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65 EW RETINA associated with high-powered lenses. He also improved the optics so that the 2-lens system can maintain image quality even if physiological variations cause the lenses to end up slightly closer or farther apart. iolAMD vs. other telescopic IOLs Other telescopic IOL designs have been successful in restoring central vision in AMD patients, but they have several limitations, Dr. Qureshi said. These include a long and complex surgery and the need for a large, 6- to 12-mm sutured incision. "Large incisions mean long recovery time and potential for intraoperative complications, and therefore, this type of surgery has been limited to end-stage AMD patients," Dr. Qureshi said. "The major breakthrough of this system is that it's introduced into the eye in a modern procedure, through a very small incision, which does not require any suturing, and is associat- ed with a short recovery time." The iolAMD lenses are made of hydrophobic acrylic material that can be folded and inserted through an injector, allowing surgeons to implant them through a sutureless, 3-mm incision that does not impact corneal astigmatism. The improved design has al- lowed surgeons to lift the end-stage disease restriction on telescopic IOLs. Indications for the iolAMD continue to expand, from early- or intermediate-stage dry AMD to established forms of wet AMD, dia- betic maculopathy, macular holes, myopic degeneration, and even hereditary retinal diseases such as Stargardt and Best disease. Surgical procedure Candidate patients undergo a simulation test before surgery to determine if they will benefit from implantation and which area of adjacent retina should receive the magnified image. "We insert a lens in a trial frame and show the patient what type of vision they may achieve with a 30% magnification and movement of the picture on the macula," Dr. Qureshi said. Both lenses can be implanted during any routine cataract proce- dure—no special surgical skills are by Lauren Lipuma EyeWorld Staff Writer New telescopic IOL design revolutionizes surgical treatment of dry AMD W ith new IOL technol- ogy, cataract surgeons can now turn a rou- tine procedure into an effective treatment for dry age-related macular generation (AMD). The latest incarnation of telescopic IOLs, the iolAMD (London Eye Hospital Pharma, London), is the world's first foldable, injectable telescope implant that can restore central vision to the millions of worldwide sufferers of dry AMD. "I wanted to give desperate patients an option for renewed in- dependence," said Bobby Qureshi, MD, FRCS, inventor of the lens and chief medical officer and founder, London Eye Hospital Pharma. With no medical or surgical treatments available and no way to halt progres- sion of the disease, restoring vision to dry AMD patients represents a huge unmet need in the field of ophthalmology, Dr. Qureshi said. Ophthalmologists began devel- oping telescopic IOLs for AMD in the 2000s, and Dr. Qureshi created the iolAMD to overcome the limita- tions of existing designs. The device consists of a highly hyperopic lens (+65 D) with a 5.0-mm optic placed in the sulcus and a highly myopic lens (–60 D) with a 4.0-mm optic placed in the capsular bag. The hyperopic IOL has asym- metric haptics that offset it 0.85 mm from the myopic IOL. In this configuration, the lenses magnify the image 1.3x and displace it 3 degrees from the center of the fovea to an area not affected by AMD. This healthy section of retina then takes over the function of the degenerated macula. Dr. Qureshi approached Pablo Artal, PhD, professor of optics, University of Murcia, Spain, to optimize the lenses' optics to correct both low- and high-order aberra- tions. "I have been working with the optics of IOLs for many years, and obviously this was a new and exciting challenge that I accepted," Dr. Artal said. Dr. Artal designed the lenses to have hyper-aspheric surfaces and unique wavefront characteristics that reduce the distortions typically The IOL that can save sight August 2015 continued on page 66 Basic principle: The Galilean telescope –Sequential convex and concave lenses magnify an image –Offsetting the lenses displaces the image several degrees Specs: The 2 lenses are connect- ed via an air-filled chamber; the implant is secured in the capsular bag after large-incision phaco. The device is implanted unilaterally, in the better of the 2 eyes. Magnification: 2.2x or 3x Pros: Air-filled chamber allows for greater magnification; it is the only implantable telescope available in the U.S. Cons: The implant is roughly the size of a pea; it requires a 12-mm sutured incision. Implantation requires specific wound and capsular bag preparation, and there is a high level of endothelial cell loss due to surgical trauma. Specs: Made of 2 hydrophobic acrylic IOLs. The hyperopic lens is implanted in the sulcus, the myopic lens in the capsular bag. Magnification: 1.3x Pros: Lenses are foldable and injected through a 3-mm sutureless incision. Can be implanted bilaterally and is not limited to end-stage AMD patients. If AMD spreads to the area where the image is projected, the surgeon can dial the lens to another position. Cons: Relative unpredictability in the location of the lenses after surgery, which could affect the final refraction. Specs: IOLVIP Classic consists of a hyperopic lens in the anterior chamber and myopic lens in the capsular bag. A newer model, the IOLVIP Revolution, has both lenses inside the bag, held together by an equatorial capsular ring. Magnification: 1.3x Pros: Can be implanted bilaterally. The IOLVIP Revolution can be used for wet AMD, glaucoma, and degenerative myopia. Cons: Surgery is long and requires a sutured 8.0-mm incision. The Classic model requires patients to have a peripheral iridotomy 1 week prior to surgery. The evolution of implantable telescope technology 2007 Intraocular Lens for Visually Impaired People (IOLVIP, Lenspecial, Pontecorvo, Italy) 2010 Implantable Miniature Telescope (IMT, VisionCare Ophthalmic Technologies, Saratoga, Calif.) 2014 iolAMD (London Eye Hospital Pharma, London)

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