (10 mg/ml)
 Anti-VEGF

76. ANIRIDIA IOLs
 Various designs
 Overall size = 12.5 to 14 mm
 Optic diameter = 3.5 to 5 mm
 Central clear optic
 Surrounding colored diaphragm

77. PHAKIC IOLs

78. Primary vs secondary implantation
 Primary implantation – use of IOLs during surgery for
cataract
 Secondary implantation – implantation of IOL to
correct aphakia in a previosly operated eye

79. PHAKIC IOLs
 Implantation of IOL without removing natural
crystalline lens.
 ADVANTAGE: Preserves natural accommodation
 Mostly used in Myopic eyes: -5 to -20 DS
 Also used in Hyperopic eyes
 Concern in Hyperopes:
 More chances of endothelial damage
 Increased risk of angle closure glaucoma
 Life-long regular follow up required.

80. PHAKIC IOLs
 Posterior Chamber
 Iris fixated
 Angle fixated
PHAKIC IOLs

81.  Implantable collamer lens (ICL) (VISIAN; STAAR)
 Phakic refractive lens (Mellennium)
 Sticklens
 COMPLICATIONS:
 Endothelial cell damage
 Inflammation
 Pigment dispersal
 Elevated IOP
 Cataract

82. Implantable Collamer Lens (ICL)
 Pre-crystalline lens made of silicone or collamer.
 Length of the lens = white-to-white limbal diameter -
0.5 mm
 Overall size- 11-13 mm
 Otical zone - 4.5-5.5 mm
 Toric model also available

83.  COMPLICATIONS:
 Constant contact pressure
 Cataract
 Ciliary body reactions
 Prevent free passage of aqueous.- Iridectomy required
 SPINNAKER EFFECT: Blowing sail of a boat

84. IRIS FIXATED PHAKIC IOL
 VERISYSE/ARTISAN (AMO/OPTECH)
 Made of PMMA
 convexo-concave
 Length = 7.2 – 8.5 mm
 Optic size = 5-6 mm
 Haptics fixed to iris –claws

85. IRIS FIXATED PHAKIC IOL
 ADVANTAGES OVER ICL:
 Customized smaller size possible
 Easier examination from end-to-end
 COMPLICATIONS-
 Early post op AC inflammation
 Glaucoma
 Iris atrophy on fixation sites
 Implant dislocation
 Decentration
 Endothelial cell loss

86. ANGLE FIXATED PHAKIC IOL
 TWO TYPES –
 4 point fixation
 Baikoff’s modification of Kelman type haptic design
 NuVita MA20 (Bausch and Lomb)
 3 point fixation
 Vivarte (IOL Tech)
 Separate optic and haptic

87. ANGLE FIXATED PHAKIC IOL
 COMPLICATIONS –
 Endothelial cell loss
 Irregular pupil
 Iris depigmentation
 Post-op inflammation
 Halos and glare
 Surgical induced astigmatism

88. PIGGYBACK IOLs
 An intraocular lens that “piggybacks”
onto an existing intraocular lens or two
IOLs are implanted simultaneously.
 First IOL is placed in the capsular bag.
 The second (piggyback) IOL is placed in
the bag or sulcus.

89.  2 types-
 classically- secondary iol in bag
 Add on type- secondary iol in sulcus

90.  Easier to place 2nd IOL than to explant IOL & replace
it
 Lesser risk
 More predictable
 Can change power with time-by adding IOL or
explanting an IOL
 Better image quality
 Increased depth of focus

91.  COMPLICATIONS
 Interlenticular opacification
 (Interpseudophakos Elshnig’s pearls)
 (RED ROCK SYNDROME)
 Unpredictable final IOL position

92. ASPHERIC IOLS

93. ASPHERIC IOLs
 Human eye : Aspheric
Optics
 Cornea : Positive spherical
aberration
 Young crystalline lens :
Negative spherical
aberration
 Ageing crystalline lens :
Increased positive
spherical aberration

95. Conventional IOL increase
the spherical aberration of the eye

96. HOW TO OVERCOME ?
 Strategy 1:
 Lens with negative spherical aberrations to balance the
normally positive corneal spherical aberrations
 Strategy 2:
 Lens with minimum spherical aberrations so that no
additional spherical aberration is added to the corneal
spherical aberrations

100. ASPHERIC IOLs
 Need perfect centration
 Decreased depth
perception
 More expensive
 Need corneal topography
for optimal results
 Not much difference in
photopic conditions and in
older age group
 Not for previous hyperopic
refractive surgery
 Better contrast sensitivity
 Better mesopic vision
 Night time driving
 AcrySof® IQ Aspheric IOL
patients had an average
increase of 130+ feet (vs
the control lens) in which
to stop after identifying a
warning sign
 Better option for younger
patients