TYPES OF

IOL
Kanishka Kathir
3rd
year MBBS
 Definition
Intraocular lens (IOLs) are lens implanted
in the eye as a part of treatment of cataract or
refractive errors or aphakic patients

HISTORY OF IOL
Harold Ridley was a British ophthalmology surgeon and medical scientist
who utilized his observations and inspirations from the injured pilots of
World War II in the creation of the first IOL. In 1949, Ridley performed
the first successful implantation of an IOL at St. Thomas's Hospital . The
lens was made from Perspex CQ (clinical quality)
 Generations of IOL

1) First generation IOL- Ridley lenses.Posterior chamber lens. Cause Uveitis, Glaucoma and IOL
dislocation

2) Second generation IOL- Early ACIOL.Rigid/Semi-rigid IOL. Cause corneal decompensation and
UGH syndrome.

3) Third generation 10L- Iris supported iOL.Cause less corneal decompensation, but causes iris
shaffing, pupillary distortion, inflammation.

4) Fourth generation IOL- Modern Anterior Chamber IOL Flexible loop design, more stable, better
results, less complications.

5) Fifth generation IOL- Posterior chamber rigid PMMA lenses.

6) Sixth generation IOL- Posterior chamber Foldable IOL

7) Seventh generation IOL- Multifocal IOL.

8) Eight generation IOL- Accomodative IOL, Toric IOL, Phakic refractive IOL.
 Parts of iol
1. Optic- Clear part of the lens that focuses light on the retina.

2.Haptic- Filament attached to the optic that hold the lens in position in the
eye.

3.Size-The average size of capsular bag is of 10.4mm. The IOL haptic to

haptic distance is 13mm, it is slightly oversized to provide centripetal force
for lens stabilization and this lens can also be placed in the sulcus if required.
The optic is 6mm in size.
Properties of an IOL

An ideal IOL should be -

1. Transparent.

2. High optical resolution.

3. Non-reactive (inert).

4. Non-toxic.

5. Non-biodegradable.

6.Optically compatible.
Iol designs
 Plate haptic

First foldable silicon IOL design

ADVANTAGE:-
Plate haptics provide better stability in

postoperative period and prevent IOL rotation in the bag in case of

silicon IOL.
DRAWBACKS :-

Incomplete fusion of the anterior and posterior capsule that leaves

space along the plate haptic axis and cause migration of LECs onto the
posterior capsule causing PCO.
 OPEN LOOP
Single-piece IOL- These IOLs are produced from a

single material, i.e, optic and haptic is of the

same material . it is resistant to damage when useed in

Injectors they are prefered in Bag placement iol

Multi-piece IOL- These IOL are produced from 2 materials,Most common haptic material is
PMMA, Polyvinylidene(PVDF), Polyimide (Elastimide) and Polypropylene (Prolene).

J loop design-Preferred for sulcus placement

C loop design- More preferred for in the bag

lens placement.
 Haptic Angulation

The optic-haptic angulation are present is

some lenses. This cause better apposition

of the lens with the posterior capsule causing less space between them and hence
reducing chances of PCO.

a) Planar- They have a straight optic-haptic plane with no angulation.Eg- Single piece
IOLS.

b)Angulated -The angulation between the optic and haptic is around 5-10 degree.Eg-
Multipiece

c) Offset Haptics- The haptics are placed behind the optics. Eg. Technis
 Optic edge design
a)Round edge design-The edges of the optic

is rounded, this allows migration of lens

epithelial cells (LECs) behind the IOL and

cause formation of PCO.

b)Sharp edge or square edge design- It causes blocking of the migration of the LECs as
it causes firm apposition with the posterior capsule and prevent migration of cells and
PCO formation. But the sharp edge causes diffraction of the light at the periphery
causing edge-glare phenomenon.

c)Sloping edge design- The newer modification in the IOL is the sloping edge design
that cause less edge glare phenomenon
 Iol materials
1) Rigid PMMA IOLs- The most common used

material for IOL. It is rigid, chemically

stable compound.. The specific gravity is about 1.2 and is much closer to
neutral buoyancy.

2) Silicon- Silicon polymers have lower index

of refraction (n=1.43) than PMMA (n=1.49)

and must be thicker for the same refractive

correction. Made from a number of formulations of polyorganosiloxane.

HYDROPHOBIC ACRYLIC :-

It is a copolymer acrylate and methacrylate,It absorbs minimal water.It is

most successful foldable IOLs today.It have low PCO
rates.Photopsias,glistenings occur commonly’

HYDROPHILIC ACRYLIC IOL:-

Mixture of poly-HEMA and hydrophilic acrylic monomer.18-26% water

content.suitable for single piece design.It has higher PCO rate.calcium
deposits occur.

HYDROGEL:-

Hydrate to form soft swollen rubbery mass copolymer of methacrylate

ester.implanted by phaconit technique
UV absorption in IOL
These IOLs contain chromophore material, that mimic

the ageing process of a normal human crystalline

lens and UV blocking property.

Principle- Normal human lens turns yellow with age due to oxidation of
tryptophan and glycosylation of lens proteins which leads to progressive
absorption of blue range wavelength. This protects the lipofuscin containing RPE
cells from blue light damage, which may result in reducing risk of ARMD.

Chromophore- Hydroxybenzophenone, Hydroxyphenyl Benzotriazole.Absorbs

visible blue light 200-550 nm.Demerits- Decrease night vision since blue light is
important in scotopic vision.
Aspheric iOLs
• They are designed to reduce the spherical aberration(SA)

• Spherical aberration occurs when parallel rays of light

do not focus on one point.

• Positive SA- Peripheral rays of light focus in front of the central rays.

• Negative SA- Peripheral rays of light focus behind the central rays.

• The cornea has positive SA which in young patients gets compensated by negative SA of the lens,
but with age the lens thickens and develops a positive SA. So in old age the eye assumes a total
positive SA leading to reduced contrast sensitivity.

• Conventional spherical IOLs have positive SA, resulting in reduced contrast sensitivity under
mesopic and scotopic condition, Aspheric iOLs have shown improvement in contrast sensitivity
under low luminance and high spatial frequency.
Types of Aspheric IOLS-

• Anterior prolate surface

- Tecnis

• Posterior prolate surface

- Acrysof IQ

• Both Anterior and Posterior prolate surfaces

- Akreos AO, SofPort AO

Disadvantages of Aspheric IOLs-

Need corneal topography for optimal results

• Not much difference in photopic conditions and in older age group

• Not for previous hyperopic refractive surgery

. more expensive

.Decrease depth perception

 Multifocal IOLs
• Multifocal iOLs focus for distance as well as near vision .
• The IOL implanted in the capsular bag loose the accommodation property of the normal lens,
thus causing difficulty in near vision in pseudophakic eyes. Here comes the role of premium
IOLs.
• Types of Multifocal IOLs-
1) Refractive- The IOLs have concentric rings of different focal length, thus helping distant and
near rays focus on the retina.
a) Two-zone lens- These have a central near vision segment and an surrounding distant vision
segment.
Drawback- Pupil also constricts in presence of strong light and patient feels difficulty in
viewing distant objects. Not suitable for people involved in outdoor sports)
b)Annulus sye/Buls con /enti segments-
Inner segment- Distant vision
Middle segment- Near vision
Outer segment- Distant vision
 Diffractive IOLs
• It utilizes the the principle of wavefront optics of light.

• The diffraction optics lens combines a standard convex curvature placed on the front surface with approximately 25 annular
zones cut on the posterior surface with microscopic steps between coterminous annuli. The step height is in the range of the
wavelength of light.

• Such lens design produces 2 diffractive orders in which the incoming waves of light will be in phase, resulting in discrete
optical foci of equal intensity.

• 82% of the light is found in 2 major foci (41% of light is in phase and 41% of light is for near vision). Rest 18% is lost.

• If the lens gets decentered or pupil is eccentric still the lens would be able to focus distant and near rays.

• Drawbacks of Multifocal IOL-

1)The intermediate vision is compromised.

2)Glare and halos caused by randomly diffracted rays can occur,

night driving is difficult.

3)Contrast sensitivity and scotopic vision are compromised.

4) Perception of rings around point source of light

Further modifications in Diffractive IOLs to overcome the drawbacks-

1) Height and spacing of diffractive rings are reduced to reduce peripheral scatter and glare.

2) Rings are made smooth rounded edges to reduce glare. Eg. Acri.LISA (Zeiss)

3) Partial optic diffractive lens, only cover the central 3mm of the lens. Eg. Restor (Alcon)

4) Full optic diffractive lens. Eg. Technis (AMO)

5) Apodisation-

In this the diffractive rings are progressively sloped greater

from centre to periphery,

this changes the angle of diffraction of light affording good intermediate vision.

Eg. - iDIFF Plus, AcriDIFF., ReSTOR.

 Accommodative IOLs
• These IOLs afford both near and distance vision with the help of haptics which can
flex and the lens expands and contracts within the capsular bag, along with the
contraction of the ciliary muscles.

• Ciliary muscle contraction → IOL moves forward → 0.7mm anterior movement cause
1D increase in refractive power.

• The patient achieves about J3 vision with these

lenses which is sufficient for driving and reading newspaper.

• In comparison to multifocal lenses there is no loss of contrast sensitivity, colour

distortion and no halos at night.

• With blended vision concept; one eye is made slightly myopic and the other
emmetropic with accommodative IOLs, the patient achieves good near, intermediate
and distant vision.
Types-
1)Single optic Accommodative IOLs-Eg. Crystalens, Kelman Tetraflex.

Designed to translate anteriorly with accommodative effort. The forward movement increases effective lens power.

2) Dual optics Accommodative IOLs-Eg. Visiogen

The optic consists of 2 lenses - a high plus anterior

lens and a minus posterior lens which are separated by a spring

haptic.

In non-accommodative phase- the tension in the capsular

bag and zonules keeps the two optics in close proximity,

whereas spring haptic is collapsed and exhibit potential energy.

With accommodative effort the zonules relax, the capsular bag expands and the spring exhibits kinetic energy, the
optics separate the anterior plus lens moves forward producing higher optical power and aids in near vision.
 Toric IOLs
• These IOLs provide the opportunity to correct corneal astigmatism, offering patients with pre-existing astigmatism optimal
distance vision without the use of spectacles or contact lenses with a cylinder correction.

• Indications-

1) Patient with regular astigmatism.

2) Good visual potential with no other ocular pathology.

• STAAR surgical IOL was the first FDA approved toric IOL (plate-haptic)

• Technique of Toric lens placement-

1) Pre-operative marking of the horizontal axis with the patient in upright

position to correct for cyclotorsion, the axis can also be marked by using a bubble marker.

2) Rhexis should be well-centered 5.5-6mm in size with anterior flap overlap.

3) Intraoperatively the pre-operative horizontal marks are used to position an angular gradation instrument, gross alignment is
done followed by OVD removal and final alignment is done. The markings on the IOL indicates flat meridian or plus cylinder
axis of the lOL.
 Newer techniques to ensure accurate IOL alignment
1) Iris fingerprinting- Detailed images of iris is taken preoperatively, the
desired alignment is drawn in this image.

2) Intraoperative wavefront aberrometry.

3) Verion image guided system uses real time eye tracking based on iris and
blood vessels characteristics.

• Rotational stability- Is a crucial factor. For every 1 degree rotation 3.3%

astigmatic correction is lost, at 30 degree rotation complete lens power is
lost.

• IOL design & material used- Hydrophobic acrylic lens is preferred due to
highest bioadhesion property. 13mm IOL diameter with plate or loop haptic
design is preferred.
 Locations of IOL placement in the Eye
Anterior chamber IOL :

• Lie entirely in front of the iris and supported in the

angle of the anterior chamber.

• Indicated when posterior chamber is not suitable for

lOL placement, with deficient capsular support.

The anterior chamber depth should be 3mm or greater.

• Contraindications-Any corneal endothelial disease, Iridocorneal angle damage such as peripheral

synechiae, Shallow chamber, Lack of substantial iris tissue, Rubeosis.

• Complications- UGH syndrome (Uveitis, Glaucoma, Hyphema), PBK, Corneal decompensation,

Chronic inflammation, Pupillary block

• Common lens design used- Plate Haptic (Kelman multiflex).

 Iris supported IOL
• These lenses are placed on the iris with the help of sutures, loops or claws.

• They are indicated when there is loss of bag-lens complex or in cases of

zonular dialysis, where the IOL cannot be placed in the bag.

Iris clip lens

• Pre pupillary iris claw lens- Singh and Worst lens, Maltese cross lens, Iris
clip lens. Not much used
 Retropupillary iris claw lens
Fixed/clawed behind the iris. Cosmetically these are more acceptable give good visual outcome. Retro-pupillary
fixation offers the advantage with physiological posterior chamber implantation, resulting in a deeper anterior
chamber and a lower intraoperative and postoperative risk of corneal decompensation than anterior fixation. The
lobster claw IOL allow direct fixation of IOL in the iris stroma.

Advantages:Away from angle structures

• Rate of dislocation was less

• Less contact with corneal endothelium

Disadvantages:

• Iris chaffing and pigment dispersion

• Pupillary distortion

Transillumination defects

• Chronic inflammation

• Distortion on pupillary dilatation

 Ciliary Sulcus IOL
• These lenses rest entirely behind the iris .They are supported by the ciliary sulcus or the
capsular bag.

• The haptics are placed in the sulcus and

is supported by the capsular complex, the

optic may be captured inside the

capsulorhexis to allow the IOL optic to be in the physiological position.

• For sulcus placement of IOL, it is required to have at least the anterior capsular
support .Done in cases of a Posterior capsular rupture with intact anterior capsular support.

• Rigid PMMA lens can be implanted in the sulcus, 3 piece IOL can be implanted in the
sulcus. Single piece IOL is not recommended for sulcus fixation.
 Scleral fixated IOL (SFIOL)
• The IOL is placed in the sulcus with scleral support sutures to support the

IOL, this is the preferred position of IOL fixation in case of loss of capsular bag complex during surgery or in case of a
large zonular dialysis.

• The IOL generally comes with eyelets that allow the passage of the sutures through it for attachment.

The Alcon CZ70BD PMMA lens contains eyelets along the haptics that facilitate suture fixation.

The Bausch & Lomb Akreos A060 hydrophilic acrylic lens contains 4 eyelets through which

suture can be passed, providing 4 point fixation.

The Bausch & Lomb enVista MX60 IOL is a hydrophobic acrylic IOL that contains eyelets at

the 2 haptic-optic junctions

• Suture material used:

1) Polypropylene sutures -most commonly used

2)Gore-tex- non-absorbable, polytetrafluoroethylene monofilament suture.

 Contraindications of SFIOL placement :
1)High myopia (thin sclera).

2) Scleritis or Scleromalacia

Complications of scleral-fixated IOLs:

1) corneal edema

2) Increased chance of Cystoid macular oedema.

3) intraocular hemorrhage (due to the passage of suture through uveal

tissue),

4) suture erosion and infection (due to externalized or exposed sutures),

5) 10L dislocation or tilt.

 In the bag IOL
• Most physiologic and preferred site of IOL implantation in the eye.

• The IOL is placed in the capsular bag, formed after anterior capsulorhexis and removal of the lens nucleus and the cortex.

• It is supported in the bag by the posterior capsule and is held in position.

• Advantages:

Proper anatomical site

Symmetrical loop placement

Minimal magnification (<2%;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

SPECIAL IOL PLACEMENT TYPES

1. Aniridia IOL
2. Piggyback IOL
3. Implantable collamer lens
4. Phakic refractive IOL
5. Implantable miniature telescope
 IOL Power calculation
• Precise IOL power calculation is essential for good optical outcomes.

• Generations of IOL calculation formulae :

First Generation - SRK- 1 and Binkhorst formula

Second Generation - SRK-2

Third Generation - SRK T, Holladay. Hoffer-Q Fourth Generation - Holladay 2, HAIGIS

Fifth Generation- Hoffer H-5

• Theoretical formula- Mathematical principles revolving around the schematic eye.

• Regression formula- Derived from looking at postoperative outcomes retrospectively

 Complications of an IOL
• Lens malposition:

- Pupillary capture of the IOL- May occur following postoperative iritis or proliferation of remains on lens fibre

- Decentration- Sunset syndrome (inferior subluxation of lens), Sunrise syndrome(superior subluxation of lens)

- Windshield wiper syndrome- It is when a small IOL is placed in the sulcus, the superior haptic moves left and right with movement of the
head.

- Lost lens syndrome- Refers to complete dislocation of the IOL in the vitreous cavity.

: Politeror celia opacid leftiver left behind after 0L implantation, due to wrong biometry

readings.

• Dysphotopsias- Unwanted image or flashes seen by the patient after uneventful cataract surgery

- Positive : night time glare and halos

- Negative : black ring in the field

• Cystoid macular oedema (CME) - CME is more common after IOL implantation. Incidence is more in case of ACIOL.
 Posterior Capsular Opacity
• PCO remains a common problem after cataract surgery with implantation of an IOL.

Clinically 2 types-

1) Regenerative type- More common. Caused by the residual LECs from the the lens equator region, E cells, migrating and
proliferating into the space between posterior capsule and the lOL, forming layers of lens material and Elschnig pearls.

2) Fibrotic PCO- Caused by LECs from the anterior capsule A-cells that undergo transformation into myofibroblasts and gain
access to the posterior capsule,causing whitening and wrinkling of the cells.

PCO relation with IOL-

• Hydrophobic Acrylic has least PCO causing effect, followed by Silicon lens

followed by Hydrophilic acrylic and PMMA.

• Square edge design prevents migration of LECs behind the IOL, inhibiting PCO.

• 3 piece lens has a angulation and cause better IOL-capsule contact, inhibiting PCO.

Treatment- YAG laser capsulotomy

 Recent advances
1) Light adjusted IOL

• Developed by Calhoun Labs with Zeiss Meditec.

These lenses are designed to correct residual refractive error post implantation in the
eye.

3 piece, silicone polymer lens with PMMA haptics, square edge design.

• Near UV light is irradiated on the lOL with the help of a slit lamp. When a portion of
the lens is irradiated with near-UV light, it polymerizes the macromers in that portion.
That creates an excess concentration of macromers in the non irradiated portion and
sets up a diffusion gradient over which the free macromers move from the
concentrated area to the less concentrated area.

• Adjustment of 2D Hypermetropia, Myopia or Astigmatism can be corrected

2) Injectable Gel lOLs

• Also known as Phaco-Ersatz.

• After femtosecond cataract surgery, the lens is broken down in many pieces
and is aspirated out.

• The lens is introduced into the eye through this small opening.

• The lens is hydrophobic, thermoplastic, acrylic gel that fills the capsular
bag.

• Main advantage of restoring

accommodation.

• Cannot be used in case of posterior capsular rupture.

• Flexoptix (AMO), Fluidvision (Belmont CA),

NuLens(NuLens
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