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Der hintere Augenabschnitt bezeichnet die Strukturen des Auges, die hinter der Linse gelegen sind. Zu diesen gehoren der Glaskorper, die Netzhaut, die Aderhaut und der Sehnerv sowie als umgebene Hulle die Lederhaut.

Presbyopia and cataract patients' desire for increased spectacle independence after surgery is one of the main drivers for the development of multifocal intraocular lenses (MIOLs) and extended depth of focus (EDOF) intraocular lenses (IOLs). As education, biometry, diagnostics, surgical techniques, and MIOL/EDOF IOL designs have improved over the past decade, an increasing number of cataract surgeons have become cataract-refractive surgeons to help address this need. There is not 1 single MIOL/EDOF IOL, however, that suits all patients' needs. The wide variety of MIOLs and EDOF IOLs, their optics, and their respective impact on our patients' quality of vision have to be fully understood to choose the appropriate IOL for each individual; MIOL/EDOF IOL surgery has to be customized. This review article looks at the different optical aspects and clinical consequences of MIOLs/EDOF IOLs to help surgeons find an appropriate solution for each of their individual patients.

PURPOSE: To evaluate and compare quality of vision and reading performance outcomes after implantation of bifocal refractive-diffractive, bifocal apodized diffractive, or trifocal diffractive-refractive intraocular lenses (IOLs). METHODS: This randomized, prospective, three-armed multicenter (Spain, Germany, and France) trial included 104 eyes of 52 patients (mean age: 63.2 ± 7.7 years). Patients underwent cataract surgery with bilateral implantation of either AT LISA 809M (Carl Zeiss Meditec, Jena, Germany: AT LISA group, 38 eyes), AT LISA tri 839MP (Carl Zeiss Meditec: AT LISA tri group, 32 eyes), or ReSTOR SN6AD1 (Alcon Laboratories, Inc., Fort Worth, TX: ReSTOR group, 34 eyes) IOLs. Visual and refractive outcomes, depth of focus, and reading performance were evaluated at 1, 6, and 12 months postoperatively. RESULTS: The AT LISA tri group showed significantly better 12-month uncorrected (UIVA) and binocular distance-corrected (DCIVA) intermediate visual acuity ( P ≤ .016) than the AT LISA group. The AT LISA tri group showed a significantly better 3-month UIVA compared to the ReSTOR group ( P = .042). Binocular uncorrected and corrected distance visual acuities were not significantly different among groups ( P ≥ .092) at the 12-month follow-up. A total of 85.3%, 90.0%, and 78.1% of eyes had a spherical equivalent within ±0.50 D in the AT LISA, AT LISA tri, and ReSTOR groups, respectively, at 12 months ( P = .038). No statistically significant differences between the trifocal and bifocal groups were detected for reading performance ( P ≥ .055). CONCLUSIONS: The trifocal diffractive-refractive IOL provides enhanced intermediate visual restoration compared to bifocal diffractive-refractive or apodized diffractive IOLs. The addition of an intermediate focal point did not deteriorate far or near vision. A comparable reading performance was maintained with the trifocal lens. [ J Refract Surg. 2017;33(10):655–662.]

Purpose To compare the tilt and decentration of a single-piece aspheric intraocular lens (IOL) and the position of the natural crystalline lens in young individuals. Setting Department of Ophthalmology, Knappschafts Hospital, Sulzbach, Germany. Methods This prospective noncomparative single-center study included volunteers younger than 40 years with no ocular abnormalities (crystalline lens group) and patients older than age 62 who had uneventful cataract surgery and Tecnis ZCB00 IOL implantation (IOL group). All eyes were examined with the OPD-Scan II; spherical aberration, vertical coma Z(3,−1), and horizontal coma Z(3,1) were analyzed with a 5.0 mm pupil. Lens tilt and decentration were studied with a new Purkinje meter. Results The crystalline lens group and IOL group comprised 20 subjects (40 eyes) each. Both groups showed compensation for corneal spherical aberration and neutralization of horizontal corneal coma. All lenses were tilted upward (mean 2.2 degrees, crystalline lens; 2.5 degrees, IOL) and to the temporal side (mean 3.1 degrees, crystalline lens; 2.6 degrees, IOL). The crystalline lenses were decentered downward (mean 0.16 mm) and to the temporal side (mean 0.07 mm). The IOL was displaced to the nasal side of the pupil (mean 0.06 mm) with almost no vertical mean decentration (0.02 mm upward). Conclusions The aspheric IOL and young crystalline lens compensated for mean corneal spherical aberration, resulting in low total spherical aberration. The position of the IOLs showed minimal decentration and tilt and was mirror symmetrical, comparable to the position of the crystalline lens in young individuals. The slight malpositioning partially compensated for corneal horizontal coma.

In a prospective and intraindividually comparative study, we investigated visual performance after implantation of two multifocal intraocular lenses. Eight patients received the ReSTOR (Alcon) bilaterally, and eight patients received the Tecnis ZM900 (AMO). The nondominant eye of each patient was trained based on the concept of perceptual learning using orientation discrimination of near-vertical bars. The fellow eye served as a control. After 3 h of training distributed over 2 weeks, the mean improvement of orientation discrimination in the trained eyes was 44%, which was significantly higher compared with the control eyes (9%). Moreover, contrast sensitivity and near vision under different contrast levels showed a significant benefit of training. These results support the concept of improving visual function by training after multifocal lens implantation. The superior function of the trained eyes was still present at the 6-month follow-up.

Durch die aspharische Optikgestaltung einer IOL soll postoperativ eine moglichst geringe okulare spharische Aberration (SA) erreicht werden. Dieses Ziel wird bei einer standardisierten SA der IOL von deren Brechkraft, der Pupillenweite und der kornealen Aspharizitat beeinflusst. Die Zusammenhange sollten in einer vergleichenden Studie untersucht werden. In einer prospektiven Studie wurde die aspharische Blaulichtfilterlinse AcrySof IQ (Alcon) in 70 Augen mit einer konventionellen IOL (AcrySof SA60AT, Alcon) bei 36 Augen verglichen. Untersucht wurden 6 Wochen postoperativ: Sehscharfe, Aberrationen hoherer Ordnung, Pupillenweite und korneale Aspharizitat. Im Vergleich zwischen 42 Augen mittlerer Dioptrienstarke ( 22,4±2,0 dpt) mit der IQ-IOL und 20 entsprechenden Augen mit der Kontrolllinse (22,0±2,7 dpt) zeigte sich kein Unterschied in der Sehscharfe. Fur eine 5-mm-Pupille resultiert eine SA von 0,04 (±0,05) µm bei den Augen mit der IQ-Linse und 0,20 (±0,06) µm bei den Kontrollaugen. Auch umgerechnet auf eine 4-mm-Pupille war die SA der IQ-IOL signifikant geringer. Eine getrennte Betrachtung von 28 weiteren Augen mit besonders hoher oder niedriger Brechkraft ergab bei der IQ-Linse eine annahernd gleiche SA wie bei den Linsen mittlerer Brechkraft. Der groste Unterschied zwischen aspharischer und konventioneller IOL zeigte sich bei den Augen, die eine IOL mit hoher Brechkraft benotigten. Die Aspharizitat der Hornhaut (Q-Wert) zeigte eine signifikante Korrelation zur postoperativen SA. Die aspharische AcrySof IQ reduziert die postoperative SA im Vergleich zu einer konventionellen IOL signifikant, auch bei geringerer Pupillenweite und weitgehend unabhangig von der IOL-Brechkraft. Die Messung der kornealen Aspharizitat ermoglicht eine individuelle Prognose uber die postoperative SA.

PURPOSEThe development of aspheric intraocular lenses (IOL) designed to compensate for the positive spherical aberration of the cornea has been shown to improve the image quality of pseudophakic eyes. This prospective clinical study compared an aspheric IOL with a blue light filter (AcrySof IQ) with its spherical platform–the SA60AT IOL with conventional optic. METHODSAfter uneventful phacoemulsification, 42 and 20 eyes were implanted with the AcrySof IQ aspheric lens and the SA60AT, respectively. Six weeks after surgery, higher order aberrations, visual acuity, contrast sensitivity, depth of focus, pupil size, and corneal asphericity were assessed. RESULTSVisual acuity was good with both IOLs. A significant difference was found regarding spherical aberration. Mean values of spherical aberration, calculated for a 5-mm pupil were 0.20±0.06 µm with the SA60AT and 0.04±0.05 µm with the AcrySof IQ lens. Contrast sensitivity was significantly superior in the AcrySof IQ group in 7 of 15 measurement conditions. Asphericity of the cornea proved to be correlated with postoperative ocular spherical aberration. CONCLUSIONSThe aspheric optic design of the AcrySof IQ results in significant reduction of postoperative ocular spherical aberration and improved contrast vision. Measuring the corneal asphericity allows estimation of postoperative ocular spherical aberration. [J Refract Surg. 2008;24:817-825.] ABOUT THE AUTHORS From the Department of Ophthalmology, Bundesknappschaft’s Hospital, Sulzbach, Germany. The authors have no financial or proprietary interest in the materials presented herein. Presented in part at the American Society of Cataract and Refractive Surgery Symposium; March 17-22, 2006; San Francisco, Calif. Correspondence: Ulrich Mester, MD, Augenklinik der Bundesknappschaft, An der Klinik 10, 66280 Sulzbach, Germany. Tel: 49 6897 5741118; Fax: 49 6897 5742139; E-mail: sek-augen@kksulzbach.de Received: September 5, 2006 Accepted: September 5, 2007 Posted online: March 15, 2008

PURPOSESeveral studies have shown that after multi-focal intraocular lens (IOL) implantation visual function improves gradually over a period of several months. To accelerate this learning process, a prospective, intra-individual comparative study was performed to investigate the efficacy of a special visual training program on the postoperative visual performance. METHODSSixteen patients with bilateral phacoemulsification and multifocal IOL implantation in both eyes (Alcon ReSTOR [n=8] and AMO Tecnis ZM900 [n=8]) received computer-based visual training 6 weeks postoperatively based on the concept of perceptual learning of discrimination line orientations. The training was performed over 2 weeks in six sessions in one eye of each patient. The untrained fellow eye served as control. Before and after the training period and at 6 months, orientation visual acuity, distance visual acuity, contrast sensitivity, and near visual acuity for different contrast levels were assessed. RESULTSAfter 2 weeks of training, the mean improvement of orientation visual acuity in the trained eyes was 82%, which was significantly higher than the control eyes (P CONCLUSIONSVisual performance after multifocal IOL implantation can be significantly accelerated by a specific 2-week training program. This effect is sustained over a 6-month period. [J Refract Surg. 2008;24:287-293.] ABOUT THE AUTHORS From the Department of Ophthalmology, Knappschafts Hospital, Sulzbach (Kaymak, Ott, Mester); and the Institute of Brain Research, Human Neurobiology, University of Bremen (Fahle), Bremen, Germany. The authors have no commercial or proprietary interest in the materials presented herein. Correspondence: Ulrich Mester, MD, Dept of Ophthalmology, Knappschafts Hospital, D-Sulzbach, Germany. Tel: 49 6897 574 1118; Fax: 49 6897 574 2139; E-mail: sek-augen@kksulzbach.de Received: May 13, 2007 Accepted: November 2, 2007

Bestimmung der funktionellen Ergebnisse mit einer neuen bifokalen Intraokularlinse. Bei 20 Patienten wurde binokular die *Acri.LISA (*Acri.Tec) implantiert. Diese Linse hat eine unterschiedliche Lichtverteilung: Ferne: 65%, Nahe 35%. Das diffraktive Design weist gerundete Ubergange zwischen den Stufen zur Reduktion von Blendung auf und erstreckt sich uber 6 mm, um eine Unabhangigkeit vom Pupillendurchmesser zu erreichen. Die aspharische Linsenruckflache korrigiert eine Aspharizitat der Hornhaut von −0,26. Untersucht wurden 6 Wochen postoperativ: unkorrigierte und korrigierte Sehscharfe monokular und binokular in Ferne (ETDRS-charts) und Nahe (C.A.T.-Charts, Birkhauser-Tafeln), Kontrastempfindlichkeit unter photopischen und mesopischen Bedingungen (F.A.C.T.) sowie Pseudoakkommodationsbreite und subjektive Halointensitat. Sechs Wochen postoperativ betrug die mittlere binokulare Sehscharfe(LogMAR) in der Ferne −0,02±0,10 unkorrigiert, –0,07±0,09 mit Korrektur. Die unkorrigierte Nahsehscharfe (LogMAR)lag bei 0,09±0,16, mit Fernkorrektur bei 0,04±0,13. Der binokulare Visus war signifikant besser als bei monokularer Prufung. Die Defokussierkurve ergab ein bifokales Profil mit einem Dezimalvisus von 0,6±0,21 in 70 cm sowie eine Pseudoakkommodationsbreite von 5,5 dp. 16 der 20 Patienten gaben auf Befragen an, schwach ausgepragte Halos wahrzunehmen, waren aber dadurch nicht wesentlich beeintrachtigt. Die *Acri.LISA MIOL zeigte 6 Wochen postoperativ sehr gute funktionelle Ergebnisse.

To evaluate the functional outcome after implantation of the Tecnis ZM900 multifocal intraocular lens (IOL) (AMO) and the Array SA40 multifocal IOL (AMO).Department of Ophthalmology, Bundesknappschaft s Hospital, Sulzbach, and the Department of Ophthalmology, Marienhospital, Aachen, Germany.In a prospective comparative 2-center trial, Tecnis ZM900 and the Array SA40 multifocal IOLs were bilaterally implanted in 50 patients (50 eyes Tecnis, 50 eyes Array) by 1 surgeon at each center. The following parameters were assessed 30 to 60 days and 120 to 180 days after surgery in both eyes: refraction, pupil size, uncorrected and best corrected visual acuities for distance and near at different contrast levels, and photopic and mesopic contrast sensitivity at different spatial frequencies. Patient satisfaction (spectacle independence, photic phenomena, overall satisfaction) was assessed by a questionnaire.The main differences between the 2 multifocal IOLs were the better uncorrected near visual acuity (P.001), distance-corrected near visual acuity (P.001), the mesopic contrast sensitivity at high spatial frequencies (P.05) as well as greater independence from spectacles in patients with the Tecnis multifocal IOL, resulting in higher levels of patient satisfaction.The aspherical diffractive Tecnis multifocal IOL gave better outcomes than the Array multifocal IOL.

PURPOSE: To evaluate the visual, refractive, and contrast sensitivity outcomes, as well as the level of photic phenomena, after cataract surgery with implantation of a trifocal diffractive toric intraocular lens (IOL). METHODS: This prospective study included 56 eyes with corneal astigmatism of 1.00 diopters (D) or greater of 28 patients (age: 23 to 78 years) undergoing cataract surgery with implantation of the trifocal toric IOL AT LISA tri toric 939MP (Carl Zeiss Meditec, Jena, Germany). Monocular and binocular visual outcomes, refractive changes, contrast sensitivity, and photic phenomena perception (Halo & Glare Simulator; Eyeland-Design Network GmbH, Vreden, Germany) were evaluated at 3 months postoperatively. RESULTS: Mean 3-month postoperative monocular uncorrected distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuities were 0.13 ± 0.15, 0.08 ± 0.15, and 0.13 ± 0.18 logMAR, respectively. Binocular postoperative CDVA, DCIVA, and DCNVA values were 0.10 logMAR or better in all cases. A total of 88.2%, 88.2%, and 95.5% of eyes achieved binocular UDVA, UIVA, and UNVA values of 0.20 logMAR or better, respectively. Postoperative refractive cylinder was 0.50 D or less and 1.00 D or less in 78.6% and 98.2% of eyes, respectively. Photopic contrast sensitivity was significantly better than mesopic values for the spatial frequencies of 6 ( P = .007), 12 ( P = .005), and 18 cycles/degree ( P = .011). Mean size and intensity of halos were 50.67 ± 15.69 and 54.89 ± 17.86, respectively. Mean glare size and intensity were 39.67 ± 3.51 and 44.67 ± 15.01, respectively. CONCLUSIONS: The evaluated trifocal diffractive toric IOL provides an effective restoration of the distance, intermediate, and near vision after cataract surgery with good levels of visual quality and minimal photic phenomena. [ J Refract Surg. 2015;31(8):504–510.]

Purpose.To evaluate visual, refractive, and contrast sensitivity outcomes, as well as the incidence of pseudophakic photic phenomena and patient satisfaction after bilateral diffractive trifocal intraocular lens (IOL) implantation.Methods. This prospective nonrandomized study included consecutive patients undergoing cataract surgery with bilateral implantation of a diffractive trifocal IOL (AT LISA tri 839MP, Carl Zeiss Meditec). Distance, intermediate, and near visual outcomes were evaluated as well as the defocus curve and the refractive outcomes 3 months after surgery. Photopic and mesopic contrast sensitivity, patient satisfaction, and halo perception were also evaluated.Results.Seventy-six eyes of 38 patients were included; 90% of eyes showed a spherical equivalent within ±0.50 diopters 3 months after surgery. All patients had a binocular uncorrected distance visual acuity of 0.00 LogMAR or better and a binocular uncorrected intermediate visual acuity of 0.10 LogMAR or better, 3 months after surgery. Furthermore, 85% of patients achieved a binocular uncorrected near visual acuity of 0.10 LogMAR or better.Conclusions.Trifocal diffractive IOL implantation seems to provide an effective restoration of visual function for far, intermediate, and near distances, providing high levels of visual quality and patient satisfaction.

To investigate the geometry, penetration force, and cutting profile of 23-gauge trocar systems for pars plana vitrectomy based on their grinding methods in a standardized laboratory setting.In this experimental study, Eleven different commercially available 23-gauge sclerotomy trocar systems were divided into 4 groups according to their needle grinding and deburring: "back" bevel, "spear" bevel, "lancet" bevel, and "spatula" bevel. The normative geometrical data of the trocar systems were systematically analyzed according to nomenclature ISO 7864 and ISO 9626. Force to penetrate a 0.4-mm thick polyurethane foil was measured by a Penetrometer, when the trocar needle was piercing, cutting, and sliding through the foil at different defined loading phases and plotted as a load-displacement diagram. Magnified images of the consecutive cut were taken under a microscope after the entire penetration through the foil. Three physicians used all trocar systems in a masked fashion on human sclera to evaluate the manual penetration force in 30° and 90°.The mean outer diameter of the trocar systems was 0.630 ± 0.009 mm, and the mean outer diameter of the trocars was 0.750 ± 0.013 mm. The mean point length was 3.11 ± 0.49 mm, and the mean length of the bevel was 1.46 ± 0.23 mm. The primary bevel angle was 10.75 ± 0.41°, and the secondary bevel angle was 65.9 ± 42.56°. The piercing forces of the back bevel and spear-pointed trocars/needles were at the same level (0.087 ± 0.028 N). The lancet-pointed needle had remarkable low piercing and cutting forces with 0.41 N (range, 0.35-0.47 N). The spatula bevel tip showed the highest penetration piercing force with 1.6 N (range, 1.59-1.73 N). The back bevel systems induced frequently triangular-shaped incisions, with two nearly rectangular cuts of short length. The spear bevels produced a regular characteristic linear cut. Especially, the lancet blade created straight cut with a linear wound apposition. Spatula trocar systems caused usually an arched accurate incision. The manual force to penetrate the human sclera in an angled and rectangular angle appeared in the surgeons hand lower with a back bevel, lancet, or spear tip, whereas higher with spatula bevel systems.Lancet and back bevel systems show less penetration force of inner needles than the spatula systems. The results of the penetration force experiments correlated well with the manual force on sclera.

Hintergrund: Viele pseudophake Patienten benötigen aufgrund von Anisometropie und/oder fehlender Lesefähigkeit nach Katarakt Chirurgie immer noch eine Brille. Methode: Wir implantierten unsere ersten sphärischen multifokalen Add-On IOL (Rayner) durch astigmatismusneutrale 1,6[for full text, please go to the a.m. URL], 172. Versammlung des Vereins Rheinisch-Westfälischer Augenärzte

The only multifocal IOL that fits through the 1.5 mm incision size is the *Acri.LISA (*Acri. Tec, Zeiss, Henningsdorf, Germany). Acri.LISA is an acronym of the main optical properties of the lens. Visual acuity for distance vision is very good with Acri.LISA and is comparable with that of monofocal IOLs, at least under photopic lighting conditions. Near vision is also sufficient despite the unequal light distribution of the *Acri.LISA in favor of the far distance. Patients with the AcriLISA have a pseudo-accommodation range of 5.5 diopters. Initial results of the toric version of the Acri. LISA are very promising.

Die neue Generation von Multifokallinsen (MIOL) zielt durch unterschiedliche Designanderungen (aspharische bzw. aberrationskorrigierte Oberflache, diffraktives System, asymmetrische Lichtverteilung) auf bessere funktionelle Ergebnisse nach MIOL-Implantation. In zwei prospektiven, nicht randomisierten Studien wurde die Tecnis ZM001-MIOL (14 Patienten) und das bilaterale, asymmetrische Twinset-System (16 Patienten) jeweils mit der Array-MIOL (12 bzw. 14 Patienten) verglichen. Nach 3 Monaten wurden folgende Untersuchungen durchgefuhrt: Fernvisus, Nahvisus, Nahvisus mit Fernkorrektur, Niedrigkontrastvisus (EDTRS-charts) und Kontrastempfindlichkeit (Ginsburg-Box). Die Evaluierung photischer Phanomene erfolgte durch einen standardisierten Fragebogen. 3 Monate postoperativ zeigte sich weder beim Vergleich der Tecnis ZM001-MIOL gegen die Array noch beim Vergleich des Twinset gegen die Array ein signifikanter Unterschied bezuglich des Fernvisus und des Kontrastsehens. Dagegen war der fernkorrigierte Nahvisus sowohl nach Implantation der Tecnis ZM001 als auch des Twinset signifikant besser als nach Implantation einer Array-MIOL. Unabhanig vom Linsentyp berichtete etwas mehr als ein Drittel der Patienten spontan uber Halos. Die neuen aspharischen, diffraktiven MIOL-Systeme bringen, verglichen mit der Array, eine deutliche Verbesserung im Nahbereich jedoch ohne signifikante Verbesserung des Kontrastsehens oder photischer Phanomene.

In addition to genetic factors, refractive development and eye growth are controlled by retinal image analysis via three mechanisms: (1) a “deprivation” detector (causing “deprivation myopia”); (2) a mechanism that detects whether the image plane is behind the retina and causes compensatory axial myopia; (3) a mechanism that detects whether the image is in front of the retina and causes choroidal thickening, inhibition of scleral growth, and compensatory hyperopia. It is a fundamental question whether mechanisms 1–3 are all based on similar retinal processing, i.e., a quantification of the amount of deprivation. It is common to all three mechanisms that they operate in local retinal areas and that they directly affect the growth of the underlying tissues. Local operation could most easily be explained if they were all based on quantification of the loss of image contrast at certain spatial frequencies, due to either diffusors or defocus. Such a “deprivation detector” could provide information about emmetropization because, ignoring accommodation, deprivation reaches a minimum if the refractive status of the eye matches the average viewing distance. A computer simulation to quantify deprivation showed that reduction of hyperopia can be explained, but not the compensation of myopia. Since chickens became hyperopic rather than myopic when they wore +7D lenses (which imposed myopia) even if only one viewing distance (33 cm) was available, the image processing causing hyperopia must be different from simple deprivation detection. On the other hand, we provide evidence that both types of myopia (mechanisms 1 and 2) share common features, and may both be dependent on deprivation and dopaminergic transmission. This conclusion complicates the extrapolation of results of animal experiments with negative lenses onto spectacle correction in humans who are already myopic. Further implications are that drugs that suppress deprivation myopia may also be efficient in suppressing defocus-induced myopia, and that hyperopia development must implicate different retinal circuits and transmitters.