Accommodative ArchingAccommodative Arching

Eyeonics BriefingEyeonics Briefing2 February 20052 February 2005

Kevin L. Waltz, OD, MDKevin L. Waltz, OD, MDEye Surgeons of IndianaEye Surgeons of Indiana

Indianapolis, INIndianapolis, IN

Outline of BriefingOutline of Briefing

BackgroundBackground

Measurement limitationsMeasurement limitations

Historical assumptionsHistorical assumptions

Fortuitous patientFortuitous patient

Archeological evidenceArcheological evidence

Theory fit with known data Theory fit with known data

Background for AA TheoryBackground for AA Theory

KLW’s interest in refractive lens surgeryKLW’s interest in refractive lens surgery

Tracey experience since summer 2002Tracey experience since summer 2002

i i Trace experience since fall 2003Trace experience since fall 2003

Experience with capsular effects on IOL’sExperience with capsular effects on IOL’s

KLW’s frustration with initial AT-45 outcomesKLW’s frustration with initial AT-45 outcomes

Extensive wavefront testing of distance and Extensive wavefront testing of distance and

near vision with IOL’s, including AT-45 pts near vision with IOL’s, including AT-45 pts

Array Eye for Tracey ReviewArray Eye for Tracey Review

Experience with Capsular/YAG Effects Experience with Capsular/YAG Effects on Multifocal Opticson Multifocal Optics

10 minutes10 minutes Pre-YAG Post-YAGPre-YAG Post-YAG 20/20 & J3 20/20 & J1 20/20 & J3 20/20 & J1

Experience with Monofocal IOL’s Experience with Monofocal IOL’s “Pseuodaccommodation”“Pseuodaccommodation”

Measurement LimitationsMeasurement Limitations

Original Tracey 64 sequential spotsOriginal Tracey 64 sequential spots

i i Trace Trace sequential 256 spotssequential 256 spots

Variable spot positioning on TraceyVariable spot positioning on Tracey

Tracey can readily measure wavefront at nearTracey can readily measure wavefront at near

Shack-Hartmann simultaneous spotsShack-Hartmann simultaneous spots

NIPEK OPD simultaneous topo and wavefrontNIPEK OPD simultaneous topo and wavefront

COAS direct imagingCOAS direct imaging

Historical AssumptionsHistorical Assumptions

Near wavefront ignoredNear wavefront ignored

Near wavefront assumed to be the same Near wavefront assumed to be the same as distance with some amount of as distance with some amount of uniformly increased poweruniformly increased power

Reading glasses = accommodationReading glasses = accommodation

Low HOA @ distance = low HOA @ nearLow HOA @ distance = low HOA @ near

Low HOA @ near is good Low HOA @ near is good

Zachary Waltz 13 yoZachary Waltz 13 yo

OD – 5 D accommodationOD – 5 D accommodation OD – No accommodationOD – No accommodation

Successful College Student 19yoSuccessful College Student 19yo

OS – 5 D accommodationOS – 5 D accommodation OS – No accommodationOS – No accommodation

Successful Medical Student Successful Medical Student S/P LASIK 23 yoS/P LASIK 23 yo

OD – 5 D accommodationOD – 5 D accommodation OD – No accommodationOD – No accommodation

Fortuitous PatientFortuitous Patient

72 year old white male cataract pt72 year old white male cataract pt

Desired to be less dependent on glassesDesired to be less dependent on glasses

Uneventful cataract surgeryUneventful cataract surgery

PO: Little to no near vision and myopicPO: Little to no near vision and myopic

Repositioned IOL in bag at 7 weeks to Repositioned IOL in bag at 7 weeks to decrease myopia, rotated IOL 90°decrease myopia, rotated IOL 90°

Improved distance and near visionImproved distance and near vision

Prior to IOL RotationPrior to IOL Rotation

Accommodation with CrystalensAccommodation with CrystalensS/P IOL Rotation by 90S/P IOL Rotation by 90°°

Distance refractive mapDistance refractive map Near refractive Near refractive

mapmap

0.186 rms total error 0.464 rms total 0.186 rms total error 0.464 rms total

errror errror

0.69+0.36X0780.69+0.36X078 -2.37+0.92x008 -2.37+0.92x008

Crystalens Accommodative ArchingCrystalens Accommodative Arching

AA at a Different Meridian 8:46AA at a Different Meridian 8:46

AA at a Different Meridian 8:47AA at a Different Meridian 8:47

AA Relaxed 8:52AA Relaxed 8:52

AA relaxed 8:53AA relaxed 8:53

AA at Maximum 10 Diopters 8:54AA at Maximum 10 Diopters 8:54

Archeologiccal EvidenceArcheologiccal Evidence

“The aberrations in some Tracey images are not “The aberrations in some Tracey images are not compatible with high quality vision.”compatible with high quality vision.”

Archeologiccal EvidenceArcheologiccal Evidence

Archeologiccal EvidenceArcheologiccal Evidence46 yo Optometrist46 yo Optometrist

Phakic Patients have AAPhakic Patients have AA33 yo WF Preop Cataract33 yo WF Preop Cataract

50 yo Optometrist Preop Cataract50 yo Optometrist Preop Cataract

17 yo Son of Optometrist17 yo Son of Optometrist

17 yo w/ 5 Diopters Stimulus17 yo w/ 5 Diopters Stimulus& 3.25 Diopters AA Response& 3.25 Diopters AA Response

50 yo Optometrist Dilated PO #150 yo Optometrist Dilated PO #1

50 yo Optometrist Dilated PO Week 350 yo Optometrist Dilated PO Week 3

48 yo Prelex Preop Distance48 yo Prelex Preop Distance

48 yo Prelex Preop Near48 yo Prelex Preop Near1.25 Diopters of “Accommodation”1.25 Diopters of “Accommodation”

AA Theory Fit With Known DataAA Theory Fit With Known Data

Images are almost certainly realImages are almost certainly real

Axial movement of 0.3 mm needed for Axial movement of 0.3 mm needed for

10 D of AA flexing over 2mm diameter 10 D of AA flexing over 2mm diameter

Variations in Crystalens orientation Variations in Crystalens orientation relative to power axis in eye would relative to power axis in eye would create inconsistent measured near create inconsistent measured near vision in patientsvision in patients

Capsule effects might change with Capsule effects might change with timetime

AA Theory Fit With Known DataAA Theory Fit With Known Data

Variations in IOL power with AA and Variations in IOL power with AA and emerging concept of neuroplasticity emerging concept of neuroplasticity could explain inconsistency in could explain inconsistency in

measured accommodation measured accommodation

vs vs

observed near visionobserved near vision