Accommodating intraocular lenses: a critical review of present and future concepts

  • R. Menapace
  • O. Findl
  • K. Kriechbaum
  • Ch. Leydolt-Koeppl
Review Article



Significant efforts have been made to develop lens implants or refilling procedures that restore accommodation. Even with monofocal implants, apparent or pseudoaccommodation may provide the patient with substantial though varying spectacle independence. True pseudophakic accommodation with a change of overall refractive power of the eye may be induced either by an anterior shift or a change in curvature of the lens optic.

Materials and methods

Passive-shift lenses were designed to move forward under ciliary muscle contraction. This is the only accommodative lens type currently marketed (43E/S by Morcher; 1CU by HumanOptics; AT-45 by Eyeonics). The working principle relies on various hypothetical assumptions regarding the mechanism of natural accommodation. Dual-optic lenses were designed to increase the dioptric impact of optic shift. They consist of a mobile front optic and a stationary rear optic which are interconnected with spring-type haptics. With active-shift lens systems the driving force is provided by repulsing mini-magnets. Lens refilling procedures replace the lens content by an elastic material and provide accommodation by an increase of surface curvature.


Findings with passive-shift lenses have been contradictory. While uncorrected reading vision results were initially reported to be favorable with the 1CU, and excellent with the AT-45 lens, distant-corrected near vision did not exceed that with standard monofocal lenses in later studies. Mean axial shift from laser interferometric measurements under stimulation with pilocarpine showed a moderate anterior shift with the 1CU, while the AT-45 paradoxically exhibited a small posterior shift. With the 1CU, the shift-induced accommodative effect was calculated to be less than +0.5 D in most cases, while +1 D was achieved in a single case only. Ranges and standard deviations were very large in relation to the mean values. Under physiological near-point stimulation, however, no shift was seen at all. Prevention of capsule fibrosis by extensive capsule polishing did not enhance the functional performance. Dual optic lenses are under clinical investigation and are reported to provide a significant amount of accommodation. However, possible long-term formation of interlenticular opacifications remains to be excluded. Regarding magnet-driven active-shift lens systems, initial clinical experience has been promising. Prevention of fibrotic capsular contraction is crucial, and it has been effectively counteracted with a special capsular tension ring, or lens fixation technique, together with capsule polishing. Lens refilling has been extensively studied in the laboratory and in primates. Though it offers great potential for fully restoring accommodation, a variety of problems must be solved, such as achieving emmetropia in the relaxed state, adequate response to ciliary muscle contraction, satisfying image quality over the entire range of accommodation and sustained functioning. The key problem, however, is again after-cataract prevention.


As opposed to psychophysical evaluation techniques, laser interferometry measures what shift lenses are designed to provide: axial shift on accommodative effort. While under pilocarpine some movement was recorded, no movement at all was found under near-point stimulation with any of the lenses currently marketed. In contrast, magnetic-driven active-shift lens systems carry the potential of sufficiently topping up apparent accommodation to provide for clinically useful accommodation while using conventional lens designs with proven after-cataract performance. Dual optic implants significantly increase the impact of axial optic shift. The main potential problem, however, is delayed formation of interlenticular regenerates. Lens refilling procedures offer the potential of fully restoring accommodation due to the great impact of increase in surface curvature on refractive lens power. However, various problems remain to be solved before clinical use can be envisaged, above all, again, after-cataract prevention. The concept of passive single-optic shift lenses has failed. Concomitant poor capsular bag performance makes these lenses an unacceptable trade-off. Magnet-assisted systems potentially combine clinically useful accommodation with satisfactory after-cataract performance. Dual optic lenses theoretically offer substantial accommodative potential but may allow for interlenticular after-cataract formation. Lens refilling procedures have the greatest potential for fully restoring natural accommodation, but will again require years of extensive laboratory and animal investigations before they may function in the human eye.


Accommodative intraocular lenses Working principle and clinical performance of current lenses Future concepts 


  1. 1.
    Auffarth GU, Martin M, Fuchs HA, Rabsiber TM, Becker KA, Schmack I (2002) Validity of anterior chamber depth measurements for the evaluation of accommodation after implantation of an accommodative HumanOptics 1CU intraocular lens. Ophthalmologe 99:815–819PubMedCrossRefGoogle Scholar
  2. 2.
    Coleman DJ (1986) On the hydraulic suspension theory of accommodation. Trans Am Ophthalmol Soc 84:846–868PubMedGoogle Scholar
  3. 3.
    Coleman DJ, Fish SK (2001) Presbyopia, accommodation, and the mature catenary. Ophthalmology 108:1544–1551PubMedCrossRefGoogle Scholar
  4. 4.
    Croft MA, Glasser A, Kaufman PL (2001) Accommodation and presbyopia. Int Ophthalmol Clin 41:33–46PubMedCrossRefGoogle Scholar
  5. 5.
    Cumming JS, Slade SG, Chayet A (2001) Clinical evaluation of the model AT-45 silicone accommodative intraocular lens: results of feasibility and the initial phase of a food and drug administration clinical trial. Ophthalmology 108:2005–2008PubMedCrossRefGoogle Scholar
  6. 6.
    De Groot JH, van Beijma FJ, Haitjema HJ, Dillingham KA, Hodd KA, Koopmans SA, Norrby S (2001) Injectable intraocular lens materials based upon hydrogels. Biomacromolecules 2:628–634PubMedCrossRefGoogle Scholar
  7. 7.
    Elder MJ, Murphy C, Sanderson GF (1996) Apparent accommodation and depth of field in pseudophakia. J Cataract Refract Surg 22:615–619PubMedGoogle Scholar
  8. 8.
    Fercher AF, Roth E (1986) Ophthalmic laser interferometer. Proc SPIE 658:48–51Google Scholar
  9. 9.
    Findl O, Drexler W, Menapace R, Hitzenberger CK, Fercher AF (1998) High precision biometry of pseudophakic eye using partial coherence laser interferometry. J Cataract Refract Surg 24:1087–1093PubMedGoogle Scholar
  10. 10.
    Findl O, Menapace R (2000) Piggyback intraocular lenses. J Cataract Refract Surg 26:308–309PubMedCrossRefGoogle Scholar
  11. 11.
    Findl O, Kiss B, Petternel V, Menapace R, Georgopoulos M, Rainer G, Drexler W (2003) Intraocular lens movement caused by ciliary muscle contraction. J Cataract Refract Surg 29:669–676PubMedCrossRefGoogle Scholar
  12. 12.
    Findl O, Kriechbaum K, Menapace R, Koeppl C, Sacu S, Wirtitsch M, Buehl W, Drexler W (2004) Laserinterferometric assessment of pilocarpine-induced movement of an accommodating intraocular lens: a randomized trial. Ophthalmology 111:1515–1521PubMedCrossRefGoogle Scholar
  13. 13.
    Fukuyama M, Oshika T, Amano S, Yoshitomi F (1999) Relationsship between apparent accommodation and corneal multifocality in pseudophakic eyes. Ophthalmology 106:1178–1181PubMedCrossRefGoogle Scholar
  14. 14.
    Glasser A, Campbell MC (1999) Biometric, optical and physical changes in the isolated human crystalline lens with age in relation to presbyopia. Vision Res 39:1991–2015PubMedCrossRefGoogle Scholar
  15. 15.
    Greenbaum S (2002) Monovision pseudophakia. J Cataract Refract Surg 28:1439–1443PubMedCrossRefGoogle Scholar
  16. 16.
    Haefliger E, Parel JM, Fantes F, Norton EW, Anderson DR, Forster RK, Hernandez E, Feuer WJ (1987) Accommodation of an endocapsular silicone lens (Phaco-Ersatz) in the nonhuman primate. Ophthalmology 94:471–477PubMedGoogle Scholar
  17. 17.
    Haefliger E, Parel JM (1994) Accommodation of an endocapsular silicone lens (Phaco-Ersatz) in the aging rhesus monkey. J Refract Corneal Surg 10:550–555PubMedGoogle Scholar
  18. 18.
    Haigis W, Auffarth GU, Limberger IJ, Rabsilber TM, Reuland AJ (2005) [Precision measurements of accommodative shift of the 1CU-lens for assessment of resulting refractive changes.] Proceedings 19th Congress of the German-speaking Society of Intraocular Lens Implantation and Refractive Surgery, Magdeburg pp241–255Google Scholar
  19. 19.
    Hara T, Yasuda A, Yamada Y (1990) Accommodative intraocular lens with spring action. 1. Design and placement in an excised animal model. Ophthalmic Surg 21:128–133PubMedGoogle Scholar
  20. 20.
    Hara T, Yasuda A, Mizumoto Y, Yamada Y (1992) Accommodative intraocular lens with spring action. 2. Fixation in the living rabbit. Ophthalmic Surg 23:632–635PubMedGoogle Scholar
  21. 21.
    Hara T, Sakka Y, Sakanishi K, Yamada Y, Nakamae K, Hayashi F (1994) Complications associated with endocapsular balloon implantation in rabbit eyes. J Cataract Refract Surg 20:507–512PubMedGoogle Scholar
  22. 22.
    Hardman Lea SJ, Rubinstein MP, Snead MP, Haworth SM (1990) Pseudophakic accommodation? A study of the stability of capsular bag supported, one piece, rigid tripod, or soft flexible implants. Br J Ophthalmol 74:22–25PubMedGoogle Scholar
  23. 23.
    Hayashi K, Hayashi H, Nakao F, Hayashi F (2003) Aging changes in apparent accommodation in eyes with a monofocal intraocular lens. Am J Ophthalmol 135:432–436PubMedCrossRefGoogle Scholar
  24. 24.
    Hettlich HJ, Lucke K, Asiyo-Vogel MN, Schulte M, Vogel A (1994) Lens refilling and endocapsular polymerization of an injectable intraocular lens: in vitro and in vivo study of potential risks and benefits. J Cataract Refract Surg 20:115–123PubMedGoogle Scholar
  25. 25.
    Hettlich HJ, Asiyo-Vogel M (1996) [Experimental experiences with balloon-shaped capsular sac implantation with reference to accommodation outcome in intraocular lenses] Ophthalmologe 93:73–75PubMedGoogle Scholar
  26. 26.
    Holladay JT (1993) Refractive power calculations for intraocular lenses in the phakic eye. Am J Ophthalmol 116:63–66PubMedGoogle Scholar
  27. 27.
    Horton JC, Jones MR (1997) Warning on inaccurate Rosenbaum charts for testing near vision. Surv Ophthalmol 42:169–174PubMedCrossRefGoogle Scholar
  28. 28.
    Huber C (1981) Planned myopic astigmatism as a substitute for accommodation in pseudophakic eyes. Am Intraocular Implant Soc 3:244–249Google Scholar
  29. 29.
    Kessler J (1964) Experiments in refilling the lens. Arch Opthalmol 71:412–417Google Scholar
  30. 30.
    Kirchhoff A, Stachs O, Guthoff R (2001) Three-dimensional ultrasound findings of the posterior iris region. Graefes Arch Clin Exp Ophthalmol 239:968–971PubMedGoogle Scholar
  31. 31.
    Koeppl C, Findl O, Menapace R, Kriechbaum K, Wirtitsch M, Buehl W, Sacu S, Drexler W (2005) Pilocarpine-induced shift of an accommodating intraocular lens: AT-45 Crystalens. J Cataract Refract Surg 31:1290–1297PubMedCrossRefGoogle Scholar
  32. 32.
    Koopmans SA, Terwee T, Barkhof J, Haitjema HJ, Kooijman AC (2003) Polymer refilling of presbyopic human lenses in vitro restores the ability to undergo accommodative changes. Invest Ophthalmol Vis Sci 44:250–257PubMedCrossRefGoogle Scholar
  33. 33.
    Koopmans SA, Terwee T, Haitjema HJ, Barkhof J, Kooijman AC (2003) Effect of infusion bottle height on lens power after lens refilling with and without a plug. J Cataract Refract Surg 29:1989–1995PubMedCrossRefGoogle Scholar
  34. 34.
    Koopmans SA, Terwee T, Haitjema HJ, Deuring H, Aarle S, Kooijman AC (2004) Relation between injected volume and optical parameters in refilled isolated porcine lenses. Ophthalmic Physiol Opt 24:572–579PubMedCrossRefGoogle Scholar
  35. 35.
    Kriechbaum K, Findl O, Kiss B, Sacu S, Petternel V, Drexler W (2003) Comparison of anterior chamber depth measurement methods in phakic and pseudophakic eyes. J Cataract Refract Surg 29:89–94PubMedCrossRefGoogle Scholar
  36. 36.
    Kriechbaum K, Findl O, Koeppl C, Menapace R, Drexler W (2005) Stimulus-driven versus pilocarpine-induced biometric changes in pseudophakic eyes. Ophthalmology 112:453–459PubMedCrossRefGoogle Scholar
  37. 37.
    Kuechle M, Nguyen NX, Langenbucher A, Gusek-Schneider GC, Seitz B, Hanna KD (2002) Implantation of a new accommodative posterior chamber intraocular lens. J Refract Surg 18:208–216Google Scholar
  38. 38.
    Kuechle M, Seitz B, Langenbucher A, Martus P, Nguyen NX (2003) Erlangen Accommodative Intraocular Lens Study Group. Stability of refraction, accommodation, and lens position after implantation of the 1CU accommodating posterior chamber intraocular lens. J Cataract Refract Surg 29:2324–2329CrossRefGoogle Scholar
  39. 39.
    Kuechle M, Seitz B, Langenbucher A, Gusek-Schneider GC, Martus P, Nguyen NX (2004) The Erlangen Accommodative Intraocular Lens Study Group. Comparison of 6-month results of implantation of the 1CU accommodative intraocular lens with conventional intraocular lenses. Ophthalmology 111:318–324CrossRefGoogle Scholar
  40. 40.
    Langenbucher, Langenbucher A, Huber S, Nguyen NX, Seitz B, Gusek-Schneider GC, Kuechle M (2003) Measurement of accommodation after implantation of an accommodating intraocular lens. J Cataract Refract Surg 29:677–685PubMedCrossRefGoogle Scholar
  41. 41.
    Legeais JM, Werner L, Abenhaim A, Renard G (1999) Pseudoaccommodation: BioComFold versus a foldable silicone intraocular lens. J Cataract Refract Surg 25:262–267PubMedCrossRefGoogle Scholar
  42. 42.
    Lesiewska-Junk H, Kaluzny J (2002) Intraocular lens movement and accommodation in eyes of young patients. J Cataract Refract Surg 26:562–565CrossRefGoogle Scholar
  43. 43.
    Leyland M, Ziniola E (2003) Multifocal versus minifocal intraocular lenses in cataract surgery: a systematic review. Ophthalmology 110:1789–1798PubMedCrossRefGoogle Scholar
  44. 44.
    Lucke K, Hettlich HJ, Kreiner CF (1992) A method of lens extraction for the injection of liquid intraocular lenses. Ger J Ophthalmol 1:342–345PubMedGoogle Scholar
  45. 45.
    Maloof AJ. Selective targeting of lens epithelial cells during human cataract surgery using sealed-capsule irrigation with distilled water. ARVO 2004, Fort Lauderdale, Abstract B291Google Scholar
  46. 46.
    Mastropasqua L, Toto L, Nubile M, Falconio G, Ballone E (2003) Clinical study of the 1CU accommodating intraocular lens. J Cataract Rferact Surg 29:1307–1312CrossRefGoogle Scholar
  47. 47.
    McDonald JP, Croft MA, Vinje E, Glasser A, Heatley GA, Kaufman P, Sarfarazi FM (2003) Sarfarazi elliptical accommodating intraocular lens (EAIOL) in rhesus monkey eyes in vitro and in vivo. Invest Ophthalmol Vis Sci;44: Abstract 256Google Scholar
  48. 48.
    McLoed SD, Portney V, Ting A (2003) A dual optic accommodating foldable lens. Br J Ophthalmol 87:1083–1085CrossRefGoogle Scholar
  49. 49.
    Menapace R (2004) Prevention of after cataract. In: T Kohnen, DD Koch (eds) Cataract and refractive surgery, Series Essentials in Ophthalmology. pp 101–122Google Scholar
  50. 50.
    Menapace R, Wirtitsch M, Findl O, Buehl W, Kriechbaum K, Sacu S (2005) Effect of anterior capsule-polishing on posterior capsular opacification and neodymium-YAG capsulotomy rate: a three-year randomized trial. J Cataract Refract Surg 31:2067–2075PubMedCrossRefGoogle Scholar
  51. 51.
    Menapace R (2006) Primary posterior buttonholing for eradication of after-cataract: report of 500 cases. J Cataract Refract Surg 32:929–943PubMedCrossRefGoogle Scholar
  52. 52.
    Menapace R (2006) “Aspiration Curette”: an instrument for efficient and safe anterior capsule polishing: laboratory and clinical results. J Cataract Refract Surg, in pressGoogle Scholar
  53. 53.
    Mester U, Dillinger P, Anterist N, Kaymak H (2005) Functional results with two multifocal intraocular lenses (MIOL). Array SA40 versus Acri.Twin] Ophthalmologe 102:1051–1056PubMedCrossRefGoogle Scholar
  54. 54.
    Nakazawa M, Ohtsuki K (1983) Apparent accommodations in pseudophakic eyes after implantation of posterior chamber lenses. Am J Ophthalmol 96:435–438PubMedGoogle Scholar
  55. 55.
    Nakazawa M, Ohtsuki K (1984) Apparent accommodation in pseudophakic eyes after implantation of posterior chamber lenses: optical analysis. Invest Ophthalmol Vis Sci 25:1458–1460PubMedGoogle Scholar
  56. 56.
    Nguyen NX, Seitz B, Reese S, Langenbucher A, Kuchle M (2005) Accommodation after Nd: YAG capsulotomy in patients with accommodative posterior chamber lens 1CU. Graefes Arch Clin Exp Ophthalmol 243:120–126PubMedCrossRefGoogle Scholar
  57. 57.
    Niessen AGJE, de Jong LB, van der Heijde GL (1992) Pseudo-accommodation in pseudophakia. Eur J Implant Refract Surg 4:91–94Google Scholar
  58. 58.
    Nishi O, Sakka Y (1990) Anterior capsule-supported intraocular lens. A new lens for small-incision surgery and for sealing the capsular opening. Graefes Arch Clin Exp Ophthalmol 228:582–588PubMedCrossRefGoogle Scholar
  59. 59.
    Nishi O, Hara T, Hara T, Sakka Y, Hayashi F, Nakamae K, Yamada Y (1992) Refilling the lens with a inflatable endocapsular balloon: surgical procedure in animal eyes. Graefes Arch Clin Exp Ophthalmol 230:47–55PubMedCrossRefGoogle Scholar
  60. 60.
    Nishi O, Nakai Y, Yamada Y, Mizumoto Y (1993) Amplitudes of accommodation of primate lenses refilled with two types of inflatable endocapsular balloons. Arch Ophthalmol 111:1677–1684PubMedGoogle Scholar
  61. 61.
    Nishi O, Nishi K, Mano C, Ichihara M, Honda T (1997) Controlling the capsular shape in lens refilling. Arch Ophthalmol 115:507–510PubMedGoogle Scholar
  62. 62.
    Nishi O, Nakai Y, Mizumoto Y, Yamada Y (1997) Capsule opacification after refilling the capsule with an inflatable endocapsular balloon. J Cataract Refract Surg 23:1548–1555PubMedGoogle Scholar
  63. 63.
    Nishi O, Nishi K (1998) Accommodation amplitude after lens refilling with injectable silicone by sealing the capsule with a plug in primates. Arch Ophthalmol 116:1358–1361PubMedGoogle Scholar
  64. 64.
    Nishi O, Nishi K, Mano C, Ichihara M, Honda T (1998) Lens refilling with injectable silicone in rabbit eyes. J Cataract Refract Surg 24:975–982PubMedGoogle Scholar
  65. 65.
    Nishi O (2005) [After-cataract prevention and the restitution of accommodation—A new lens-refilling procedure. PPCCC+PBH: Proceedings 19th Congress of the German-speaking Society of Intraocular Lens Implantation and Refractive Surgery, Magdeburg 2005, pp247–250Google Scholar
  66. 66.
    Olsen R, Mamalsi N, Haugen B (2006) A light-adjustable lens with injectable optics. Curr Opin Ophthalmol 17:72–79CrossRefGoogle Scholar
  67. 67.
    Oshika T, MimuraT, Tanaka S, Amano S, Fukuyama M, Yoshitomi F, Maeda N, Fujikado T, Hirohara Y, Mihashi T (2002) Apparent accommodation and corneal front aberration in pseudophakic eyes. Invest Ophthalmol Vis Sci 43:2882–2886PubMedGoogle Scholar
  68. 68.
    Payer H (1997) Ringwulstlinse mit Zoomwirkung zur Verstärkung einer Pseudoakkommodation und deren Erklärung aus erweiterter Akkommodationstheorie. [Posterior chamber lens allowing cases of pseudoaccommodation]. Spektrum Augenheilkd 11:81–89Google Scholar
  69. 69.
    Payer H, Reiter J (2003) Five years of experience with the Annular Ring Lens In: Guthoff R, Ludwig K (eds) Current aspects of human accommodation II. Kaden, Heidelberg, pp 179–192Google Scholar
  70. 70.
    Preussner PR, Wahl J, Gerl R, Kreiner C, Serester A (2001) Accommodative lens implant. Ophthalmologe 98:97–102PubMedCrossRefGoogle Scholar
  71. 71.
    Sacca Y, Hara T, Yamada Y, Hara T, Hayashi F (1996) Accommodation in primate eyes after implantation of refilled endocapsular balloon. Am J Ophthalmol 121:210–212Google Scholar
  72. 72.
    Sacu S, Menapace R, Wirtitsch M, Buehl W, Kriechbaum K (2004) Effect of anterior capsule polishing on fibrotic capsule opacification: three-year results. J Cataract Refract Surg 30:2322–2327PubMedGoogle Scholar
  73. 73.
    Schaeffel F (2003) Optical techniques to measure the dynamics of accommodation. In: Guthoff R, Ludwig K (eds) Current aspects of human accommodation II. Kaden, Heidelberg, pp 71–94Google Scholar
  74. 74.
    Schwartz DM (2003) Light-adjustable lens. Trans Am Ophthalmol Soc 101:417–436PubMedGoogle Scholar
  75. 75.
    Smith SG, Snowden F, Lamprecht EG (1987) Topographical anatomy of the ciliary sulcus. J Cataract Refract Surg 13:543–547PubMedGoogle Scholar
  76. 76.
    Stachs O, Martin H, Kirchhoff A, Stave J, Terwee T, Guthoff R (2002) Monitoring accommodative ciliary muscle function using three-dimensional ultrasound. Arch Clin Exp Ophthalmol 240:906–912Google Scholar
  77. 77.
    Tassignon MJ, De Groot V, Vrensen GF (2002) Bag-in-the-lens implantation of intraocular lenses. J Cataract Refract Surg 28:1182–1188PubMedCrossRefGoogle Scholar
  78. 78.
    Verzella F, Colossi A (1993) Multifocal effect of against-the-rule myopic astigmatism in pseudophakic eyes. Refract Corneal Surg 1:58–61Google Scholar
  79. 79.
    Werblin TP (2003) Discussion of article “Clinical evaluation of model AT-45 silicone accommodative intraocular lens: results of feasibility and the initial phase of a food and drug administration clinical trial”. Ophthalmology 108:2010CrossRefGoogle Scholar
  80. 80.
    Werner L, Pandey SK, Izak AM, Vargas LG, Trivedi RH, Apple DJ, Mamalis N (2004) Capsular bag opacification after experimental implantation of a new accommodating intraocular lens in rabbit eyes. J Cataract Refract Surg 30:1114–1123PubMedCrossRefGoogle Scholar
  81. 81.
    Yamamoto S, Adachi-Usami E (1992) Apparent accommodation in pseudophakic eyes as measured with visually evoked potentials. Invest Ophthalmol Vi Sci 33:443–446Google Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • R. Menapace
    • 2
  • O. Findl
    • 1
  • K. Kriechbaum
    • 1
  • Ch. Leydolt-Koeppl
    • 1
  1. 1.Department of OphthalmologyMedical University of ViennaViennaAustria
  2. 2.Department of OphthalmologyUniversity of Vienna Medical SchoolViennaAustria

Personalised recommendations