1. Visual Acuity and Patient
Satisfaction Results With A New
Trifocal Diffractive IOL
Dr Anil Arora
Central Coast Optometrist Conference
2nd March 2014

2. Introduction
• The aim of the study was to evaluate the visual
acuity outcomes and patient satisfaction results of a
new diffractive trifocal intraocular lens.
• 32 patients underwent bilateral implantation with
the AT LISA 839MP (Carl Zeiss Meditec)
• Patients had their unaided distance, intermediate
and near vision measured at about 8 to 12 weeks
post-op and were asked to complete a questionnaire
on post-op spectacle independence, ocurence and
severity of glare and haloes and overall satisfaction

3. Background
• Significant concern still exists about the
potential negative side effects of multifocal IOL
implantation – glare, haloes, loss of contrast
sensitivity and quality of vision
• Currently estimates by companies producing
multifocal IOLs are that less than 10% of
ophthalmologists in Australia are implanting
them or offering them to patients

4. Background
• Previous diffractive multifocal IOLs have generally
had a bifocal design with incoming light being split
into near and distance foci
• Many tasks, especially the use of computers, require
good intermediate vision.
• Many patients who have had implantation with
bifocal diffractive MFIOLs , whilst generally being
happy with the result, have needed to wear +1 or
+1.5 readers for good intermediate vision (eg.
working on the computer, labels and prices on
supermarket shelves, dashboard of the car).

5. Concerns with multifocal IOLs
• Multifocals takes too much chair time which I don't have to spare
• I have seen unhappy multifocal patients in the past
• Multifocals significantly reduce contrast sensitivity
• Patients like wearing reading glasses
• Monovision is just as good and easier
• I heard you need to touch up with a LASER in 30% of cases - I don't have
access to a laser
• All my monofocal patients are happy
• What if I need to explant - are these rates high?
• I am worried about picking the wrong patient (personality)
• What about the 6/6 N5 unhappy patient - do these happen and how do I
council them?
• What happens if they develop AMD in the future?
• Splitting light is not going to work....
• I don't see the benefit in using multifocals only the downsides!!!!!!
• Patients with multifocal IOLs still need glasses for intermediate tasks like
computer work or seeing prices on supermarket shelves

6. The intraocular lens
• AT Lisa 839MP
• Preloaded
• Single-piece trifocal diffractive
• MFIOL
• 6.0 mm biconvex optic with an
• overall length of 11mm
• Hydrophilic acrylic IOL with a
• hydrophobic surface
• Diffractive rings cover the entire
• optic diameter

7. The intraocular lens
• Central 4.34mm trifocal zone
• Peripheral bifocal zone from 4.34 – 6.00 mm
• Fewer rings on the optic surface compared with
its bifocal MFIOL predecessor to reduce risk
of visual disturbances
• Aspheric optic to correct
for corneal spherical
aberration.
Q value – 0.18 um.

8. LISA – more than just a pretty name
• L Light distributed asymmetrically between distant
(50%), near (30%) and intermediate (20%) focus
I Independency from pupil size due to high
performance diffractive- refractive micro-structure
covering the complete 6.0 mm optical diameter
S SMP technology for a lens surface without any sharp
angles for ideal optical imaging quality with reduced
light scattering
A Aberration correcting optimized aspheric
optic for better contrast sensitivity, depth of field and
sharper vision

9. 100 % 30 %
NEAR
50 %
FAR
20 %
INTERMEDIATE
Light distribution

10. Light transmittance – about 85-87%
irrespective of pupil size

11. Appearance in the eye

12. The study
• 64 eyes of 32 bilaterally implanted patients
(some results only available for 30 of these
patients – 60 eyes)
• November 2012 – Nov 2013
• Part of an ongoing study comparing the Zeiss
839MP trifocal multifocal IOL to the Alcon
ReSTOR 3.0 bifocal multifocal IOL

13. Visual acuity testing
• Visual acuity checked
• Monocular and binocular
unaided visual acuity
tested at
▫ - 6metres
▫ - 80cm
▫ - 40cm

14. Patient satisfaction survey
• Patients asked to complete a
questionnaire on :
• Subjective quality of vision before
and after surgery for distance,
intermediate and near
• Incidence of glare and halos before
and after surgery
• Impact of glare and halos on daily
life
• Spectacle dependency before and
after surgery for distance,
intermediate and near
• Would you have it again and would
you recommend it to a friend?

15. Patient survey
• Generally given to patients
at about one month after
second eye surgery
• Quality of unaided vision
graded subjectively from
excellent to poor before
and after surgery for
distance, intermediate and
near
• Incidence of halos and
glare and spectacle
dependency graded never,
sometimes or regularly
before and after surgery

16. Painstaking analysis of results
• Thorough double-checking by
the doctor to ensure accuracy
of nurse’s measurements

17. Results
Visual acuity results

18. Monocular unaided near visual acuity
N5 or better
89%
N6
11%
UCVA Reading n = 60 eyes

19. Binocular unaided near visual acuity
0
5
10
15
20
25
30
N5 or Better N6
Binocular UCVA Reading
n = 30 Patients 28 patients N5 or better, 2 patients N6

20. Monocular unaided intermediate visual acuity
0
5
10
15
20
25
6/12 6/9 6/7.5 6/6
UCVA Intermediate VA @ 80 cm n= 60 eyes
6/12
6/9
6/7.5
6/6

21. Binocular intermediate visual acuity
0
2
4
6
8
10
12
14
6/12 6/9 6/7.5 6/6 or better
Binocular Intermediate UCVA n = 30 patients
6/12
6/9
6/7.5
6/6 or better

22. Monocular unaided distance visual acuity
0
5
10
15
20
25
30
6/12 6/9 6/6 6/5 or better
Distance UCVA n = 30 patients n = 60 eyes

23. Binocular unaided distance visual acuity
0
2
4
6
8
10
12
14
16
18
20
6/9 6/6 6/5 or better
Binocular UCVA Distance n = 30 patients

24. Monocular unaided distance visual acuity
5 16
79
Unaided distance visual acuity 6/6 0r better in
47/60eyes (79%), 6/9 in 10/60 eyes (16%) and
6/12 in 3/60 eyes (5%)
6/12
6/9
6/6 or better

25. Reasons for unaided visual acuity of
6/9 or worse
0
1
2
3
4
5
6
7
Uncorrected cylinder Macular Hole Dry Eyes Unknown - No refraction
performed
7
1
2
3
VA 6/9 or worse

26. Results
Patient satisfaction results

27. Unaided distance vision
N = 32 Pre-op Post-op
Excellent 0 18
Very good 1 10
Good 10 3
Fair 12 1
Very poor 9 0

28. Unaided near vision
N = 32 Pre-op Post-op
Excellent 2 15
Very good 0 14
Good 1 3
Fair 3 0
Very poor 26 0

29. Unaided intermediate vision
N = 32 Pre-op Post-op
Excellent 0 16
Very good 1 12
Good 3 3
Fair 13 0
Very poor 15 1

30. Photic phenomena – glare, halos and
starbursts
N = 32 Pre-op Post-op
Never 18 2
Sometimes 8 19
Regularly 4 11

31. Photic phenomena
When do you notice them?
At night (night driving ) 28
In bright light 8
In artificial light 7

32. Photic phenomena
Do they bother you?
Never 16
Sometimes 14
Regularly 2

33. Asked at about 1month post-op
• Knowing what you know now about halos and
glare, and knowing the reduced dependence you
have on glasses after surgery, would you have
the same type of IOL again and would you
recommend it to a friend?
• 31/32 said yes

34. Contrast sensitivity testing
• Not carried out in our study
• Carried out by others and
shows a high degree of
contrast sensitivity, similar to
that of a 30 year old phakic
patient

35. Contrast Sensitivity results for the AT
LISA 839MP(courtesy of Dr Peter Mojzis)

36. 1
10
100
1000
1,5 3 6 12 18
Contrastsensitivity
Spatial Frequency [CPD]
Reference Range
LISA 839M (trifocal)
LISA 809M (bifocal)
Phakic
Contrast Sensitivity: Ginsbergh Box
Courtesy of Dr Detlev Breyer
36
Photopic Mesopic
Age (years): Phakic: 31 ± 10; LISA 839M® (trifocal): 63 ± 9; LISA 809M®
(bifocal): 72 ± 5
Photopic conditions: almost juvenile phakic-like results
1
10
100
1000
1,5 3 6 12 18
ContrastSensitivity
Spatial Frequency [CPD]
Reference Range
LISA 839M (trifocal)
LISA 809M (bifocal)
Phakic
0.0
5.0
10.0
Diameter[mm]
Pupil Diameter
0.0
2.0
4.0
6.0
8.0
Diameter[mm]
Pupil Diameter

37. 37
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
-5-4-3-2-1012 Defocus [D]
LISA 839M LISA 809M
-0.26
-0.20
-0.15
-0.08
±0.00
+0.10
+0.20
+0.40
+0.70
logMAR Decimal visual
acuity
Defocus curves for LISA 809 and 839
LISA 839M® shows increased plateau at 70 cm (-1.5 D Defocus)
Far- & near visual acuity show the same high level as the previous MIOL generation LISA 809M®
High level intermediate visual performance without loss of far- or near distance visual quality
Defocus results of LISA839® by CZM

38. Defocus curves of Alcon ReSTOR IOLs

39. 39
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
-5-4-3-2-1012
Defocus [D]
LISA 839M LISA 809M
-0.26
-0.20
-0.15
-0.08
±0.0
+0.10
+0.20
+0.40
+0.70
logMAR
Best of both worlds in one lens?
839 has the same logMAR values (about+0.05) as the Alcon ReSTOR +2.5 at about
70cm (-1.5 D, intermediate) and the ReSTOR +3.0 at about 40cm (-2.5D, near).

40. Who do I implant MFIOLs in?
• Patients who are 50+ years old and very keen to be
spectacle or contact lens independent (often present
requesting laser vision correction)
• Patients who understand that there will be glare and
halos and that these lenses have limitations but are
ready to accept this for spectacle independence
(realistic expectations – lots of pre-op discussion)
• More “younger” presbyopic patients (40+) are
starting to ask about MFIOL over LASIK as they can
see the upside of not having to worry about cataract
surgery in the future with MFIOL.

41. Unhappy patients and need for further
intervention
• No AT LISA 839 IOLs explanted so far!
• Only one patient unhappy with IOL result and would not
have a MFIOL again or recommend it. He completed the
survey at about one month post-op and was contacted
recently at 9 months post-op and much happier about it now.
• One patient with ocular surface issues. 6/6 and N5 vision but
“hazy”, “foggy”. Trying Restasis.
• 2 patients have had LASIK for correction of post-op
refractive errors that were limiting unaided VA
• Some patients with less than perfect vision (13 out of 60 eyes
had 6/9 -6/12 unaided) but still very happy. Many of these
due to pre-op astigmatism that persisted post-op. At LISA
939 trifocal toric now available for these patients.

42. Conclusion
• Very good visual acuity and patient satisfaction results.
• Fantastic near vision results – all N6 or better, 93%N5 or better
• True intermediate distance clarity.
• Contrast sensitivity within normal range according to studies from
Europe.
• Virtually every patient does get halos and glare but 50% are “never”
bothered by it and another 45% are only “sometimes” bother by it. 6%
regularly bothered by photic phenomena.
• 12/32 patients had photic phenomena either sometimes or regularly
pre-operatively. Many monofocal IOL patients troubled by glare post-
op.
• Having experienced the “downside” of photic phenomenon, even
without much time for neuroadaptation, almost all patients would
have the same IOL again and would recommend it to a friend because
of what they feel is the far greater “upside” of spectacle
independence, or al least greatly reduced spectacle dependence.

43. MCQ’s
• Q1) Multifocal or accommodating IOLs use the
following methods to reduce spectacle dependence
except:
a) Having a diffractive grating on the IOL surface to
create separate images on the retina
b) Having zones of different refraction to create
separate images on the retina
c) Being able to move slightly forwards within the
eye when focussing at near
d) Altering the retinal and optic nerve processing of
the images that reach the retina

44. MCQ’s
• Q2) Concerns that ophthalmologists and
optometrists have with multifocal IOLs include all of
the following except:
a) they are associated with haloes and glare
b) they may reduce contrast sensitivity as compared
with a monofocal IOL
c) they increase the risk of postoperative dry eye
d) they are sometimes associated with "waxy" or
"foggy" vision

45. MCQ’s
• Q3) The main advantage of a trifocal multifocal IOL over the
traditional bifocal multifocal is:
a) the trifocal comes in a choice of colours
b) the trifocal provides better intermediate vision for tasks
such a working on the computer
c) the trifocal produces x-ray vision for looking through solid
objects
d) with the trifocal lens one does not need the specia glasses
to watch 3-D movies

46. Answers
• Correct answers: Q1 - d, Q2 - c, Q3 - b