Slide 1. Slide 2. Slide 3 3 CATEGORIES. 4 th CATEGORY Depth-of-Focus. Depth-of-Focus Lenses. Historically Intraocular Lenses

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1 Slide 1 Depth-of-Focus Lenses Slide 2 Historically Intraocular Lenses 3 CATEGORIES Traditional Monofocal Monofocal Toric Multi-focal 4 th CATEGORY Depth-of-Focus Slide 3 Monofocal and Monofocal Toric lenses give patient s vision at one focal point Traditional multifocal lenses give distance and near focal points with a dip in visual acuity in between (peaks and valleys)

2 Slide 4 Depth-of-Focus Lenses Latest technology in cataract surgery Gives a distance and near point with a smooth transition in between Currently 2 styles of depth-of-focus lenses available ReSTOR 2.5 Lifestyle Lens Symfony Lens / Symfony Toric Lens Slide 5 Lifestyle Lens A 0.94 mm refractive monofocal central zone 7 defractive rings Slide 6 What is the significance of a depth-of-focus lens having a monofocal central zone?

3 Slide 7 Modulation Transfer Function (MTF) Modulation Transfer Function or "MTF" is the most widely used scientific method of describing lens performance. The modulation transfer function is, as the name suggests, a measure of the transfer of modulation (or contrast) from the subject to the image. In other words, it measures how faithfully the lens reproduces (or transfers) detail from the object to the image produced by the lens. Slide 8 Modulation Transfer Function (MTF) [A] is the original test pattern [B] is the image of the test pattern [C] is the line profile of the original test pattern where 255=white and 0=black [D] is the line profile of the image of the test pattern where 255=white and 0= black Slide 9 Modulation Transfer Function (MTF) MTF at 100 lp/mm mm Distance 3 mm Distance 3 mm Near Axis Title Lifestyle Lens ReSTOR 3.0 Tecnis

4 Slide 10 Symfony 9 Defractive Rings Slide 11 Symfony Continued Slide 12 Comparison of Depth-of-focus Lifestyle vs. Symfony

5 Slide 13 MTF Comparison Study: Effect of Large Apertures on the Optical Quality of Three Multifocal Lenses Jose Juan Esteve-Taboada, PhD; Alberto Domínguez-Vicent, MSc; Antonio J. Del Águila-Carrasco, MSc; Teresa Ferrer-Blasco, PhD; Robert Montés-Micó, PhD PURPOSE: To compare the optical quality under large apertures among three multifocal intraocular lenses (IOLs): the TECNIS Symfony ZXR00 (Abbott Laboratories, Abbott Park, IL), the AT LISA tri 839MP (Carl Zeiss Meditec, Jena, Germany), and the Finevision (PhysIOL, Liège, Belgium). METHODS: The in vitro optical quality of each lens was assessed with an instrument that measured the modulation transfer function (MTF). The optical quality of each lens was described in terms of MTF and through focus average MTF. The Strehl ratio, cut-off frequency, area of visibility, and percentage energy were calculated to objectively describe the optical quality of each lens. These metrics were assessed for the best lens distance focus and at four vergences (from to D in 0.50-D steps) at a 4.5-mm aperture. RESULTS: The through focus average MTF of the AT LISA and Finevision IOLs showed three mean areas corresponding to distance, intermediate, and near vision. The TECNIS Symfony IOL showed two main areas corresponding to distance and intermediate vision. All metrics revealed that the Finevision IOL showed the best optical quality at distance vision, the TECNIS Symfony IOL at intermediate vision, and the AT LISA IOL at near vision. The TECNIS Symfony IOL showed the most homogeneous light distribution between its best vision foci. CONCLUSIONS: The TECNIS Symfony IOL is less vergence dependent than the AT LISA and Finevision IOLs under dim conditions. These results may help clinicians to choose the proper lens depending on the patient s visual requirements. [J Refract Surg. 2015;31(10): ] Slide 14 MTF at 100 lp/mm MTF at 100 lp/mm Average MTF mm Distance 3 mm Distance 3 mm Near Lifestyle Lens ReSTOR 3.0 Tecnis Slide 15 Relative Height of Defractive Rings Lifestyle Lens

6 Percent of Sample (%) Slide 16 Dysphotopsias Lifestyle Lens Slide 17 Use of Femtosecond Laser with Lifestyle and Symfony Lenses Observations in January 2012 Discussion with Louis Probst, M.D. Slide 18 Reproducible Capsulotomy Capsulotomy Diameter Accuracy (Absolute difference between Attempted and Achieved) Laser (n=60) Manual (n=60) 0 <=0.25 <=0.5 <=0.75 <=1.0 <=1.25 <=1.5 Diameter Error (mm) Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg. 2009;25(12):

7 MIX12459SK MIX12459SK Slide 19 Table 1 Demographics of Patients Who Underwent Manual Continuous Curvilinear Capsulorrhexis or Femtosecond Laser Capsulotomy Mean+Standard Deviation CCC Group FS Group Demographic (n=51) (n=48) P Value* Age (y) >.05 Sex (M:F) 7:31 9:34 >.05 Spherical refractive error (D) >.05 Cylinder refractive error (D) >.05 CCC = continuous curvilinear capsulorrhexis, FS = femotosecond *Unpaired t test. Internal Aberrations and Optical Quality After Femtosecond Laser Anterior Capsulotomy in Cataract Surgery. Journal of Refractive Surgery Vol. 27, No. 10, Michael C. Knorz, MD; Zoltan Z. Nagy, MD, DSc; et al Slide 20 Table 2 Ocular, Corneal, and Internal Aberrometry Parameters 6 Months After Surgery in Eyes That Underwent Continuous Curvilinear Capsulorrhexis or Femtosecond Laser Capsulotomy Mean+Standard Deviation CCC Group FS Group Parameter (n=51) (n=48) P Value* Ocular Vertical tilt >.05 Vertical coma >.05 Corneal Vertical tilt >.05 Horizontal tilt >.05 Vertical coma >.05 Horizontal coma >.05 Internal Vertical tilt Horizontal tilt >.05 Vertical coma CCC = continuous curvilinear capsulorrhexis, FS = femotosecond *Unpaired t test. Internal Aberrations and Optical Quality After Femtosecond Laser Anterior Capsulotomy in Cataract Surgery. Journal of Refractive Surgery Vol. 27, No. 10, Michael C. Knorz, MD; Zoltan Z. Nagy, MD, DSc; et al 20 Slide 21 CCC = continuous curvilinear capsulorrhexis, FS = femotosecond UDVA = uncorrected distance visual acuity, CDVA = corrected distance visual acuity, MTF = modulation transfer function, cpd = cycles per degree *Unpaired t test. Table 3 Visual Quality Characteristics in Eyes That Underwent Continuous Curvilinear Capsulorrhexis or Femtosecond Laser Capsulotomy Mean+Standard Deviation CCC Group FS Group Parameter (n=51) (n=48) P Value* UDVA >.05 CDVA >.05 Strehl ratio MTF (cpd) Internal Aberrations and Optical Quality After Femtosecond Laser Anterior Capsulotomy in Cataract Surgery. Journal of Refractive Surgery Vol. 27, No. 10, Michael C. Knorz, MD; Zoltan Z. Nagy, MD, DSc; et al

8 Slide 22 Representative Point Spread Function Images (PSF) FS vs. CCC Slide 23 If you get flare with a manual rhexus and a monofocal lens imagine how much flare you can get using a manual rhexus and a depth-of-focus lens? Slide 24 Lifestyle Lens vs. Symfony Lens A clinical study was done comparing both lenses 18 patient eyes (EP and PE Surgeons) received Symfony or Symfony Toric. 12 patient eyes (PE Surgeon) received Lifestyle Lens Parameters that were evaluated include: UDVA (Lights on) UIVA (70 cm) UNVA (40 cm) AR Preferred MR Depth-of-focus (maximum plus MR vs. maximum minus MR with no decrease in UDVA) Do you experience any problems with your vision?

9 Slide 25 Results UDVA (Lights on) Lifestyle (n=12) Symfony (n=18) 20/20 58% 33% 20/25 17% 33% 20/30 25% 34% Slide 26 Results UIVA (70 cm) Lifestyle (n=12) Symfony (n=18) 20/20 0% 17% 20/25 0% 17% 20/30 9% 39% 20/40 18% 5% 20/50 0% 11% 20/60 73% 11% Slide 27 Results UNVA (40 cm) Lifestyle (n=12) Symfony (n=18) 20/20 8% 28%* 20/25 0% 11% 20/30 42% 44% 20/40 33% 0% 20/50 0% 11% 20/60 17% 6% The average refractive error for the lifestyle lens was D ( > D) The average refractive error for the symphony lens was D (plano -> D) *The symfony patients that were 20/20 UNVA had refractive error of D -> D

10 Slide 28 Sx Pt. Date Lens type DVA IVA NVA Preferred MR Most minus MR Most plus MR Best thing about lens? (20ft) (70cm) (40cm) Symfony "Not needing glasses for AP 2/9/17Toric multi 20/20 20/50 20/50 plano DS DS DS distance." "Not needing glasses for " 2/2/17Lifestyle 20/20 20/40 20/30 plano DS DS DS distance." Least favorite thing about lens? "Not able to read anything." "Not able to read anything." 28 Slide 29 Do you experience any problems with your vision? Lifestyle Lens 18% Nothing 82% Difficulty reading small print Symfony Lens 15% Nothing 85% Halos / Starburst around lights Important to note: 100% of patients in each group were well satisfied with their visual result and would recommend the same lens to others Slide 30 Study Summary Lifestyle lens has better uncorrected distance vision than the Symfony lens Higher MTF values for distance Symfony lens has better uncorrected intermediate vision than the Lifestyle lens Greater depth of focus Higher MTF values for intermediate Symfony lens has better uncorrected near vision than the Lifestyle lens due to patients being left more myopic Patients with the Symfony lens seem to tolerate more myopia for their distance vision than patients with the Lifestyle lens having similar amounts of myopia

11 Slide 31 3 Bucket Assessment Distance Beyond 20 Feet Driving Golf Tennis Bowling Hunting Hiking Walking TV & Movies Intermediate Beyond 30 Inches Computer Watch Cell Phone Car Dashboard Counter Top Desk Work Certain Hobbies: Crafts Working on Cars Near Within 30 Inches Reading Crocheting Needle Point Slide 32 Patients are asked to prioritize the buckets Slide 33 Priority of Buckets Scenario 1 1. Distance 2. Intermediate 3. Near Doesn t mind wearing reading glasses Bilateral Lifestyle Lens

12 Slide 34 Priority of Buckets Scenario 2 1. Intermediate 2. Near 3. Distance Doesn t mind wearing part-time distance glasses Bilateral Symfony Lens (target -0.50D) 34 Slide 35 Priority of Buckets Scenario 3 Wants all 3 1. Distance 2. Near 3. Intermediate Plan: Lifestyle Lens Dominant eye Symfony Lens Non-dominant eye targeting > D Slide 36 Priority of Buckets Scenario 4 Monovision patient that wants depth-of-focus Plan A: Lifestyle Lens Distance eye target plano Symfony Lens Near eye target D > D Plan B: Monofocal Lens Distance eye target plano Symfony Lens Near eye target D -> D

13 Slide 37 Priority of Buckets Scenario 5 Post LVC Patient wants to be relatively glasses free Due to variance D Plan: 1. Operate on non-dominant eye first Symfony Lens, target myopia ( > D) 2. Assess patient s results 1 week post-op If patient is happy, Symphony lens on dominant eye target D If patient wants better distance on dominant eye Lifestyle lens, target plano Slide 38 Halos / Dysphotopsias Lifestyle Lens Professions Airline pilots School bus drivers Truck drivers Recommend Lifestyle Lens Slide 39 Challenges you may face with depth-of-focus lenses Patient expectations Corneal surface issues

14 Slide 40 Case Studies JB 68 YO WM 3/29/16 - KPE OD Lifestyle Lens 4/5/16 KPE OS Lifestyle Lens 12/23/16 Patient called office complaining not satisfied with distance vision without glasses Refractive error OD Plano x 80 20/20 OS Plano x /20 PLAN? Slide 41 Case Studies 59 YO WF KPE Lifestyle OD 1/28/16 2/4/16 KPE Lifestyle OS Developed secondary iritis OS Pred forte every 2 hours while awake 4/29/16 MR OS x 150 Pred Forte discontinued. Intensive artificial tear treatment initiated 5/20/16 MR OS x 160 8/4/16 MR OS Plano sphere Slide 42 Closing Comment Depth-of-focus lenses are the latest advancements in treatment of patients with cataracts Lifestyle Lens and the Symfony Lens are excellent depth-offocus lenses We can now customize patients vision with these lenses

15 Slide 43 Questions?