Presentation of Detlev Breyer (MD) at ERLS Meeting in Paris in 2017. Title: MIOL Treatment – Quo Vadis? This presentation discusses the treatment of presbyopia with Multifocal Lenses.

1. MIOL Treatment – Quo Vadis?
Detlev R.H. Breyer

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. Dr. med.
Detlev Breyer
Dr. med.
Hakan Kaymak
Dr. med.
Karsten Klabe
Dr. rer. nat.
Philipp Hagen
Prof. Dr. med.
Gerd U. Auffarth
Dr. rer. nat.
Andreas Fricke
Dr. med. Florian
T. A. Kretz
IVCRC.net

4. MIOL Treatment – Quo Vadis?
Patients are different
Doctors are different
Mentalities are local
There`s no such thing as a one trick pony

5. How Would You Like To Be Treated?
• Sperical IOL?
• I personally never treated a colleague with a standard IOL
• Quo Vadis?
• Individualized treatment with different MIOL

6. Road Map – Individualized Treatment
I. Know your patients visual needs
II. Know MIOL Specific Defocuscurves
III. Know Specific MIOL Photopic Phenomena
IV. Honest Informed Consent
V. Recommend a MIOL
VI. Encourage Disappointed Patients

7. Know Your Patients Visual Needs and Document Those
7

8. „schwach“„keine“
„mittel“ „stark“
Halo und Glare Simulator

9. Patient Does Not Know Anything!
Gretchenfrage: Hatten Sie

10. Road Map – Individualized Treatment
I. Know your patients visual needs
II. Know MIOL Specific Defocuscurves
III. Know Specific MIOL Photopic Phenomena
IV. Honest Informed Consent
V. Recommend a MIOL
VI. Encourage Disappointed Patients

11. AcrySof IQ PanOptix:Trifocal
• Material: Copolymer
• UV- und Blaulichtfilter (Cutoff bei 401nm)
• Optikdurchmesser: 6mm
Gesamtdurchmesser: 13mm
• Dioptrienbereich:
+13.0 to +30.0dpt (0.5dpt Schrittweite)
+31.0 to +34.0dpt (1.0dpt Schrittweite)
• Intermediäraddition: +2.17dpt
Nahaddition: +3.25dpt

12. AT LISA tri: Trifocal
• Trifokale diffraktive Optik bis 4.34mm
+3.33dpt Addition für Nahbereich
+1.66dpt Addition for Intermediärbereich
• Bifokale Optik von 4.34mm bis 6.0mm
• Bitorisch (im Falle von AT LISA tri 939MP)
• Innovative Oberflächenprofile:
12
Gleiche
Phasenzonen
 2 Foki
2 alternierende
Zonen  3 Foki
Reduzierte Ringanzahl:
• Weniger Streulicht an
Ringkanten
• Weniger Blendung / Photopsien
• Verbesserte Kontrastsensitivität

13. Tecnis Bifocal

14. LENTIS Comfort MF15 (Oculentis) - EDOF

15. TECNIS Symfony (AMO) - EDOF

16. Ex Vivo: MTF-Curves
0.0
0.1
0.2
0.3
0.4
0.5
0.6
-0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
MTF
Defokus [dpt]
MTF-Focus-Through Kurve
Comfort Symfony
Gerät: PMTF (Lambda-X)
Augenmodell: ISO11979-2 (aberrationsfrei)
Wellenlänge: 546nm (grün)
Blendenweite: 3mm
Raumfrequenz: 50cycles/mm
Effektive Addition: 1.5dpt 1.78dpt

17. WIOL-CF (Medicem): Polyfocal
0%
20%
40%
60%
80%
100%
1 2 3 4 5
Ferne
Nähe
Intermediär
Pupillendurchmesser
Lichtaufteilung

18. MiniWell (Sifi Meditec): Continous Multifocal Progressive
D1: SA > 0
D2: SA < 0
D3: SA = 0
Zonenübergänge im
Purkinjereflex sichtbar

19. Monofocal IOL (mon, cc)
Comfort MF15 (mon, cc, n=52)
Symfony (mon, cc, n=35)
MplusX MF30 (mon, cc, n=12)
Lisa Tri (mon, cc, n=16)
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]
• Comfort und Symfony: Very similar defocus curves
• MplusX und Lisa Tri: Differences in defocus curves relatively low
 Good comparability
Defocus Curves
n = Number of eyes
mon = monocular
cc = corrected

20. Monofokale 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)
Referenzkurve Visus=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
Dezimalvisus
Defokus [dpt]
Düsseldorf Formula
85%
43%
91%
100%
92%
95%
n = Anzahl der Augen
mon = monokular
bin = binokular
sc = unkorrigiert
cc = fernkorrigiert
EV = Emmetropic Vision
BV = Blended Vision
% = MIOL-Kapazität
(Fläche unter Kurve)

21. Monofokale IOL (mon, cc)
WIOL-CF (mon, cc, n=9)
MiniWell (mon, cc, n=19)
MplusX MF30 (mon, cc, n=12)
Mplus MF20 (mon, cc, n=17)
Comfort MF15 (mon, cc, n=63)
Referenzkurve Visus=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
Dezimalvisus
Defokus [dpt]
72%
74%
43%
100%
n = Anzahl der Augen
cc = fernkorrigiert
MIOL-Kapazität = Fläche
unter der Defokuskurve
76%
• Form der WIOL-CF Kurve ähnelt der für Comfort MF15,
Form der MiniWell Kurve ähnelt der für Mplus MF20
• Leicht höhere monokulare MIOL-Kapazitäten für
rotationsasymmetrische segmentale MIOL
Monocular Defocuscurves Refractive MIOL
69%
62%

22. Defocuscurves Restor Family
22
0
0.2
0.4
0.6
0.8
1
1.2
1.4
-4-3.5-3-2.5-2-1.5-1-0.500.5
Visus[dezimal]
Defokus [Dioptrien]
Alcon ReSTOR +3
Alcon ReSTOR +4
AMO Tecnis
Oculentis Mplus
Zeiss LISA 809M
Zeiss LISA tri

23. Monofokale IOL (mon, cc)
PanOptix (bin, sc, n=6)
Lisa Tri (bin, sc, n=36)
Referenzkurve Visus=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
Dezimalvisus
Defokus [dpt]
n = Anzahl der Augen
bin = binokular
sc = unkorrigiert
89%
43%
100%
85%
MIOL-Kapazität:
Fläche unter der Kurve
von -3.0dpt bis 0.0dpt
Binocular Defocuscurves Trifocal MIOL

24. Road Map – Individualized Treatment
I. Know your patients visual needs
II. Know MIOL Specific Defocuscurves
III. Know Specific MIOL Photopic Phenomena
IV. Honest Informed Consent
V. Recommend a MIOL
VI. Encourage Disappointed Patients

25. • Investigated correlations for Halo & Glare:
 Refractive IOL overall appear to have higher tolerance regarding photopsia
compared to diffractive IOL
• For better validity: more data required
• Note: Neuroadaptation (up to 3 months postoperatively) in most cases leads to
a subjective decrease of Halo & Glare
• Cave: Patient expectation
 Preoperatively inform patient about the possibility of halo & glare
Influencing factor Less H&G More H&G fulfilled?
1. Optical Principle refractive diffractive 
2. Addition low high  (only for diffractive)
3. Target refraction emmetropia emmetropia (only for diffractive)
Correlations For Photopic Phenomena

26. Road Map – Individualized Treatment
I. Know your patients visual needs
II. Know MIOL Specific Defocuscurves
III. Know Specific MIOL Photopic Phenomena
IV. Honest Informed Consent
V. Recommend a MIOL
VI. Encourage Disappointed Patients

27. Patient Knows Nothing!
• It´s our duty to speak patients language and inform well
• MIOL: Honest informed consent including optical side effects

28. 28
How to Understandibly Explain it to the Patient?
1. Defocus Capacity Chart
2. Photopic Phenomena Chart
3. Near Reading Test – Nieden
4. Explanation of Blended Vision
Düsseldorf Formula Chart

29. 29
How to Understandibly Explain it to the Patient?
Rough adjustment in the OR?!

30. Unrealistic Patient Exspectations
30

31. Monofokale IOL (mon, cc)
PanOptix (bin, sc, n=6)
Lisa Tri (bin, sc, n=36)
Referenzkurve Visus=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
Dezimalvisus
Defokus [dpt]
n = Anzahl der Augen
bin = binokular
sc = unkorrigiert
89%
43%
100%
85%
MIOL-Kapazität:
Fläche unter der Kurve
von -3.0dpt bis 0.0dpt
Binocular Defocuscurves

32. „schwach“„keine“
„mittel“ „stark“
Halo und Glare Simulator

33. Road Map – Individualized Treatment
I. Know your patients visual needs
II. Know MIOL Specific Defocuscurves
III. Know Specific MIOL Photopic Phenomena
IV. Honest Informed Consent
V. Recommend a MIOL
VI. Encourage Disappointed Patients

34. Personal Recommendation
I. Repeat Patients Wishes
II. Recommend a MIOL
III. Repeat H&G and DF once more
IV. Document

35. Road Map – Individualized Treatment
I. Know your patients visual needs
II. Know MIOL Specific Defocuscurves
III. Know Specific MIOL Photopic Phenomena
IV. Honest Informed Consent
V. Recommend a MIOL
VI. Encourage Disappointed Patients

36. Encourage Dissappointed Patients

37. Ermuntere Enttäuschte Patienten sich zu Äussern
LEAP
Listen
Emphasize
Apologize
Problem solution
Show them the signed informed consent
Be generous ( add on Iol, touch up)

38. MIOL Treatment – Quo Vadis?
Individual Patient Care

39. Herzlichen Dank für Ihre Aufmerksamkeit!