Refractive

Surgery
Refractive
Surgery

Aspheric IOLs -Facts &

Myth

J.S. Bhalla
MS, DNB

J.S. Bhalla MS, DNB, Ankur Singh MS

Deen Dayal Upadhyay Hospital, New Delhi

n the current age of refractive cataract surgery, we measure

the quality of vision in addition to the quantity of vision.
The patients image quality is as important as his Snellen
acuity, particularly when we operate on patients with high
expectations and high demands for their vision.
Wavefront technology has been applied in cataract surgery
to correct spherical aberration that is responsible for
decreased contrast sensitivity despite patient gaining 20/20
vision postoperatively. The obvious goal of wavefront
technology is to correct both lower order aberrations
(LOAs) and higher order aberrations (HOAs) in an attempt
to achieve an ideal correction that produces super vision.
To this end, wavefront-guided refractive surgery, aberrationcorrecting intraocular lenses, adaptive spectacle lens optics
and aberration-controlling contact lenses all represent
attempts to provide patients with higher quality vision. In
the last few years the clinical use of aspheric intraocular
lens (IOLs) has grown dramatically. Understanding the
concepts behind these new IOL designs is instrumental to
their effective use1.

Aberration Descriptions and Definitions

Spherical aberration (SA) is an optical effect observed in

Figure 1

an optical device (lens, mirror, etc.) that occurs due to

the increased refraction of light rays when they strike a
lens or a reflection of light rays when they strike a mirror
near its edge, in comparison with those that strike nearer
the centre. It signifies a deviation of the device from the
norm, i.e., it results in an imperfection of the produced
image. Spherical aberration is a rotationally symmetrical
aberration that typically contributes considerably to higherorder wavefront errors and, depending upon lens power,
can induce either positive or negative aberration (Figure 1).
Positive spherical aberration occurs when the peripheral
rays of light are refracted more than the central rays (plus
lenses) (Figure 2) while negative spherical aberration
occurs when peripheral rays are refracted less (either less
positive or more negative) than the central rays (minus
lenses) (Figure 3).
We know, for example, that the cornea induces
approximately +0.27 units of spherical aberration to the
wavefront error, which is fairly constant throughout life
unless any refractive surgical interventions occur. Other
factors which influence spherical aberration include
pupil size (larger pupils increase spherical aberration),
accommodation (spherical aberration becomes negative
with active accommodation) and the application of different
contact lenses (induces negative spherical aberration).
The total higher-order aberrations of the phakic eye are
composed of aberrations arising from the anterior corneal
surface, the posterior corneal surface, the crystalline lens
and the retina. In the aphakic eye, however, 98.2 percent
of the aberrations arise from the anterior corneal surface.
As this discussion is about pseudophakia, then necessarily
the corneal aberrations are of importance, and for our
purposes, can be thought of being representative of the
whole aphakic eye.

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of visual performance. It can also enable individualized

comparisons to patients who demonstrate higher quality
vision. The PSF defines how a single object is imaged by
the optical system and provides a means to display how
various aberrations affect a point of light, and therefore
demonstrates the fundamental quality of a patients vision.
When evaluating routine refractive errors with aberrometry,
uncorrected LOAs typically mask the presence of HOAs,
which are relatively small in magnitude.

Measuring Aberrations

Figure 2

Various devices have been developed to measure

HOAs. One of the more common methods of aberration
measurement uses Shack-Hartmann wavefront technology,
which was originally designed for astronomical studies
and was later applied to measuring ocular aberrations.
Aberration measuring devices such as, i Trace Ray Tracing,
Shack-Hartmann Aberrometer, Tscherning Aberrometer,
Nidek OPD-Scan Aberrometer and Emory Vision Inter
Wave Aberrometer have improved our ability to measure,
detect and understand the influence and effect that HOAs
have on the human ocular system.

What Impact Do Higher-Order Aberrations Have on

Vision Quality?

Figure 3

Two categories of aberrations commonly are used to describe

vision errors, LOAs consist primarily of near sightedness and
farsightedness (defocus), as well as astigmatism. They make
up about 85 percent of all aberrations in an eye. HOAs
comprise many varieties of aberrations. Some of them have
names such as coma, trefoil and spherical aberration, but
many more of them are identified only by mathematical
expressions (Zernike polynomials). They make up about
15 percent of the total number of aberrations in an eye
(Figure 4).
The shape of a wavefront is typically described by a
complex series of mathematical functions called Zernike
polynomials. These polynomials have varying radial orders
and meridional frequencies and can be demonstrated as
different wavefront error maps. Another way to describe
the wavefront shape uses a single number to describe the
amount the wavefront deviates from a plane wave. The
amount of the deviation is called the root mean square
(RMS) error, As the RMS approaches zero, a perfect optical
system would exist.
Two other important measurements used in wavefront
aberrometry are modulation transfer function (MTF) and
point spread function (PSF). The MTF describes the ratio of
image contrast to object contrast as a function of the spatial
frequency of a sinusoidal grating across a patients range

36 l DOS Times - Vol. 19, No. 7 January, 2014

The impact of higher-order aberrations on vision quality

depends on various factors, including the underlying cause
of the aberration. People with larger pupil sizes generally
may have more problems with vision symptoms caused
by higher-order aberrations, particularly in low lighting
conditions when the pupil opens even wider. Other causes
are as scarring of the eyes surface (cornea) or cataracts that
cloud the eyes natural lens.

What Symptoms are Associated with Higher-Order

Aberrations?
An eye usually has several different higher-order aberrations
interacting together. Therefore, a correlation between a
particular higher-order aberration and a specific symptom
cannot easily be drawn. Nevertheless, higher-order
aberrations are generally associated with double vision,
blurriness, ghosts, haloes, starbursts, loss of contrast and
poor night vision.
For cataract patients, it is possible to measure the corneal
SAs using corneal topography preoperatively and then use
this data to manipulate the outcome of cataract surgery by
implantation of aspheric intraocular lenses, with the goal
of achieving an optimum SA for the eye and maximum
contrast sensitivity both of which indicate the overall
quality of the retinal image2.

Can Higher-Order Aberrations be Corrected?

Quite a bit of attention is being focused on higherorder aberrations these days because they finally can be
diagnosed by wavefront technology (aberrometry) and

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Figure 4: Classification of Aberrations

because they recently have been identified as sometimes

serious side effects of refractive surgery.
At present, various forms of adaptive optics have been
or are being developed to custom correct higher-order
aberrations. The aim of adaptive optics is to achieve the
type of vision correction that can make the shape of the
wavefront emerging in the plane of the pupil flatter by
offsetting its distortion.

Figure 5: Spherical lenses have a constant curvature, as they are derived

from spheres, which results in peripheral light rays being defocused.
Aspheric lenses have a variable curvature, but the lens power is constant
at all points, resulting in equal focus of all light rays.

Change of contrast senstivity with age

With age there is a loss of contrast sensitivity due to
degradation of the eyes optical quality. Decrease in the
modulation transfer function that occurs with age is partly
due to an increase of intraocular scattering and an increase
of optical aberrations. Corneal astigmatism has been shown
to change from with-the-rule to against-the rule with age,
and an increase of prevalence of astigmatism with age has
been reported.

Change of Spherical Aberration with age

Negative spherical aberration of the crystalline lens shifts
toward positive values with age. The normal human cornea
has a mild amount of positive spherical aberration, which
is cancelled out by the mild amount of negative spherical
aberration present in the young crystalline lens2. while the
corneas level of mild positive spherical aberration stays
relatively constant throughout life, the crystalline lens
changes. The young crystalline lens has negative spherical
aberration, but it moves in the positive direction with age. In
middle age, the lens has zero aberration and as the cataract
develops it moves towards positive spherical aberration
The most dramatic change happens at the time of cataract
surgery, when a traditional IOL is implanted. This
dramatically increases the amount of positive spherical
aberration in the eye. Studies have shown that for agematched eyes, pseudophakic eyes have significantly

Figure 6: Comparison of various IOLs

more positive spherical aberration than the cataracts they

replaced (Figure 5).
By implanting an IOL with negative spherical aberration,
we can aim to offset the mild amount of positive spherical
aberration present in the normal cornea. This gives a total
of zero spherical aberration to the eye as a whole, as was
the case at 25 years of age. By implanting an IOL with
zero spherical aberration, we leave the eye with the mild
amount of positive spherical aberration that is present in
the normal cornea. This leaves the eye as a whole with a

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Refractive Surgery

aberration and those with negative spherical aberration.

The traditional IOLs with positive spherical aberration were
the most commonly used lenses for pseudophakia. This has
changed in recent times as traditional IOLs gave a poorer
quality image than the aspheric IOLs in the vast majority
of patients.

Figure 7: Comparison of image quality of a photo (left)

taken through a 22 D Aspheric IOL (SofPort AO) and
a 22 D traditional IOL (SofPort SE), though a camera
with a 5-mm pupil size (right).

Figure 8: Longitudal and Tranverse

Spherical Aberrations

small amount of spherical aberration, similar to a normal

45-year-old eye (Figure 5,6).

Spherical lenses V/S Aspherical lenses

Spherical lenses have a constant curvature on their surface,
much in the same way that a sphere has a constant
curvature. However, the power of the lens at different points
is variable, resulting in relative defocus of more peripheral
light rays. Due to this constant curvature, these lenses are
easier to make; however, their optics are worse. A perfectly
aspheric lens has a variable curvature but a constant power
even at the periphery of the lens. This results in the same
focus of all light rays, both central and peripheral resulting
in a sharper, higher-quality image. These lenses are more
difficult to make, but their optics are better.

The zero aberration IOL that is now available is the Soft

Port AO Advanced Optics silicone IOL (Bausch & Lomb,
Rochester, N.Y). This zero spherical aberration design is
achieved via aspheric anterior and posterior surfaces of
the IOL.Negative aberration IOLs that are available are. (1)
Tecnis (Z9000, Z9002, Z9003) from AMO with S.A -0.27
due to prolate anterior surface. (2) Acrysof IQ (SN60WF)
from Alcon Labs with S.A of -0.20 due to prolate posterior
surface (Figure 7,8).
We know from our experiences with corneal-based
refractive surgery that there is far more to vision than
Snellen acuities. Contrast sensitivity is an important
determinant of the quality of vision, and the more spherical
aberration that the eye has, the poorer the quality of vision
is. Studies have shown an improvement in simulated
driving reaction time in patients with the Tecnis aspheric
IOL3,4,5,6. Perhaps the best example of the difference among
image qualities between spherical and aspheric lenses is
obtained by taking a photograph of the U.S. Air Force test
targets as seen through actual IOLs. When we compare the
image quality of the photographs, the improvement with an
aspheric IOL compared to an IOL that has spherical optics
but is otherwise identical (same power, same material,
same design, same manufacturer) is dramatic 7-10.

Relationship of Depth of Field to Image Quality

With other factors such as pupil size, ambient lighting
and other aberrations kept constant, the effect of spherical
aberration on depth of field is inversely related to the
image quality of the eye. With less spherical aberration, the
image quality is better, but the depth of field is decreased.
Similarly, with more spherical aberration, the image quality
suffers, but the depth of field is increased (Figure 9)11.

Which IOL for Which Patient?

With three distinct classes of IOLs, which IOLdo we choose
for which patient? To properly match the IOL to the patient,
the questions that we should ask are

What is the patients mesopic or scotopic pupil size?

Since the peripheral light rays are the ones that are
most affected by spherical aberration, if the patient has
small pupils at all times, he is unlikely to notice the
difference between an aspheric IOL and a traditional
IOL.

Classifications of IOLS
We can classify IOLs as either spherical or aspheric. Spherical
IOLs have positive spherical aberration. The aspheric
category is subdivided into lenses with zero spherical

38 l DOS Times - Vol. 19, No. 7 January, 2014

What are the patients requirements for vision?

Patients who are active, still working, still driving at

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night and are more demanding are more likely to notice

the difference between aspheric and traditional IOLs.
Patients who spend a considerable amount of time at a
fixed focal point, such as professional drivers watching
the road, would benefit from the best possible image
quality, even if it means a decreased depth of field.
How hyperopic is the patient?

The amount of spherical aberration increases with

dioptric power in traditional IOLs. Therefore, the
patients who need a +28 D IOL will have significantly
more induced spherical aberration than those who
need a +14 D IOL.

Has the patient had previous corneal refractive

surgery?

A patient with a history of prior myopic refractive

surgery is likely to have flattening of the cornea
with a resultant increase in the corneal positive
spherical aberration. In this case, implanting an IOL
with negative spherical aberration will help to offset
this change and will result in better visual quality. A
patient with a history of prior hyperopic refractive
surgery is likely to have steepening of the cornea with
a resultant decrease in the corneal spherical aberration,
often to the point of negative spherical aberration.
By implanting a traditional IOL that induces positive
spherical aberration, we can help to balance out this
change and give better visual quality. This is one of the
rare situations where a traditional IOL will outperform
an aspheric one (Figure 10).

Figure 10

How is the capsular support and what is the

likelihood of IOL decentration?
The negative spherical aberration aspheric IOLs require
very good centration with respect to the visual axis of the
eye. Decentration of these IOLs results in a significant
decrease in their performance and can even induce higherorder aberrations such as coma.In case of loose zonules,
creation of irregular capsulorhexis or eyes likely to undergo
significant capsule contraction, the centration of the IOL is
variable.These eyes would do well with a zero aberration
IOL because it is relatively immune to decentration.

Can Patients Tell the Difference?

In reality, the difference made by addressing asphericity is
usually very small compared to correcting spherical error
and astigmatism. Under low-contrast conditions, such as
driving at dusk, a patient with large pupils would be more
likely to notice the difference but the average cataract
patient doesnt have enormous mesopic pupils, but a
patient with an older style lens and a Plano prescription
will be happier than a patient with an aspheric lens who is
1 D hyperopic or still has a diopter of astigmatism.
The most useful residual amount of asphericity to target
may depend on the full spectrum of corneal higher order
aberrations, not just on corneal spherical aberration alone.
This is because of the way spherical aberration interacts
with other higher-order aberrations sometimes dampening
them and also has effects on residual defocus, as well as
chromatic aberration.

Imprecision of Surgery

Figure 9: When we compare the three classes of IOLs, we see

that the best image quality comes with the least amount of splay at
the focal point; however, this lessens the depth of field.

Whether surgery is precise enough to avoid offsetting the

potential benefit of an aspheric IOL is also an issue. Were
not at a point yet in cataract surgery that we can predict a
refractive outcome with absolute certainty. We cant tell
corneal aberrations or creating a model predicting the exact
effective position of the IOL. Furthermore, the capsular
bag can contract as part of the healing process, shifting

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Table 1: Different IOLs for different SA

Corneal SA

Lens Implanted

-0.15 to +0.15 mm

AMO Clariflex, B&L SofPort AO, or B&L Akreos AO

+0.16 to +0.33 mm

Alcon IQ (SN60WF)

>+0.33 mm

AMO Tecnis (Z9002, ZA9003 and ZCB00)

>-0.15 mm

Standard intraocular lens

on the Zernike tree. As is better to have a patient with no

residual astigmatism than one who has no spherical and
other higher-order aberrations.

Figure 11: Performance of aspheric and traditional

IOLs at various degree of defocus

the axial position or centration of the lens. And being

centered in the bag may not be the same as being centered
in the line of sight. In fact, there could be some advantage
to leave a little bit of spherical aberration to offset other
refractive errors that may occur as a result of the surgery.
From a theoretical viewpoint, IOL decentration could limit,
cancel, or turn into disadvantages the benefits of aspheric
IOLs. For example, the advantages of asphericity are lost
when IOL decentration is greater than 0.5 mm. Holladay
et al.report that optical quality measurements provide
evidence that if an aspheric IOL were centered within 0.4
mm and tilted fewer than 7 degrees, it would exceed the
optical performance of a conventional spherical IOLt.
Another point is that best-corrected eyes with spherical IOLs
should perform better at near tasks than best corrected eyes
with aspheric IOLs. Marcos et al. found that the tolerance
to defocus was significantly higher with spherical IOLs than
with aspheric IOLs, it was necessary to add 1.5 diopters
(D) with the spherical IOL and 1.1 D with the aspheric IOL
to make the 20/20 line illegible on simulation. Recently,
Rocha et al11, concluded that the reduction in spherical
aberration after aspheric IOL implantation may degrade
distance-corrected near visual acuity and intermediate visual
acuity. They point out that residual spherical aberration can
improve depth of focus and that the tolerance to defocus
seems to be higher in eyes with a spherical IOL than in eyes
with an aspheric IOL12.
Either go for perfection or forget it. Preserving corneal
spherical aberration has the added advantage of making the
eyes more tolerant of defocus, without spherical aberration,
the quality of vision drops off much faster if one doesnt hit
refractive target exactly (Figure 11).
Conquer Zernikes lower orders first. Indeed, whichever
aspheric IOL is chosen, the surgeons accuracy in hitting the
refractive target is one of the most important determinants
of refractive success. It is more important to nail the lowerorder aberrations than it is to go after higher-order branches

40 l DOS Times - Vol. 19, No. 7 January, 2014

With the knowledge gained about advantages & limitations

of Aspheric IOLs, we can have 4 different strategies to have
optimum visual outcomes.

Strategy 1: Do Not Use Aspheric IOLs

There have been a small number of studies which have
failed to demonstrate any perceived improvement in
vision with the use of aspheric IOLs13-15. However, these
reports had some inherent errors e.g. in many, the corneal
spherical aberration is not measured. Similarly, many do
not report the pupil size. Another criticism is that patients
are assessed with subjective tests, such as the visual fields
(VF). These tests are not as sensitive as contrast sensitivity
testing and fail to show any improvement. Other factors
that need to be studied are ocular dominance. No benefit
were observed in patients with small mesopic pupils. A
small or contracted anterior capsulotomy can also negate
the effects of an aspheric lens. Finally, as will be shown,
there is an interaction between spherical aberration and
residual refractive error. If this is not controlled, then the
visual outcome will be less than ideal. Standard IOLs are of
more beneficial in patients undergoing hyperopic corneal
refractive surgery.

Strategy 2: Same Aspheric for all Patients

This approach certainly has some evidence to support it.
The main criticism of the one lens for all patients strategy
is that it is akin to using a single-powered IOL in all cases
of aphakia, irrespective of the parameters of the eye being
implanted. This is a good first step, but experience shows
that selecting the appropriate power of IOL provides
superior uncorrected vision. Similarly, it should not be a
huge leap of faith to accept that selecting an appropriate
aspheric correction should provide the best functional
vision.

Strategy 3: Target Aspheric Correction

Although the average corneal SA for the population is +0.27
m, the standard deviation is large and approaches 0.10
m, or one-third of the value. Therefore it is recommended
to measure the patients corneal SA and using an aspheric
IOL to target a specific value that approaches 0.10 m
by using the protocol in Table 1. After corneal refractive
surgery, some generalizations can be made if one cannot

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directly measure the SA. Myopic laser ablation tends to

increase the SA, so a high-negative SA lens, such as the
Tecnis, is recommended. Conversely, hyperopic ablation
tends to decrease the SA, and possibly make it negative,
so a standard lens with positive SA should be considered.

postop refraction of plano is chosen. If the predicted SA

is negative, then a hyperopic refraction of 0.25 D for each
0.10 m of SA is targeted. If there is a positive predicted
SA, then a myopic refraction of 0.25 D for each 0.10 m of
SA is targeted.

Unfortunately, since each lens design comes in only one SA

power, this targeting approach has limited success. If one
is to use a single lens design, then the following strategy
has merit.

Utilizing this approach of choosing a lens material with the

least amount of chromatic aberration, and a lens design that
corrects for spherical aberration, with a defocus adjustment
to neutralize the SA, would seem to be the best strategy
for optimizing vision in cataract or refractive lens exchange
patients.

Strategy 4: Match Corneal SA and Refraction for

Optimization of Vision
It has been known for a while that different optical
aberrations interact to affect visual performance. However,
the nature of this interaction has been elusive. Wang et al16
simulated implantation of lenses with different amounts of
SA and with different amounts of defocus. They found that
the maximum image quality depended on an interaction
between the residual SA and the defocus. For plano defocus,
a SA of -0.05 m was found to be ideal; for myopia of -0.5
D, a SA of +0.20 m; and for hyperopia of +0.5 D, a SA of
-0.2 m was found to give best image quality.
Using adaptive optics to study the optimal spherical
aberration for contrast sensitivity, researchers found that for
an SA of 0.00 m, maximum vision occurs at 0 defocus;
for positive values of SA, a negative defocus provides best
vision; and for negative values of SA, a positive defocus
was found to be the best. The basis is strategy that allows
for the interaction of the measured corneal SA (at 6 mm)
and a targeted refraction postop so as to optimize vision.
In addition to spherical aberration, it is also possible to
correct for chromatic aberration. Chromatic aberration
impacts negatively on vision and in particular on contrast
sensitivity. The chromatic aberration of a material can be
expressed in its Abbe number; the higher the number,
the lower the chromatic aberration and the greater the
optical quality. It has been shown that the AMO acrylic
hydrophobic material has the least amount of chromatic
aberration of currently used IOL materials.
It has been found that a lens which only corrects for
spherical aberration improves contrast sensitivity by 20
percent over a standard lens; however, a lens that corrects
for both spherical aberration (to 0.00 m) and chromatic
aberration improves visual performance by 50 percent.
Using the data previously presented to support the concept
of targeting a specific postoperative refraction based on
the total spherical aberration of the eye so as to optimize
vision, following protocol was decided: The corneal
spherical aberration at 6 mm diameter is measured preop.
Since the AMO Tecnis has a SA of -0.27 m, and Acrysof
has SA of -0.20, this value is subtracted from the corneal
SA. If the residual value is near 0.00 m, then a target

Summary
Aspheric IOLs are must in young patients with distinctly
larger mesopic and scotopic pupils, who work under low
contrast conditions like driving at night, and who have
undergone refractive lens exchange and after myopic
LASIK. They are not useful in 1) Senile miosis 2) Subjects
with not large mesopic pupils 3) After hyperopic LASIK, 4)
In very old patients whose macula doesnt have enough
ganglion cells to notice benefit of asphericity of in IOLS, 5)
Factors of tilt/decentration and Defocus should always be
considered while implanting aspheric IOLs.
Asphericity of the lens does not make a tremendous
difference for the average patient.
Best thing is to do a clean surgery and really nail the LOA
like residual refractory error & astigmatism, then try to
conquer HOA. In most cases, you should probably use an
aspheric lens, but the one you choose should depend on
(1) Corneas SA (2) IOLS SA (3) Cornea whether virgin or
has been subjected to refractive corneal surgery (4). Target
of residual refractory error & residual SA postoperatively.
Throw the marketing nonsense out of the window and see
what works best for your patients. IOL companies should
manufacture different combination of dioptric powers with
different values of asphericity.

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