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Commissioned Article

Newer intraocular lens materials and design

Sanjay Argal

The continued development of new intraocular lens (IOL) material and design has provided cataract surgeons more Access this article online
lens-based options than ever before. Surgeons must carefully evaluate, which IOLs may be the best for their patients Website:
and their practices. The roles of refractive index, water content, optic coloration (blue- or violet-lightblocking), and www.jcor.in
design of acrylic IOLs are widely debatable among surgeons. Ease of use, availability, cost, and surgeon preference DOI:
are also important factors that influence surgeons IOL selection. 10.4103/2320-3897.112180
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Key words: Diffractive, glistening, intraocular lens, light adjustable, multifocal, tackiness, trifocal

The IOLs have undergone a sea change since the time that Harold
Ridley first implanted a polymer lens in the eye to replace the
natural crystalline lens of the eye. One of the earlier years
ophthalmologists was overheard saying at a conference, You
have taken the simple cataract surgery of our times and have
transformed it into a complexity! The challenges have changed,
the expectations have changed, and technological advances in
the surgical technique and lens materials and manufacturing
methods have made return to near normal vision and beyond a
reality today. Earlier aphakia was the challenge and then it was
the best corrected visual acuity and today we are talking about
the quality of vision, accommodation and providing the best
corrected visual acuity at all possible points of focus.
The changes in cataract surgery can be said to have taken place
on three fronts:
Advances in cataract surgery and techniques
Advances in IOL materials
Advances in IOL designs.
Advances in IOL materials
Polymethyl metha acrylate (PMMA) ruled the roost as the material
of choice for a long time before it was eventually replaced by
silicone lenses and then by the acrylic lenses both hydrophobic
and hydrophilic.
Silicone lenses
They are biocompatible with good optical clarity. Certain features
of the silicone material put them at a disadvantage. They tend to
turn opalescent or have a slight tinge after a period of time. They
open with a snap while unfolding hence one has to be careful
while implantation.
Head of R & D, Care Group India.
Address for correspondence: Mr. Sanjay Argal, Block No. 310,
Dabhasa, Ta. Padra, Vadodara - 391 440, Gujarat, India. E-mail:
sanjayargal@gmail.com
Manuscript received: 23.10.2012; Revision accepted: 11.02.2013
An interesting feature of silicone material is its malleability and
elasticity, which makes them a good choice for the accommodating
lenses since these lenses would have to deform millions of time
over the life time of the patient. In an analysis conducted by
Arthur P. Little, it was estimated that the average frequency of
accommodation is probably on the order of 20-120 per hour (1
cycle every 3 min to one every 30 s). Assuming that an average
person is awake 16 h per day, the range would be from 20 cycles
per hour (120,000 per year) to 120 cycles per hour (720,000 per
year). With a fatigue life-time exceeding 20 million cycles, it has
been roughly estimated that the crystalens should last a minimum
of 30 years and probably much longer.
Hydrophobic and hydrophilic acrylic lenses
The acrylic lenses took over from the silicone lenses and have been
the front runners in the IOL market with the highest percentage
share of lens manufacturing and implantation. Their excellent
biocompatibility and optical clarity with ease of manufacture
and handling as well as ease of implantation have made them
the material of choice for most of the IOLs today. Even as they are
bunched as acrylic lenses significant differences exist between
different lenses from different manufacturers with each making
necessary changes to drive home the advantages and the debate
about hydrophobic and hydrophilic rages on. The materials
comparisons at various attributes can be summarized as follows:
1. Effect on consistency of refractive outcome
Hydrophilic, as the name suggests, absorbs and retains
water. Water acts as a plasticizer for the polymer chains
and polymer folds. It is the consistency in the ability of the
material to take up and retain the water, which makes IOL,
caused refractive power and elasticity deviations tending to
zero. Hydrophilic IOL, which has undergone the controlled
and seamless production procedure, is more likely to have
consistent orientation of the matrix and hence consistent
water content.
Hydrophobic material absorbs water to minimal amount. The
molecular orientation of hydrophobic material, even if varies

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Argal: Newer intra ocular lens materials and design
from batch to batch, may not lead to significant change in
its applicable characteristics as those characteristics are not
dependent on the molecular orientation but on molecules
itself. It is this reason the reproducibility, accuracy, and
sensitivity of the refractive outcome will be high in case of
hydrophobic IOLs.
2. Effect on tackiness
Hydrophilic material does not possess tackiness. The reason
is simple-water is not tacky. It makes hydrophilic IOL freely
movable and easily injectable. However, since it doesnt easily
adhere to the capsule it has a higher rate of posterior capsular
opacification (PCO).
Hydrophobic material is tacky. Such lens will not move easily
in bag once implanted. It will also adhere well to the capsule
reducing the rate of PCO with these lenses.
3. Material structure and its effect on mechanical stability inside
the capsular bag
Material structure decides the refractive index (RI), which in
turn decides the center thickness. Hence, for a given design
mechanical stability of the hydrophilic material is more than
hydrophobic material.
4. Material structure and glistening
Glistening are the air vacuoles. Generally, hydrophilic material
will not have glistening. However, not so perfect hydrophobic
IOL material may have them. As there is nothing to fill inside
the matrix, glistening is more prevalent in the hydrophobic
material.[,]
5. Material structure and cats eye effect
Lenses with higher refractive indices have a greater tendency
to reflect light. Hence, the hydrophobic lenses with higher RI
would give a shiny reflex from the pupil at night.
6. Yellow IOL material-to block or not to block
The hypothesis that filtering blue-light might increase visual
performance was first suggested in the 1970s.[] Protagonists
of these lenses argued that such an IOL would increase visual
quality by reducing longitudinal chromatic aberration, which
is three times higher with clear ultraviolet (UV)-blocking IOLs
compared with the crystalline lens.[4] Opponents of blue-light-
filter IOLs argue that these lenses might have a negative
influence on the scotopic and mesopic contrast sensitivity due
to the Purkinje shift, since blue-light is much more important
for scotopic than for photopic vision. The scotopic luminous
efficiency peak, mainly contributed to by rods, is at 507 nm,
whereas, photopic luminous efficiency peak is at 555 nm, mainly
contributed to by cones.[5] Blocking blue-light up to 500 nm
should theoretically result in a decrease in mesopic vision.
Brockmann et al. have recently shown that commercially
available blue-light-filter IOLs have a different transmission
spectrum, especially, the orange IOL,[6] and UV transmission
spectrum depending on the IOL material used. There is a
significant difference between hydrophilic and hydrophobic
acrylic materials.[7] Mainster actually propagates implantation
of orange IOLs to filter violet instead of blue-light. This would
protect the retina from the phototoxic short wavelengths
between 400 nm and 440 nm and transmit blue-light of more
than 440 nm for better scotopic vision.[5,7,8] However, the
orange IOL has been shown to have a transmission spectrum
of less than 60% at 500 nm, whereas, the yellow IOLs have a
transmission spectrum of 80-90% at 500 nm. The crystalline
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lens of a 53-year-old person shows a transmission spectrum
of 70% at 500 nm and so, in theory, scotopic vision should
actually be better with yellow IOLs in pseudophakic patients
than in the phakic eye of a 53-year-old patient.[7,8]
Advances in the design
Toric IOLs
Most IOL designs are rotationally symmetric, meaning that they
can only correct for spherical refractive error in the eye. Toric IOLs
have different powers along different meridians and can therefore,
correct for cylinder error. Two potential difficulties arise with
toric IOLs. First, accurate alignment and fixation of the lens is
required. The axis of the IOL must be aligned with the axis of the
cylinder error or a reduced correction will be seen. Furthermore,
the rotational alignment must remain fixed following surgery, so
any post-surgical rotation of the lens would degrade correction
and can even introduce additional cylinder error if the rotation
was large enough and molded hydrophobic lenses which are
inherently tacky in nature are most preferred platform for toric
lenses. Acriol EC Toric molded hydrophobic lens introduced by
Care Group is fast emerging as preferred toric IOL.
Multifocal IOLs
Multifocal IOLs are used in an attempt to simultaneously provide
good distance and near vision in a pseudophakic patient. Various
designs have been tried to achieve this multifocality, however,
the designs fall into two categories: Refractive multifocal and
diffractive multifocal.
Refractive multifocal IOLs
Refractive multifocal IOLs typically have a series of concentric
zones with different optical powers. Implantation of these types
of lenses produces two simultaneous images to be formed on
the retina of the patient. One image has distant objects in focus
and the second image has near objects in focus. It is up to the
patient to accept the in-focus portions of both images and ignore
the out-of-focus portions. Typically, these patients show losses in
contrast sensitivity for distance vision, in exchange for improved
near vision. Modulation of the number and dimensions of the
near and distance zones in refractive IOLs has been performed
by manufacturers in an attempt to optimize the performance of
these lenses. These lenses offer a good range of foci from far to
near, however, the quality of vision is not good and it is totally
a pupil dependent lens. The Rezoom (Abbot Laboratories Inc.,
Illinios, USA) and Preziol (Care Group, Vadodara, Gujarat, India)
Lenses are perfect examples of refractive multifocal lenses.
Diractive multifocal IOLs
Diffractive IOLs take advantage of diffraction caused by small,
closely spaced, annular grooves cut in to the lens surface. The
diffraction causes an infinite number of foci for the lens, however,
most of the power goes in to the first two foci. By adjusting the
spacing and shape of the grooves, the optical properties of the
diffractive IOL can be adjusted to be suitable for a multifocal lens.
The diffractive IOL gives two very distinct foci one for distance
and one for near. At both these distances the clarity of vision is
very good. The intermediate vision in these lenses however, has
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Argal: Newer intra ocular lens materials and design

been typically compromised. Another problem is the problem of
glare and halos caused by the randomly diffracted rays of light.
Furthermore, the contrast and scotopic vision are compromised
because at any given focal point only a portion of total light
intensity is utilized for creating an image. Most of the lenses split
light in the ration of 60:40 (distance: near light distribution) Many
innovative changes have attempted to correct these problems.
The height and spacing of the diffractive rings are reduced
from the center to the periphery. This reduces the scatter from
the periphery hence reducing glare. The rings are also made with
smooth rounded edges in AcriLisa (Zeiss Germany) lens to reduce
glare. Restor (Alcon Labs Inc. Forthworth, Texas) has partial optic
diffractive lens where the diffractive rings only occupy central 3
mm of the lens the peripheral lens is clear giving a better night
time driving vision. Tecnis from AMO is a full optic diffractive
lens, which provides near and far vision.
wax to the acrylic polymer creates a smart material, which
remains in a solid state at room temperature. Because the wax
component melts at body temperature, adjusting the percentage
of wax content produces a semisoft gelatinous polymer once the
lens is in the eye.
The concept of implanting the smart IOL is first to create an
optic that fills the bag with an appropriate shape and dioptric
power. The lens is then heated and compressed so that a solid,
thin, 50 mm long rod results upon cooling. Next, the rod can be
implanted through a small incision (about 3.5 mm in widths),
through a standard capsulor rhexis, and into the capsular bag. As
the rod warms to body temperature, it changes back to a pliable
lens measuring 10 mm in diameter and 3.5 mm in thickness.
The lens fills the capsular bag as it recovers the pre-determined

iDIFF Plus and AcriDIFF (Trifocal)

Another interesting design modification has been adopted by
the Care Group iDIFF Plus and AcriDIFF (Trifocal) lenses, Figure 1.
Along with the above mentioned changes in the diffractive rings
from the center to the periphery the diffractive rings are also
progressively sloped greater from the center to the periphery.
This changes the angle of diffraction of light affording good
intermediate vision. The iDIFF Plus lens is a hydrophilic lens while
the AcriDIFF (Trifocal) lens is hydrophobic lens.

Accommodating IOLs
The new IOLs are designed with haptics that will cause the lens
to move back and forth in the eye as the ciliary muscle puts
pressure on the haptics [Figure 2]. These IOLs provide good Figure 1: AcriDIFF and iDIFF plus
distance, intermediate, and near vision by allowing the lens to
shift position in the eye to adjust focus. This technology is based
on the assumption that the ciliary muscle in older adults still
functions properly, however, the crystalline lens has become too
stiff or large to accommodate properly.

The crystalens
The crystalens Figure 3, is a modified plate-haptic lens
manufactured from a high (RI = 1.430), third-generation non-
reflective silicone material (Biosil), which contains an UV filter.
The lens is hinged adjacent to the optic and has small looped
polyimide haptic, which have been shown to fixate firmly in the
capsular bag. The grooves across the plates adjacent to the optic Figure 2: Accomodative lens
make the junction of the optic with the plate haptic the most
flexible part of the haptic/optic design.

Accurate the medennium smart IOL

In the quest to provide pseudophakic accommodation, one idea
has always been to refill the capsular bag with a compressible,
clear material. The goal would be to utilize the eyes natural
accommodative mechanism according to the Helmholtz theory.
The concept behind the medennium smart IOL, Figure 4
(Medennium, Inc., Irvine, CA) may overcome many of the
aforementioned obstacles. The lens is composed of a hydrophobic
acrylic material with unique thermoplastic properties that permit
a temperature-induced change in its shape. Chemically, bonding Figure 3: The crystallens

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Argal: Newer intra ocular lens materials and design
shape and dioptric power. The smart IOL is still a long way from
becoming a clinical option. However, it represents an ingenious
approach to reviving the natural mechanism of accommodation.
Kellan tetraflex IOL
The tetraflex IOL features a square-edge design with a 5.75-mm
optic, which may be inserted through a 2-mm incision. The lens
is composed of PolyHEMA (hydroxyethylmetha acrylate), a highly
biocompatible material consisting of 26% water. The structural
configuration of the tetraflex is entirely different from that of
crystalens, which is a hinged accommodative lens designed
to vault posteriorly against the capsular. This movement is
dependent on positive vitreous pressure to shift the lens forward.
The tetraflex has no hinges and it is angulated forward (i.e., away
from the capsular bag) and therefore, has a unique mechanism of
accommodation independent of positive vitreous pressure. The
haptic configuration of the tetraflex allows the lens to move with
the entire capsular bag [Figure 5]. Unlike with the crystalens, no
atropinisation is necessary with the tetraflex IOL.
Visiogen synchrony IOL
The visiogen synchrony IOL[9] (Visiogen, Inc., Irvine, CA) is the
first dual-optic accommodating IOL to undergo clinical trials.
Figure 4: Accurate, the medennium smart intraocular lens
Figure 5: Light adjustable lens
116
For any IOL design that relies upon a moving optic to produce
near focus, the amount of accommodative shift is proportional
to the dioptric power of the optic. Consequently, hyperopes who
are implanted with high plus power IOLs should enjoy much
greater accommodative amplitude than myopes. The principal
goal behind the dual-optic system is to afford every patient a
moving +34.00D optic. This aim is accomplished by pairing
it with a variable minus power optic in order to provide each
individual with the necessary net IOL power for emmetropia. The
two silicone optics is connected by a system of spring-like struts
that pushes the optics apart.
The synchrony IOL is designed to utilize the natural
mechanism of accommodation according to the Helmholtz
theory. Made of the latest generation of silicone, the single-
piece design is sized so as to distend and fill the capsular
bag. With a relaxed ciliary muscle, the zonules become
tense, and the taut capsular bag compresses two optics
together. As the ciliary muscle contracts, the zonules and
capsular bag relax. This relaxation permits the +34.00D
anterior optic to move forward. A small-diameter, 4.5-mm
capsulor rhexis is needed to confine the moving anterior optic
(5 mm diameter) to the capsular bag. An injector system has
been developed to deliver the lens through a 3.5-mm incision.[]
Light-adjustable IOLs
Another emerging technology is light-adjustable IOLs. These
lenses are made with a material that can change shape if
exposed to UV light. The concept behind these lenses is to
implant a lens that is close to the ideal power, and then adjust
the lens power with UV light following the cataract procedure
and appropriate healing. Once the lens has been adjusted to
the proper power, it is fixed so that additional UV exposure
cannot change the shape of the lens. This technology may also
be able to correct for astigmatic errors and even aberrations
in the eye.
Calhoun visions light adjustable lens (LAL)
The LAL Figure 5 (LAL; Calhoun Vision, Inc., Pasadena, CA) enables
surgeons to adjust the lens power in situ to correct for refractive
errors occurring after the LALs implantation. The three-piece IOL
has modified C-loop, blue PMMA haptics and a 6-mm, square-edge
optic. The lens is composed of a photosensitive silicone material
that undergoes a controlled change in shape when exposed
to a specific UV-beam intensity from the light-delivery device.
The altered shape of the lens produces a corresponding power
adjustment.
Conclusion
By neutralizing spherical aberration, one of the leading causes
of patients dissatisfaction with conventional IOLs, multifocal
(Trifocal) IOL promises to be a successful means of reviving
accommodation to the post cataract patients and the second
issues is PCO, which can be minimized with cast molded
hydrophobic lenses.
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Argal: Newer intra ocular lens materials and design

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Cite this article as: Argal S. Newer intraocular lens materials and design. J
Clin Ophthalmol Res 2013;1:113-7.
Source of Support: Nil. Conflict of Interest: Head of R & D, Care Group
India.

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