PHACO ERSATZ
 HOW AND WHY DID IT START ?
 WHERE DO WE GO?
 FRANK JOSEPH GOES
 frank@goes.be
 Antwerp-Belgium.
ESCRS 2011
PHACO ERSATZ
WHAT DOES IT
MEAN?????
REPLACING THE
NATURAL LENS OF
A 60 YEARS OLD
BY AN ARTIFICIAL
LENS PERFORMING
LIKE A
2O YEARS OLD
ESCRS 2011
WHY SHOULD WE REPLACE
THE NATURAL LENS ?
ACCOMODATION
AGE
ESCRS 2011
WHAT IS ACCOMODATION ???
 Described by HELMHOLTZ1853.
 Accommodation is the process by which
the eye changes its refractive power to
bring objects of regard at different
distances into focus.
 During accomodation contraction of the
ciliary muscle releases the at rest zonular
tension around the lens equator and the
lens increases in axial thickness and in
anterior and posterior diameter.
ESCRS 2011
 The principle of accommodation was
discovered in the 17th century by Scheiner.

The theories for presbyopia are generally
addressing the age changes in the lens, the
lens capsule and/or within the lens support
structures. Recent studies have shown that
the stiffness of the lens substance increases
with age by a factor 1000 to 10000 over a
lifetime.
ESCRS 2011
. Loss of accommodative amplitude with age.
Predicted by lens stiffness changes alone,
compared to measured objective accommodative
amplitude
ESCRS 2011
WITH AGE THE LENS CHANGES











the central thickness of the (disaccommodated) lens increases.
the equatorial diameter of the (disaccommodated)lens does not change
the surface curvatures of the (disaccommodated) lens increase
the lens matrix loses its elasticity
the mechanical properties of the capsular bag change
the thickness of the lens capsule changes. The thickness of the anterior
capsule increases
the thickness of the posterior pole shows no change with age and the
posterior peripheral thickness decreases
the elasticity of the zonular fibers does not change
there is no change in the number of zonular fibers
the insertion points of the anterior zonular fibers stay fixed in relation to the
lens center, but shift in reference to the lens equator
HENK WEEBER
ESCRS 2011
IMPORTANCE !!!!
Prevalance Rate for Presbyopia:
Approx 1 in 11 = 9.00% or 24.5 M. people in USA
Read more at http://www.wrongdiagnosis.com/p/presbyopia/stats-country.htm?ktrack=kcplink

/Region Extrapolated Prevalence Population Estimated Used Presbyopia in North America (Extrapolated Statistics) USA 26,428,986 293,655,4051 Canada 2,925,708 WARNING! (Details) 32,507,8742
Mexico 9,446,363 WARNING! (Details) 104,959,5942 Presbyopia in Central America (Extrapolated Statistics) Belize 24,565 WARNING! (Details) 272,9452 Guatemala 1,285,253 WARNING! (Details)
14,280,5962 Nicaragua 482,378 WARNING! (Details) 5,359,7592 Presbyopia in Caribbean (Extrapolated Statistics) Puerto Rico 350,816 WARNING! (Details) 3,897,9602 Presbyopia in South America
(Extrapolated Statistics) Brazil 16,569,099 WARNING! (Details) 184,101,1092 Chile 1,424,156 WARNING! (Details) 15,823,9572 Colombia 3,807,969 WARNING! (Details) 42,310,7752 Paraguay 557,223
WARNING! (Details) 6,191,3682 Peru 2,478,987 WARNING! (Details) 27,544,3052 Venezuela 2,251,564 WARNING! (Details) 25,017,3872 Presbyopia in Northern Europe (Extrapolated Statistics) Denmark
487,205 WARNING! (Details) 5,413,3922 Finland 469,306 WARNING! (Details) 5,214,5122 Iceland 26,456 WARNING! (Details) 293,9662 Sweden 808,776 WARNING! (Details) 8,986,4002 Presbyopia in
Western Europe (Extrapolated Statistics) Britain (United Kingdom) 5,424,363 WARNING! (Details) 60,270,708 for UK2 Belgium 931,344 WARNING! (Details) 10,348,2762 France 5,438,179 WARNING!
(Details) 60,424,2132 Ireland 357,260 WARNING! (Details) 3,969,5582 Luxembourg 41,642 WARNING! (Details) 462,6902 Monaco 2,904 WARNING! (Details) 32,2702 Netherlands (Holland) 1,468,637
WARNING! (Details) 16,318,1992 United Kingdom 5,424,363 WARNING! (Details) 60,270,7082 Wales 262,620 WARNING! (Details) 2,918,0002 Presbyopia in Central Europe (Extrapolated Statistics) Aust
735,728 WARNING! (Details) 8,174,7622 Czech Republic 112,156 WARNING! (Details) 1,0246,1782 Germany 7,418,214 WARNING! (Details) 82,424,6092 Hungary 902,913 WARNING! (Details) 10,032,3752
Liechtenstein 3,009 WARNING! (Details) 33,4362 Poland 3,476,371 WARNING! (Details) 38,626,3492 Slovakia 488,121 WARNING! (Details) 5,423,5672 Slovenia 181,032 WARNING! (Details) 2,011,473 2
Switzerland 670,578 WARNING! (Details) 7,450,8672 Presbyopia in Eastern Europe (Extrapolated Statistics) Belarus 927,946 WARNING! (Details) 10,310,5202 Estonia 120,749 WARNING! (Details)
1,341,6642 Latvia 207,567 WARNING! (Details) 2,306,3062 Lithuania 324,710 WARNING! (Details) 3,607,8992 Russia 12,957,665 WARNING! (Details) 143,974,0592 Ukraine 4,295,887 WARNING! (Details)
47,732,0792 Presbyopia in the Southwestern Europe (Extrapolated Statistics) Azerbaijan 708,154 WARNING! (Details) 7,868,3852 Georgia 422,450 WARNING! (Details) 4,693,8922 Portugal 947,173
WARNING! (Details) 10,524,1452 Spain 3,625,270 WARNING! (Details) 40,280,7802 Presbyopia in Southern Europe (Extrapolated Statistics) Greece 958,277 WARNING! (Details) 10,647,5292 Italy
5,225,172 WARNING! (Details) 58,057,4772 Presbyopia in the Southeastern Europe (Extrapolated Statistics) Albania 319,032 WARNING! (Details) 3,544,8082 Bosnia and Herzegovina 36,684 WARNING!
(Details) 407,6082 Bulgaria 676,617 WARNING! (Details) 7,517,9732 Croatia 404,718 WARNING! (Details) 4,496,8692 Macedonia 183,607 WARNING! (Details) 2,040,0852 Romania 2,011,999 WARNING!
(Details) 22,355,5512 Serbia and Montenegro 974,331 WARNING! (Details) 10,825,9002 Presbyopia in Northern Asia (Extrapolated Statistics) Mongolia 247,618 WARNING! (Details) 2,751,3142 Presbyopia
in Central Asia (Extrapolated Statistics) Kazakhstan 1,362,933 WARNING! (Details) 15,143,7042 Tajikistan 631,040 WARNING! (Details) 7,011,556 2 Uzbekistan 2,376,937 WARNING! (Details) 26,410,416
Presbyopia in Eastern Asia (Extrapolated Statistics) China 116,896,286 WARNING! (Details) 1,298,847,6242 Hong Kong s.a.r. 616,961 WARNING! (Details) 6,855,1252 Japan 11,459,970 WARNING! (Detai
127,333,0022 Macau s.a.r. 40,075 WARNING! (Details) 445,2862 North Korea 2,042,779 WARNING! (Details) 22,697,5532 South Korea 4,341,038 WARNING! (Details) 48,233,7602 Taiwan 2,047,485
WARNING! (Details) 22,749,8382 Presbyopia in Southwestern Asia (Extrapolated Statistics) Turkey 6,200,452 WARNING! (Details) 68,893,9182 Presbyopia in Southern Asia (Extrapolated Statistics)
Afghanistan 2,566,230 WARNING! (Details) 28,513,6772 Bangladesh 12,720,642 WARNING! (Details) 141,340,4762 Bhutan 196,701 WARNING! (Details) 2,185,5692 India 95,856,354 WARNING! (Details)
1,065,070,6072 Pakistan 14,327,670 WARNING! (Details) 159,196,3362 Sri Lanka 1,791,464 WARNING! (Details) 19,905,1652 Presbyopia in Southeastern Asia (Extrapolated Statistics) East Timor 91,732
WARNING! (Details) 1,019,2522 Indonesia 21,460,765 WARNING! (Details) 238,452,9522 Laos 546,130 WARNING! (Details) 6,068,1172 Malaysia 2,117,023 WARNING! (Details) 23,522,4822 Philippines
7,761,752 WARNING! (Details) 86,241,6972 Singapore 391,850 WARNING! (Details) 4,353,8932 Thailand 5,837,897 WARNING! (Details) 64,865,5232 Vietnam 7,439,652 WARNING! (Details) 82,662,8002
Presbyopia in the Middle East (Extrapolated Statistics) Gaza strip 119,249 WARNING! (Details) 1,324,9912 Iran 6,075,288 WARNING! (Details) 67,503,2052 Iraq 2,283,722 WARNING! (Details) 25,374,691
Israel 557,910 WARNING! (Details) 6,199,0082 Jordan 505,008 WARNING! (Details) 5,611,2022 Kuwait 203,179 WARNING! (Details) 2,257,5492 Lebanon 339,949 WARNING! (Details) 3,777,2182 Saudi
Arabia 2,321,634 WARNING! (Details) 25,795,9382 Syria 1,621,518 WARNING! (Details) 18,016,8742 United Arab Emirates 227,152 WARNING! (Details) 2,523,9152 West Bank 208,008 WARNING! (Details
2,311,2042 Yemen 1,802,238 WARNING! (Details) 20,024,8672 Presbyopia in Northern Africa (Extrapolated Statistics) Egypt 6,850,567 WARNING! (Details) 76,117,4212 Libya 506,842 WARNING! (Detai
5,631,5852 Sudan 3,523,334 WARNING! (Details) 39,148,1622 Presbyopia in Western Africa (Extrapolated Statistics) Congo Brazzaville 269,823 WARNING! (Details) 2,998,0402 Ghana 1,868,132
WARNING! (Details) 20,757,0322 Liberia 305,157 WARNING! (Details) 3,390,6352 Niger 1,022,448 WARNING! (Details) 11,360,5382 Nigeria 1,597,532 WARNING! (Details) 12,5750,3562 Senegal 976,693
WARNING! (Details) 10,852,1472 Sierra leone 529,550 WARNING! (Details) 5,883,8892 Presbyopia in Central Africa (Extrapolated Statistics) Central African Republic 336,823 WARNING! (Details)
3,742,4822 Chad 858,468 WARNING! (Details) 9,538,5442 Congo kinshasa 5,248,532 WARNING! (Details) 58,317,0302 Rwanda 741,480 WARNING! (Details) 8,238,6732 Presbyopia in Eastern Africa
(Extrapolated Statistics) Ethiopia 6,420,291 WARNING! (Details) 71,336,5712 Kenya 2,968,389 WARNING! (Details) 32,982,1092 Somalia 747,414 WARNING! (Details) 8,304,6012 Tanzania 3,246,371
WARNING! (Details) 36,070,7992 Uganda 2,375,123 WARNING! (Details) 26,390,2582 Presbyopia in Southern Africa (Extrapolated Statistics) Angola 988,069 WARNING! (Details) 10,978,5522 Botswana
147,530 WARNING! (Details) 1,639,2312 South Africa 4,000,362 WARNING! (Details) 44,448,4702 Swaziland 105,231 WARNING! (Details) 1,169,2412 Zambia 992,312 WARNING! (Details) 11,025,6902
Zimbabwe 330,467 WARNING! (Details) 1,2671,8602 Presbyopia in Oceania (Extrapolated Statistics) Australia 1,792,182 WARNING! (Details) 19,913,1442 New Zealand 359,443 WARNING! (Details)
3,993,8172 Papua New Guinea 487,825 WARNING! (Details) 5,420,2802

About extrapolations of prevalence and incidence statistics

Read more at http://www.wrongdiagnosis.com/p/presbyopia/stats-country.htm?ktrack=kcplink
ESCRS 2011
CONCEPTS OF RESTORING
ACCOMODATION
 MONOVISON:not physiological
 LASER TREATMENT OF THE CORNEA?monovion
multifocality -the problem is not there
 SCERAL EXPANSION PROCEDURES :doubtful
results
 ACCOMODATIVE LENSES -DEFORMABLE ACCOMODATING
IOLS Mechanical concepts based on axial shift
principle have very limited accomodative effect
 REFILLING THE EMPTY LENS CAPSULE:WITH
SOFTER MATERIAL experimantal stage !!!! See later
ESCRS 2011
HOW TO MAKE A BETTER LENS ?
 A more basic treatment should be derived
from treating the root cause of presbyopia:
to make the lens substance softer
 A newer technique - currently proposed consists of mechanically softening the lens
substance using femto-second laser pulses
 Or one can insert an ersatz lens available now
ESCRS 2011
FUTURE
EUROTIMES
DOUGH KOCH
 IN REFRACTIVE AND CATARACT
SURGERY PRESBYOPIA CORRECTION
WILL BECOME THE NORM
 THE HOLY GRAIL OF ACCOMODATIVE
LENSES IS BECOMING CLOSER BUT
HOW CLOSE?
ESCRS 2011
LET US CONCENTRATE ON THE
PHACO ERSATZ
HOW TO BRING A NEW
ARTIFICAL BETTER
FUNCTIONING LENS
IN AN OLDER EYE
ESCRS 2011
THE EYE IN HISTORY
IMPORTANT DISCOVERIES
HOW FAR ARE WE NOW?
HOW SLOW DID IT GO UNTILL NOW !
WHAT WILL THE FUTURE
BRING?
ESCRS 2011
At C
DISCOVERY OF LIGHT
At that time the popular belief was the
emanation hypothesis of vision,advanced by IBN al-Haitham (965Pythagoras (c. 600 B.C.) and accepted by
1040
such classical writers as
Euclid, Hipparchos and Ptolemy and after
them by Galen.
In this hypothesis the visual spirit originating
in the brain emanated from the lens (the
essential organ of vision) forming a cone of
linear
ESCRS 2011
wave–particle duality,
described by Albert
Einstein in the early
DISCOVERY OF
SPECTACLES
Venice Murano 1270 and 1280.
Gutenberg’s invention of the printing press 1450
ESCRS 2011
DISCOVERY OF ANATOMY AND
FUNCTION OF THE EYE
Georg Bartisch(1535-1606)
surgeon and oculist of Dresden
published the first systematic
work on ocular disease
ESCRS 2011
JACQUES DAVIEL FRANCE 1745
FIRST REAL CATARACT SURGERY
ECCE
ESCRS 2011
HAROLD RIDLEY
THE FIRST IOL 1949
Sir Harold Ridley and his wifemedal received at the
knighthood ceremony
ESCRS 2011
CHARLIE KELMAN
receiving presedential award from
G.Bush Sr.
Modern Era of
cataract surgery
1967
ESCRS 2011
 1987 JEAN MARIE PAREL PHACO
ERSATZ
 The Ophthalmic Biophysics Center
created in 1970 - Bascom Palmerdirector Dr. Edward Norton and Dr. Parel
 WHAT HAPPENED SINCE THEN ????
 PERSONAL EXPERIENCE
 TRUE VISTA STORZ 3 ZONE DESIGN 1992
 3M APODIZED PRINCIPLE 1992
ESCRS 2011
 FDA PANEL RECOMMENDS APPROVAL OF 3M
MULTIFOCAL INTRAOCULAR LENS ST. PAUL, Minn., Jan. 23
/PRNewswire/ -- The Food and Drug Administration's Ophthalmic Advisory
Panel today recommended approval with conditions, of the 3M (NYSE: MMM)
brand Multifocal intraocular lens (IOL) for sale in the United States. The
conditions are related mainly to labeling. The FDA relies on the clinical
expertise of the advisory panels to guide its decisions. Generally, approval to
market follows advisory panel recommendation. "The advisory panel's
recommendation represents an important step forward in making this advanced
lens available to ophthalmologists for treatment of cataract patients in the
United States," said Robert B. Bomar, manager, 3M Vision Care. "The lens will
be commercially available only after final approval by the FDA," Bomar added.
Since 1987, the lens has been implanted in approximately 30,000 cataract
patients worldwide. Of those, over 700 were involved in the U.S. study, which is
currently under review by the FDA. An individual who undergoes cataract
surgery and receives a conventional monofocal lens implant typically needs to
wear eyeglasses, usually bifocals, following surgery to achieve acceptable near
and far vision. The majority of patients implanted with bilateral 3M Multifocal
IOLs, however, do not need to wear bifocals; and about half of these patients
function entirely without the aid of eyeglasses. The lens has been available for
sale to ophthalmologists in most countries for over two years. In March 1991,
the 3M Multifocal intraocular lens was the first multifocal lens to receive
commercial marketing approval from Japan's Ministry of Health and Welfare. -0-
01/23/92
ESCRS 2011
DID IT WORK ?DID IT LAST?
 YES IT WORKED !!
 BUT NO SMALL INCISION POSSIBLE
SINCE NO Foldable IOL
 6 -6.5 mm. PMMA MATERIAL
 NEEDED SUTURING
 CREATED ASTIGMATISM
 SO IT WAS NOT THE FINAL SOLUTION
ESCRS 2011
WHERE DO WE GO?
PREDICTION IS VERY DIFFICULT
SPECIFICALLY ABOUT THE
FUTURE
ESCRS 2011
Newer succesfull models
 ALCON RESTOR/old 3M apodized principle
2001
 ABBOTT AMO TECNIS:Ring principle 2003
 Later on adapations;
add on near zone
material changes etc.etc.etc.etc.
ESCRS 2011
Tecnis One Piece ZMBOO
Full diffractive posterior surface
Wavefront-designed aspheric anterior
surface
Newest generation Acrylic material
Near addition +4D=3.1 pupil plane
One piece iol :+5.0 D to +34.0 D in 0.5
D increments
Ease of insertion
Performance is Pupil Independent
ESCRS 2011
New trends
EUROTIMES MAY 2011
TOO MANY TO BE GOOD
 Dual optic Synchrony -iol more effect for less
movement-2.5 D pro 1 mm.
 Opti-K new form of laser thermal
keratoplasty LTK.Adv.it can be repeated
why?because regression
 Palliklaris group:WIOL-CF accomodative
iol2D of pseudo-accomodation. ??
ESCRS 2011
INJECTABLE ACCOMODATIVE
LENSES-AN INJECTED GEL LENS
 IS NOT A NEW CONCEPT !!!!
 MATERIAL USED_SILICONE-polyethelene-
poloxamer-monomer mixture-silicone
polymer gel
 1975-1986-1992-1998-2003
 First publ:1964 Kessler J.Arch.ophtahl.
71,412-417 Experiments in refilling the lens.
ESCRS 2011
SOME MAJOR PROBLEMS REMAIN
 CREATING A MINICAPSULORHEXIS<2MM:
we
need innovative instruments and extensive
surgical training
 PHACO THROUGH A 1 MM HOLE :innovative
approach
 SEALING THE MICROCAPSULORHEXIS :
prevent leakage
ESCRS 2011
to
SOME MAJOR PROBLEMS REMAIN
 POLYMER BIOCOMPATIBILITY: many materials used for
iols have passed years of biocompatibility testing.
 LENS CAPSULAR VOLUME VARIABILITY:varies among
patients-the optimum volume should be controlled for each
different eye.
 POLYMER REFRACTION:desired refraction will be
different for each patient-controlling the amount of gel is a
challenge.
 PREVENTING PCO: challenge yag has to be avoided
because will create leakage of the injected gel
ESCRS 2011
FACTS
 PCO PREVENTION WILL REMAIN THE PROBLEM NR 1
 New materials Guthoff Rostock:pure water-methotrexate mtx
antimetabolite-Actinomycin AM = antibioticun-DaunomycinDisulfiram.
 Untill now tested:
-Cytostatic drugs:5Fluouracil-Colchicine-DoxoribinMitomycin C-Methotrexate-Doxorubicin
Anti-inflammatory: Diclofenac-dexamethasone
Immunological agents:cyclopsorine A
Further Investigations involving non-primates are needed
Cave:Endothelial cells
ESCRS 2011
A PARADIGM SHIFT NEEDED?
INVENTION OF
Train 1803
Bicycle 1839 !!!
ESCRS 2011
MULTIFOCAL IOLS WILL BE
HERE
FOR
ANOTHER
10 -15 YEARS
BUT THEY
WILL
IMPROVE !
ESCRS 2011
WILL EVENTUALLY THE DREAM
OF PHACO ERSATZ COME
REALITY ?
 PROBABLY YES
 BUT WE NEED
 MORE TIME
ESCRS 2011
ESCRS 2011