After years of evaluation, advancement, and refinement, cataract surgery has evolved from mere removal of the natural lens to an elegant procedure with a range of state-of-the-art IOL options. Every aspect of the surgery has been designed in meticulous detail to achieve the best visual outcomes. IOLs have advanced in many ways as well. Now implanted in millions of eyes, the IOLs available to us today are well-engineered optical devices that work with the human anatomy to achieve various important goals for optical quality and visual performance.
In my career, I have used virtually every IOL that has come to market in the United States, including lenses that are not widely used, yet AcrySof IQ IOL (Alcon) remains my monofocal lens of choice (Figure). The lens has been around for almost 25 years, with over 100 million implanted worldwide. I choose the AcrySof IQ IOL because it is elegantly engineered, performs exceptionally well during surgery, and gives my patients excellent visual outcomes.
Unique Material and Filtering
The AcrySof platform's biocompatible hydrophobic acrylic polymer is different from other lens materials, because it offers a high level of fibronectin, which helps bind the IOL to the capsule. In my experience, that biocompatibility and binding ability may help decrease complications, such as posterior capsular fibrosis, following surgery.
A review of literature evaluating implants of brands of IOLs implanted worldwide showed the incidence of posterior capsular fibrosis ranged from around 5 to 50%.1-5 In general, posterior capsular fibrosis affects about 1 in 5 cataract patients, decreasing the quality of vision after surgery. With the material and square-edge design of the AcrySof IQ IOL, patients have clearer vision after surgery, which in turn reduces the number of secondary procedures I need to perform. Using the YAG laser after cataract surgery to perform a capsulotomy may increase the risk of retinal detachment, and an open capsule makes it very difficult to remove or reposition an implant. In my hands using the AcrySof IQ IOL, I’ve experienced a low YAG rate of about 2%, which is consistent with the reported YAG rates for this lens. (Range from 1.6 to 2.2% at approximately 1.5 years).6 I believe this is due to the unique material and the lens edge design.
Another important AcrySof IQ IOL feature I appreciate are the BioOptics, which play an important role in functional vision. The AcrySof IQ IOL is available with ultraviolet (UV) filtering and a yellow chromophore to filter short-wavelength blue light, as well as with UV filtering alone. The yellow chromophore’s ability to filter blue light mimics the filtering of a youthful adult's lens. Blue light filtering in the AcrySof IQ lens has been shown to help improve functional vision and aid photostress recovery versus UV-only IOLs.7,8 In addition, in night-time driving simulations, patients with the AcrySof IQ lens with blue light filtering showed improved reaction times and hazard detection versus the UV-only IOL.6 While research is ongoing on the effects of UV and blue light exposure, it is known that excessive exposure to blue light, in particular, can impair circadian rhythms and disrupt sleep.9 Lack of these filters may contribute to choroidal melanoma and changes to the retinal pigment epithelium.10-12
Design and Mechanics
Cataract surgery has become extremely sophisticated, with every critical element mapped out for optimal outcomes. Incisions are designed to leave the smallest optical footprint, minimizing surgically induced astigmatism. To insert the lens through the smallest incision possible, we rely on the thin design and elasticity of our IOLs. The more elastic the lens is, the easier it is to fold it and insert it into the eye.
The AcrySof IQ lens has a higher refractive index versus other aspheric IOLs and has excellent elasticity, allowing me to fold it easily without kinking or twisting. I implant this IOL though a 2.2-mm incision using the UltraSert Pre-loaded IOL Delivery System (Alcon). The single-use injector has a smooth feel and a depth-guard nozzle to help ensure accurate and consistent placement. Although the AcrySof IQ lens material is malleable, the lens and its haptics have shape memory. As the IOL slowly unfolds, it assumes its optimal form inside the capsular bag.
The design and mechanics of this IOL help with precise centration. The STABLEFORCE haptics limit both rotational and axial movement with contraction of the capsular bag in the postoperative period. Controlling stability ensures effective lens position leading to the best optical predictions and outcomes. In fact, when we use the AcrySof IQ toric lens in my practice, about 94% of eyes had rotated less than 5° from the same axis at 1 to 6 months postoperatively.
The AcrySof IQ IOL is a very forgiving lens for novice surgeons. After surgeons master the IQ base lens, they can incorporate optics to correct astigmatism and presbyopia. In my experience, the lens is not difficult to reposition, but the material’s “sticky” quality makes it unlikely that repositioning will be required.
The aspheric IQ lens mimics the human crystalline lens shape to help achieve the best optical quality for patients. Aspheric lenses are designed to reduce spherical aberrations (halos) and improve contrast sensitivity. This is particularly useful to patients as they read or perform tasks in dim lighting.13
In the young eye, positive corneal aberrations are compensated by negative spherical value in the crystalline lens. As the eye ages, the spherical value of the lens gradually becomes positive, causing image quality to be less clear on the periphery in eyes with pupils that are 4 mm or larger. An aspheric IOL is designed to work much the same way as a young lens works to negate some of the eye’s positive spherical value. This improves image clarity and contrast sensitivity, particularly on the perimeter.
The cornea’s positive spherical aberration averages about +0.274 μm.3 The AcrySof IQ IOL has a negative asphericity of -0.2 μm, which brings the average eye to +0.074 μm. Retaining some positive spherical value is the goal, as studies have shown a small positive spherical aberration represents optimal vision.14,15 The moderate -0.2 μm asphericity of the AcrySof IQ IOL makes the lens a good choice for a wide range of patients, resulting in minimal over or under-correction.
At the end of the day, cataract surgery is about patient outcomes. Patients want to perceptually see the best they can. On the first postoperative day with the AcrySof IQ IOL, my patients literally exclaim, “Wow!” They realize how much visual quality they have been missing, and that the AcrySof IQ lens has restored that vision for them. The AcrySof IQ IOL hits the mark with a comforting predictability that has allowed me to count on this lens for many of my patients.
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AcrySof and UltraSert are trademarks of Alcon. All other brand/product names are the trademarks of their respective owners.
1. Schmidbauer JM, Vargas LG, Apple DJ, et al. Evaluation of neodymium: yttrium-aluminum-garnet capsulotomies in eyes implanted with AcrySof intraocular lenses. Ophthalmology. 2002;109(8):1421.
2. Dholakia SA, Vasavada AR. Intraoperative performance and longterm outcome of phacoemulsification in age-related cataract. Indian J Ophthalmol. 2004;52(4):311.
3. Thompson AM, Sachdev N, Wong T, et al. The Auckland Cataract Study: 2 year postoperative assessment of aspects of clinical, visual, corneal topographic and satisfaction outcomes. Br J Ophthalmol. 2004;88(8):1042.
4. Buehl W, Sacu S, Findl O. Association between intensity of posterior capsule opacification and visual acuity. J Cataract Refract Surg. 2005;31(3):543.
5. Meacock WR, Spalton DJ, Boyce J, Marshall J. The effect of posterior capsule opacification on visual function. Invest Ophthalmol Vis Sci. 2003;44(11):4665.
6. AcrySof IQ IOL Directions for Use.
7. Hammond BR Jr, Renzi LM, Sachak S, Brint SF. Contralateral comparison of blue-filtering and non-blue-filtering intraocular lenses: glare disability, heterochromatic contrast, and photostress recovery. Clin Ophthalmol. 2010;4:1465-1473.
8. Gray R, Perkins SA, Suryakumar R, et al. Reduced effect of glare disability on driving performance in patients with blue light-filtering intraocular lenses. J Cataract Refract Surg. 2011;37(1):38-44.
9. West KE, Jablonski MR, Warfield B, et al. Blue light from light-emitting diodes elicits a dose-dependent suppression of melatonin in humans. J Appl Physiol. 2011;110(3):619-626.
10. Di Cesare S, Maloney S, Fernandes BF. The effect of blue light exposure in an ocular melanoma animal model. J Exp Clin Cancer Res. 2009;28(1):48.
11. Marshall JC, Gordon KD, McCauley CS, et al. The effect of blue light exposure and use of intraocular lenses on human uveal melanoma cell lines. Melanoma Res. 2006;16:537-541.
12. Rezai KA, Gasnya E, Seagle BL, et al. AcrySof Natural filter decreases blue light-induced apoptosis in human retinal pigment epithelium. Graefe‘s Arch Clin Exp Ophthalmol. 2008;246:671-676.
13. Piers PA, Manzanera S, Prieto PM, et al. Use of adaptive optics to determine the optimal ocular spherical aberration. J Cataract Refract Surg. 2007;33:1721–1726.
14. Liu J, Zhao J, Ma L, et al. Contrast sensitivity and spherical aberration in eyes implanted with AcrySof IQ and AcrySof Natural intraocular lens: the results of a meta-analysis. PLoS One. 2013;8(10): e77860.
15. Levy Y, Segal O, Avni I, Zadok D. Ocular higher order aberrations in eyes with supra-normal vision. Am J Ophthalmol. 2005;139:225-228.
AcrySof® Family of Single-Piece IOLs Important Product Information
(AcrySof® UV, AcrySof ®IQ, AcrySof® IQ Toric, AcrySof®IQ ReSTOR®, and AcrySof® IQ ReSTOR® Toric IOLs)
CAUTION: Federal law restricts these devices to sale by or on the order of a physician.
INDICATION: The family of AcrySof® single-piece intraocular lenses (IOLs) includes AcrySof® UV-absorbing IOLs (“AcrySof® UV”), AcrySof ®IQ, AcrySof ®IQ Toric® and AcrySof IQ ReSTOR® and AcrySof® IQ ReSTOR® Toric IOLs. Each of these IOLs is indicated for visual correction of aphakia in adult patients following cataract surgery. In addition, the AcrySof Toric IOLs are indicated to correct pre-existing corneal astigmatism at the time of cataract surgery. The AcrySof IQ ReSTOR IOLs are for cataract patients with or without presbyopia, who desire increased spectacle independence with a multifocal vision. All of these IOLs are intended for placement in the capsular bag.
General cautions for all AcrySof® and AcrySof® UV IOLs: Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting any IOL in a patient with any of the conditions described in the Directions for Use that accompany each IOL. Caution should be used prior to lens encapsulation to avoid lens decentration or dislocation. Viscoelastic should be removed from the eye at the close of surgery.
Additional Cautions associated with AcrySof® IQ ReSTOR® IOLs: Some patients may experience visual disturbances and/or discomfort due to multifocality, especially under dim light conditions. A reduction in contrast sensitivity may occur in low light conditions. Visual symptoms may be significant enough that the patient will request explant of the multifocal IOL. Spectacle independence rates vary with all multifocal IOLs; as such, some patients may need glasses when reading small print or looking at small objects. Clinical studies indicate that posterior capsule opacification (PCO), when present, may develop earlier into clinically significant PCO with multifocal IOLs.
Additional Cautions associated with AcrySof® IQ Toric, AcrySof® UV Toric and ReSTOR® Toric IOLs: Optical theory suggests that, high astigmatic patients (i.e. > 2.5 D) may experience spatial distortions. Possible toric IOL related factors may include residual cylindrical error or axis misalignments. Toric IOLs should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; if necessary lens repositioning should occur as early as possible prior to lens encapsulation.
Prior to surgery, physicians should provide prospective patients with a copy of the appropriate Patient Information Brochure available from Alcon informing them of possible risks and benefits associated with the AcrySof® IQ Toric, AcrySof® IQ ReSTOR® and AcrySof® IQ ReSTOR® Toric IOLs.
Do not resterilize. Do not store at temperatures over 45° C. Use only sterile irrigating solutions to rinse or soak IOLs.
ATTENTION: Refer to the Directions for Use labeling for the specific IOL for a complete list of indications, warnings and precautions.
IMPORTANT PRODUCT INFORMATION
UltraSert® Pre-loaded IOL Delivery System with the AcrySof® IQ aspheric IOL
CAUTION: Federal (USA) law restricts this device to the sale by or on the order of a physician.
INDICATIONS: The AcrySof IQ aspheric intraocular lens (“AcrySof IQ”) is intended for the replacement of the human lens to achieve visual correction of aphakia in adult patients following cataract surgery. This lens is intended for placement in the capsular bag.
Use the UltraSertTM Pre-loaded Delivery System (“UltraSert”) at temperatures between 18° C (64° F) and 23°C (73° F). Use only Alcon viscoelastics qualified for this device. Do not use the UltraSert if the nozzle appears damaged or deformed. Follow the Directions for Use for correct order and sequence of steps to avoid damage to the IOL or the UltraSert.
Careful preoperative evaluation and sound clinical judgement should be used by the surgeon to decide the risk/benefit ratio before implanting a lens in a patient with any of the conditions described in the Directions for Use. Caution should be used prior to lens encapsulation to avoid lens decentrations or dislocations.
Studies have shown that color vision discrimination is not adversely affected in the individuals with the AcrySof® Natural IOL and normal color vision. The effect on vision of the AcrySof® Natural IOL in subjects with hereditary color vision defects and acquired color vision defects secondary to ocular disease (e.g., glaucoma, diabetic retinopathy, chronic uveitis, and other retinal or optic nerve diseases) has not been studied. Do not resterilize: do not store over 45° C.
ATTENTION: Reference the Directions for Use for Model AU00T0 for a complete listing of indications, warnings and precautions.