Effectiveness of Accommodating Intra Ocular Lens: Department of Ophthalmology, Faculty of Medicine, Universitas Lampung

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Effectiveness of Accommodating Intra Ocular Lens

Muhammad Yusran
Department of Ophthalmology, Faculty of Medicine, Universitas Lampung

Abstract
Cataract surgery is effective in restoring distance vision. However, standard monofocal intraocular lenses (IOLs) have a fixed
refractive power, leaving patients presbyopic and dependent on spectacles for near vision. Restoring the accommodative
ability in pseudophakic patients is still challenging. This literature research focus to review the result of near visual acuity
and amplitude of accommodation of available accommodating IOLs. Conducted from the Pubmed database and library
research for journal articles that were published and related to accommodating IOLs using the keywords accommodating
intraocular lens or monofocal intraocular lens or pseudophakic accommodation. Subjective and objective and measurement
of amplitude of accommodation was observed. Subjectively, amplitude of accommodation is measured by defocus and near
point of accommodation. Accommodation amplitude was measured by dynamic streak retinoscopy, power refractor and
IOL movement objectively. Defocus measurement of accommodating IOL showed that the accommodative amplitude was
between 0.94 D to 1.90 D and near point of accommodation (NPA) resulted in power around 0.5 D to 3.83 D meanwhile in
the monofocal IOL, defocus power was between 0 to 1.52 D and NPA was between 0.42 D to 2.4 D. Dynamic retinoscopy of
accommodating IOL showed power between 0.98 D to 0.99 D while monofocal IOL ranged between 0.17 D to 0.24 D. The
movement of accommodating IOL was between 0.151 mm to 0.82 mm while it ranged between 0.02 mm to 0.4 mm for
monofocal IOLs. Measurement by using power refractor showed that the power was between 0.39 D to 1.00 D for
accommodatin IOL while it was 0.10 D to 0.17 D for monofocal IOL. Conclusion, accommodating IOL provided better near
vision compared to monofocal IOL. [JuKe Unila 2015; 5(9):147-153]

Keywords: accommodating amplitude, accommodating IOL, monofocal IOL

Efektivitas Lensa Intra Okular Akomodasi


Abstrak
Operasi katarak menggunakan lensa intra okular (LIO) monofokal dapat memperbaiki tajam pengliatan jauh akan tetapi
tidak memperbaiki tajam penglihatan dekat sehingga tetap dibutuhkan kaca mata akibat presbiopia. Studi literatur ini
bertujuan untuk membandingkan hasil-hasil penelitian yang menggunakan LIO akomodasi terhadap tajam penglihatan
dekat dan amplitudo akomodasi. Data hasil-hasil penelitian diperoleh dari pusat data Pubmed database dan studi pustaka
artikel jurnal yang diterbitkan dan berhubungan dengan LIO akomodasi menggunakan kata kunci akomodasi lensa
intraokular atau lensa intraokular monofokal atau akomodasi pseudophakic. Amplitudo akomodasi diukur secara sujektif
dan objektif. Pengukuran subjektif menggunakan defocus dan near point of accommodation (NPA). Dynamic streak
retinoscopy, power refractor dan IOL movement digunakan sebagai alat ukur objektif. Pengukuran defocus pada LIO
akomodasi menunjukkan 0.94 D - 1.90 D dan NPA sebesar 0.5 D - 3.83 D sementara itu pada LIO monofokal, kekuatan
defocus sebesar 0 - 1.52 D dan NPA sebesar 0.42 D - 2.4 D. Dynamic retinoscopy dari LIO akomodasi sebesar 0.98 D - 0.99 D
sementara pada LIO monofokal berkisar 0.17 D - 0.24 D. Pergerakan LIO akomodasi sebesar 0.15 mm - 0.82 mm dan pada
LIO monofokal sebesar 0.02 mm - 0.4 mm. Pengukuran menggunakan power refractor menunjukkan kekuatan sebesar 0.39
D - 1.00 D pada LIO akomodasi dan 0.10 D - 0.17 D pada LIO monofokal. Kesimpulan, kekuatan akomodasi LIO akomodasi
lebih baik diandingkan LIO monofokal. [JuKe Unila 2015; 5(9):147-153]

Kata kunci: amplitudo akomodasi, lensa intra okular akomodasi, lensa intra okular monofokal

Korespondensi: dr. Muhammad Yusran, M.Sc., Sp.M, alamat Jl. Soemantri Brojonegoro No. 1, HP 081272827216, e-mail
myusran.dr@gmail.com

Introduction tested with limited success. New lens-refilling


Cataract surgery is effective in restoring procedures are currently under investigation in
visual clarity and distance vision. However, animal models. However, problems such as
standard monofocal intraocular lenses (IOLs) leakage of the injectable material from the
have a fixed refractive power, leaving patients capsular bag and formation of posterior
presbyopic and dependent on spectacles for capsule opacification (PCO) must be
near vision, even after surgery. Restoring the overcome.1 Multifocal IOLs attempt to divide
accommodative ability in pseudophakic light into multifocal points to mimic
patients is still challenging. accommodation but these IOLs often reduce
In last decade, various techniques to contrast sensitivity and result in unwanted
correct postoperative presbyopia have been optical phenomena, such as glare. Scleral
Muhammad Yusran | Effectiveness of Accommodating Intra Ocular Lens

expansion surgery, zonal photorefractive Best corrected near visual acuity (BCNVA) also
keratectomy, implantation of corneal inlays, was also counted. The secondary outcomes are
diffractive multifocal PC IOLs, and bifocal PC measurement of amplitude of accommodation.
IOLs were reported no, little, or, at best, It was grouped into subjective and objective
limited success.2 Decentered laser in situ measurements. Subjective measurements
keratomileusis for presbyopia correction is still consist of defocus, near point of
considered investigational.3 Bag-in-the-lens IOL accommodation, refractometry with a near/far
technique showed no accommodative or near target. Objective measurements consist of
visual advantage over a conventional in-the- dynamic streak retinoscopy,
bag IOL.4 photorefractometry, and change in anterior
Accommodating IOLs were developed in chamber depth.
an attempt to restore the accommodative
properties in the pseudophakic eye. With Content
increasing age, the ciliary muscle maintains its Thirty two (32) articles were selected
ability to contract. The mechanism of using intended search terms. Twelve (12)
accommodating lenses are based on the articles were excluded because they could not
Helmholtz theory of accommodation, which be compared due to unrelated, using another
assumes the presence of force transmission method, could not be accessed, or just a
from the ciliary muscle to the lens via the review. All of the articles were published
zonular apparatus, or Coleman’s hydraulic between 1999 until 2010.
suspension theory, which assumes that Most of the articles were assigned as
changes in vitreous pressure are responsible level II study. The accommodating IOLs used in
for changes in lens shape. Accommodating IOLs the study were 1CU (HumanOptics),
are designed to transform forces of the ciliary BioComFold (Morcher), and AT-45 Crystalens
muscle into a forward shift of the IOL optic (the (eyeonics, Inc.) and Tetraflex (Lenstec Inc.) The
optic shift concept).5 follow up time varied from 1 month to 24
This paper presents a reviewed data of month. The largest number of participant was
the result of near visual acuity, amplitude of 772 patients.
accommodation, and safety profile of currently Measurement of the subjective near
available accommodating IOLs. It also reviewed point was performed with an
the comparation between available accommodometer. Using the previously
accommodating IOLs. determined best distance correction, the
This literature research was conducted reading target was slowly approached until the
from the Pubmed (NLM) database and library patient noted blurring of the optotype; 1/near
research for journal articles that were point (m) was the accommodative range.
published and related to accommodating IOLs Measuring of defocus was done after careful
using the keywords accommodating intraocular spherical and cylindrical distance refraction,
lens or monofocal intraocular lens or spherical minus correction was added in steps
pseudophakic accommodation. The limit used of –0.5 diopters (D) until a Snellen chart visual
of this review is using English, clinical trial, and acuity minus correction indicates of 20/50 was
human. Reference list from included study was no longer detected. The amount of added
also checked for potentially relevant articles. minus correction indicates the accommodative
The inclusion criteria are intervensional range. Measuring of dynamic streak
studies that reported on the use of retinoscopy was performed by near
accommodating IOLs, showing the details and distance refractions. For distance
about baseline and result of distance-corrected retinoscopy, patients were asked to
near visual acuity (DCNVA). The studies were fixate a visual chart projected at a distance of 5
excluded if the full text cannot be accessed, m. For near retinoscopy, patients were asked
the full text were not published in English and to maximally fixate a near chart.
the outcome of the study could not be Accommodative range was the difference
compared either directly or by calculation. between near and distance refractions.
The primary outcome of this review is Anterior chamber depth was measured by A-
distance-corrected near visual acuity (DCNVA). Scan or IOL-Master.6

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Muhammad Yusran | Effectiveness of Accommodating Intra Ocular Lens

Table 1. Characteristic of the Studies


Type of
Year of Classification Follow up Number of
No Author Accommodating
Publication of study (month) participant
IOL
7
1 Findl et al 2004 I 1CU 3 18
8
2 Mastropasqua et al 2003 I 1CU 6 42
9
3 Heatley et al 2005 I 1CU 6 60
10
4 Sauder et al 2005 I 1CU 6 38
11
5 Hancox et al 2006 I 1CU 18-24 20
12
6 Legeais et al 1999 I BioCom 1 30
13
7 Wolffsohn et al 2006 I TetraFlex 6 48
14
8 Dogru et al 2005 II 1CU 3 22
15
9 Uthoff et al 2007 II 1CU 12 772
16
10 Vargas et al 2005 II 1CU 3 19
17
11 Ku¨ chle et al 2003 II 1CU 6 15
6
12 Ku¨ chle et al 2004 II 1CU 6 20
18
13 Langenbucher et al 2003 II 1CU 6 15
5
14 Koeppl et al 2005 II Crystalens AT-45 3 21
19
15 Cumming et al 2001 II Crystalens AT-45 1 48
20
16 Marchini et al 2004 II Crystalens AT-45 6 20
21
17 Cumming et al 2006 II Crystalens AT-45 12 246
22
18 Sanders et al 2007 II TetraFlex 6 95
23
19 Zhe et al 2010 II TetraFlex 3 42
24
20 Sanders et al 2010 II TetraFlex 12 332

Table 2. Distance-Corrected Near Visual Acuity (DCVNA) and Best Corrected Near Visual Acuity (BCNVA)
DCNVA BCNVA
No Author P-value P-value
Acc IOL Mono IOL Acc IOL Mono IOL
7
1 Findl et al 20/80 (J9) 20/80 (J9) 0.35 20/25 (J 2) 20/20 (J1) 0.01
(median) (median)
8
2 Mastropasqua et al J3.7 + 2.1 J7.4 + 0.5 < 0.001 J1 J1
9
3 Heatley et al J9.3 + 0,7 J12.4 + 0.5 0.004 - - -
10
4 Sauder et al J8.5 + 1.2 J11.6 + 1.8 0.03 N 2.46 + 0.9 N 2.01 + 0.82 0.34
(J3) (J3)
11
5 Hancox et al J 10 J10 NS - - -
12
6 Legeais et al J 3.66 + 2.12 J7.43 + 0.50 <0.001 - - -
13
7 Wolffsohn et al 0.58 + 0.20 0.62 + 0.25 0.684 - - -
(J9) (J9)
14
8 Dogru et al J 3 100% J 3 0% < 0.05 20/30 (J3) 20/30 (J3) > 0.05
15
9 Uthoff et al N 5.77+ 1.33 N 6.24 + 1.23 <0.01
(J6) (J8)
16
10 Vargas et al 0.5 (J5) - - 0.9 (J2) - -
17
11 Ku¨ chle et al 0.39 + 0.11 (J6) - - - - -
6
12 Ku¨ chle et al 0.36 + 0.10 (J7) 0.16 + 0.06 <0.001 - - -
(J12)
2
13 Langenbucher et al 0.32 + 0.11 (J8) 0.14 + 0.10 < 0.05 - - -
(J13)
5
14 Koeppl et al J4 - - - - -
19
15 Cumming et al J5 or better - - J3 or better - -
100% 100%
20
16 Marchini et al J7,3 + 2,1 - - J1 - -
21
17 Cumming et al J3 or better - - J2 or better - -
90,1% 99%
22
18 Sanders et al 20/40 (J5) or - - 20/25 (J2) - -
better 63,2 %
23
19 Zhe et al J4 or better 66% - - - - -
24
20 Sanders et al 20/50 (J6) or 20/50 (J6) or < 0.001 - - -
better 67% better 50%

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Muhammad Yusran | Effectiveness of Accommodating Intra Ocular Lens

Table 3. Amplitude of Accommodation Measurements


Subjective measurement Objective measurement
No Author P-Value P-value
Acc IOL Mono IOL Acc IOL Mono IOL
7 f f
1 Findl et al - - - - 0.37 + 0.29 0.060 + 0.13 0.001
8 a
2 Mastropasqua et al 1.90 + 0.77 0 <0.05 - - -
b b
9 3.83 + 1.72 2.40 + 0.47 0.0001 - - -
3 Heatley et al a a
1.727 + 0.56 1.014 + 0.55 0.03 - - -
10 b b f f
4 Sauder et al 1.01+0.4 0.5+0.11 0.01 -0.82 + 0.3 -0.40 + 0.32 0.01
b b f f
43.26 + 11.9 47.4 + 5.5 0.11 -0.220 + 0.169 0.028 + 0.095 < 0.0001
11
5 Hancox et al (2.3) (2.1)
a a
1.09+ 0.58 0.88+0.51 0.214 - - -
12 f f
6 Legeais et al - - - -0.71 + 0.55 -0.29 + 0.37 < 0.05
13 b b e e
7 Wolffsohn et al 3.1+1.6 2.0+0.9 0.009 0.39+0.53 0.17+0.13 0.032
14 b
8 Dogru et al 0.5 + 0.44 0 <0.05 - - -
b b
60+ 17.13 (1.6) 70+ 18.89 - - - -
15
9 Uthoff et al (1.42)
a a
1.68+ 0.67 1.52+ 0.53 - - - -
17 b
11 Ku¨ chle et al 2.02+0.38 - - - - -
b b d d
6 1.83 + 0.49 1.16 + 0.27 <0.001 0.98 + 0.55 0.17 + 0.22 <0.001
12 Ku¨ chle et al a a f f
1.85 + 0.43 0.64 + 0.21 <0.001 + 0.42 + 0.18 0.11 + 0.06 < 0.001
b b e e
1.60 + 0.55 0.42 + 0.25 - 1.00 + 0.44 0.10 + 0.65 -
18 a a d d
13 Langenbucher et al 1.46 + 0.53 0.55 + 0.33 - 0.99 + 0.48 0.24 + 0.21 -
f
- - - - 0.78 + 0.12 - -
5 f
14 Koeppl et al - - - + 0.151 + 0.08 - -
20 c f
16 Marchini et al 1.08 + 0.54 - - -0.33 + 0.25 - -
22 c
18 Sanders et al 2.77 + 0.64 - - - - -
23 a f
19 Zhe et al 0.94 + 0.61 - - - 0.34 ± 0.12 - -
a
Defocus
b
Near point accommodation
c
Refractometry near/far
d
Dynamic streak retinoscopy
e
PowerRefractor
f
IOL shift movement, negative means decreasing anterior chamber depth in millimeter while positive means increasing anterior chamber
depth in millimeter.

Various results were reported the amplitude was between 1.08 D to 2.77 D. In
distance-corrected near visual acuity (DCNVA) the monofocal IOL, defocus power was
and best-corrected near visual acuity (BCNVA). between 0 to 1.52 D and NPA was between
The mean of DCNVA of accommodating IOL 0.42 D to 2.4 D.
ranged between J3 to J10. The mean of DCNVA Three measurements of objective
of monofocal IOL ranged between J6 to J13. accommodative amplitude were performed.
Objective and subjective measurement Dynamic retinoscopy of accommodating IOL
of amplitude of accommodation was observed showed power between 0.98 D to 0.99 D while
in several studies. Accommodation amplitude monofocal IOL ranged between 0.17 D to 0.24
was measured by dynamic streak retinoscopy, D. The movement of accommodatin IOL was
power refractor and IOL movement objectively. between 0.151 mm to 0.82 mm while it ranged
Subjectively, amplitude of accommodation is between 0.02 mm to 0.4 mm for monofocal
measured by defocus, near point of IOLs. Objective measurement using power
accommodation, and refractometry refractor showed the power was between 0.39
near/far. D to 1.00 D for accommodatin IOL while it was
Three measurements of subjective 0.10 D to 0.17 D for monofocal IOL.
accommodative amplitude were stated for Subjective measurements of near visual
accommodating IOL. Defocus measurement acuity are the most readily available means of
showed that the accommodative amplitude evaluating accommodation. This outcome was
was between 0.94 D to 1.90 D. Near point of stated in all studies. DCNVA of accommodating
accommodation (NPA) resulted in power IOL was better in the majority of the studies.
around 0.5 D to 3.83 D. Two measurement of Nine of 12 comparatives studies showed
refractometry showed that the accommodative DCNVA of an accommodating IOL was superior

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Muhammad Yusran | Effectiveness of Accommodating Intra Ocular Lens

than monofocal IOL with significant statisitcal and 0% respectively. A comparative study
difference.2,6,8-10,12,14,15,24 comparing 1CU, Crystalens AT-45, and
Majority of the studies indicated that monofocal IOL was performed by Marchini et
BCNVA which achieved J 3 or better was equal al.26 This study showed that DCNVA of 1CU,
among the studies. Those findings mean that Crystalens AT-45, and monofocal IOL was J 7, J
the near visual acuity achieved by 10, and J 13 (p<0.001). Brown et al27 reported
accommodating IOL provided sufficient vision that near reading ability of Tetraflex IOL was
for near work condition. Nevertheless, study better than Crystalens IOL. There was no
from Uthoff et al15 indicated that 1CU lens comparative study involving BioCom IOL
resulted in minor statistical advantage of half a compared to others accommodating IOL.
reading step towards monofocal IOL. The studies in this literature review was
Most of studies followed up the visual limited by several factors. Randomized clinical
acuity in 6 to 24 months. Several studies noted trial studies were conducted in small number
that the DCNVA acuity was decreasing during of participants. The time of follow up was
the observation period. Capsul fibrosis can limited to 12 months, thus we can not evaluate
cause movement limitation. Koeppl et al5 the stability of accommodation performance of
proposed mechanism of anterior capsule the IOLs in longer period of time.
polishing to avoid capsule fibrosis which Some conditions should be fulfilled to
prevented IOL movement. How many times create better an accommodating IOL. A driving
does the haptic of IOL can bend was still in vector force must be implemented that
question. actively moves the implant anteriorly as the
Subjective measurement of amplitude of zonules are released under ciliary muscle
accommodation by using defocus, near point contraction. Capsular fibrosis and its
of accommodation and refractometry showed immobilizing effect on the implant must be
that the amplitude of accommodation of avoided or neutralized, and regeneratory after-
accommodating IOL was better than cataract formation counteracted as much as
monofocal IOL. Eight of 10 comparative studies possible. The optic should be positioned as far
showed that subjective amplitude of posteriorly as possible to allow for maximum
accommodation of accommodating IOL was clearance to the iris and thus space for shift-
better than monofocal IOL. induced accommodation.28
Objective measurement of amplitude of
accommodation was collected by means of Summary
dynamic streak retinoscopy, power refractor Accommodating IOLs was developed to
and IOL shift movement. All of 7 studies provide free-spectacles near vision after
measuring objective amplitude of cataract surgery. This lens works by changing
accommodation indicated that accommodating its position anteriorly during near sighted
IOL was superior than monofocal IOL. activities. The effectiveness of this IOL was
Unfortunately, there was no study reported affected by several conditions such as well-
IOL forward shift of 1 mm to create 3 D of centered IOLs, extensive clearance of lens
accommodation. material during surgery and capsular fibrosis
The safety profile of accommodating IOL after surgery.
was reported by some studies. Posterior capsul
opacity was reported in most of the Conclusion
studies.8,13,17,24,25 IOL dislocation was observed Accommodating IOLs showed better
in small number of patients ranged between near visual acuity compared to monofocal IOL.
1%-3%.15,21,24 Cumming et al21 reported Meanwhile, accommodating IOL only produced
endophthalmitis (0.3%), retinal detachment moderate improvement of amplitude of
(0.6%), iritis (0.9%), and corneal edema(0.7%) accommodation. The accommodating IOLs
as adverse events of 324 patients. were safe based on several studies. Based on
Among four of accommodating IOL, limited number of study and study design,
there were no study that compared them Tetraflex accommodating IOL appeared to be
directly. Heatley et al9 compared tetraflex, 1CU superior compared to 1CU lens and Crystalens
and Acrysof. This study showed DCNVA achived lens.
by tetraflex, 1CU, and Acrysof was 89%, 7%,

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Muhammad Yusran | Effectiveness of Accommodating Intra Ocular Lens

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Muhammad Yusran | Effectiveness of Accommodating Intra Ocular Lens

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