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Case Report

Presbyopia-Correcting Intraocular Lens with Butterfly-Shaped Central Area Implanted in a Large Angle Kappa Patient: A Case Report

by
Camille Bosc
1,
Sandra Delaunay
1,
Anne Barrucand
1 and
Irene Martínez-Alberquilla
2,3,*
1
Institut Ophtalmologique de l’Ouest Jules Verne, 44300 Nantes, France
2
Optometry and Vision Department, Faculty of Optics and Optometry, Universidad Complutense de Madrid, C/Arcos de Jalón 118, 28037 Madrid, Spain
3
Clinical and Experimental Eye Research Group, Faculty of Optics and Optometry, Universidad Complutense de Madrid, C/Arcos de Jalón 118, 28037 Madrid, Spain
*
Author to whom correspondence should be addressed.
J. Clin. Transl. Ophthalmol. 2025, 3(3), 18; https://doi.org/10.3390/jcto3030018
Submission received: 5 June 2025 / Revised: 1 August 2025 / Accepted: 8 September 2025 / Published: 11 September 2025

Abstract

Background: Intraocular lens (IOL) alignment is crucial for optimal performance in presbyopia-correcting designs. The aim was to report a case of a patient with a high angle kappa implanted with the continuous transitional focus (CTF) Precizon Prebyopic NVA IOL. Case presentation: A 51-year-old patient presenting large angle kappa values (0.6/0.8 mm) was implanted with the Precizon Prebyopic NVA IOL and followed-up 1 and 10 months post-surgery. This IOL is designed with a butterfly-shaped central area that allows the orientation of the lens so that the visual axis passes through the wider diameter of the optic zone. Postoperative refraction was −0.25D of cyl at 80° for the right eye and +0.25D −0.50D cyl at 170°. Corrected distance visual acuity (CDVA) at the last visit was −0.1 logMAR monocularly and −0.2 logMAR binocularly. Binocular uncorrected distance (UDVA), intermediate (UIVA) and near visual acuities (UNVA) were −0.1, 0.1 and 0.1 logMAR, respectively. The corrected binocular defocus curve exhibited outstanding vision at the 0.00D defocus level and showed a continuous range of functional vision from distance to near. Overall excellent satisfaction was reported, along with low levels of photopic phenomena. Conclusions: Precizon Presbyopic NVA IOL provided satisfactory vision and low levels of photic phenomena in a high angle kappa patient who would potentially be excluded from presbyopia-correcting IOL implantation.

1. Background

Lens alignment is crucial in intraocular lens (IOL) implantation. IOL decentration is known to affect the optical performance of monofocal designs, even more so in the case of presbyopia-correcting IOLs [1]. One of the anatomical factors that can significantly influence IOL performance in general, and presbyopia-correcting IOL performance in particular, is the natural misalignments of the eye.
Typically, the cornea, pupil, lens and fovea are not in perfect alignment. Because of these misalignments, light passing from an object through the cornea and pupil does not pass through the geometric center of the eye’s lens. The difference between the pupillary axis and the visual axis (Figure 1I) is commonly known as either angle kappa (angular distance) or chord µ (linear distance). These two terms are often used interchangeably in the context of IOLs.
Because presbyopia-correcting lenses have more complex geometries, they are more sensitive to misalignments. The use of multiple zones creates sharp interfaces between the different zones that can lead to an abrupt change in light diffraction at the junction sites, causing glare and/or other unwanted optical effects [2,3]. Thus, this natural misalignment might affect postoperative visual performance, even more so in cases with preoperative angle kappa values above average, who have traditionally been considered poor candidates for presbyopia-correcting IOL implantation.
Some authors have evaluated the influence of angle kappa on visual, refractive and symptomatology outcomes after presbyopia-correcting IOL implantation [4,5,6,7,8,9,10,11,12,13]. Considering the published literature, there is some controversy regarding these correlations. Some studies support that preoperative angle kappa is a factor influencing postoperative performance after IOL implantation [4,5,6,7,8]. On the other hand, some studies claimed the opposite, that no correlation can be stated [9,10,11,12,13]. However, all studies share an important limitation, that the sample included limited ranges of angle kappa, with a lack of substantially high values to show a difference, as previously discussed by some authors [9,10]. Given that normal values range below 0.42 mm [14] and that critical values are speculated to be around 0.5–0.6 mm [15], it would be of great interest to evaluate the clinical performance of presbyopia-correcting IOLs in high angle kappa patients.
This case reports a large angle kappa patient implanted with the new presbyopia-correcting Precizon Presbyopic NVA Toric IOL (Ophtec BV, Groningen, Netherlands). This IOL is designed with a butterfly-shaped central area that allows the orientation of the lens so that the visual axis passes through the wider diameter of the optic zone thus avoiding the transition edge. To the best of the authors’ knowledge, this is the first report of a high angle kappa patient implanted with this IOL design.

2. Case Presentation

A 51-year-old man was referred to the Jules Verne Clinic (Nantes, France) for cataract extraction and IOL implantation in both eyes. The patient sought complete spectacle independence after surgery. Written consent for the publication of this case was obtained from the patient.
The patient was followed up at 1 month and 10 months postoperatively. Table 1 summarises all preoperative and postoperative data, along with patient-reported satisfaction after IOL implantation. Preoperative corrected distance visual acuity (CDVA) was 0.0 logMAR in both eyes. The right eye presented a sphere of +6.0D, cylinder of −1.5D and axis of 20°, whereas the left eye presented a sphere of +7.75D, cylinder of −3.5D and axis of 160°. No contraindications to IOL implantation were found after a thorough ocular examination. The particularity of this patient was his high preoperative angle kappa values of 0.6 mm at 194° for the right eye and 0.8 mm at 349° for the left eye. This anatomical feature is particularly important in the context of IOL selection, as a large angle kappa can influence postoperative visual quality, especially with presbyopia-correcting designs.
The selected IOL design was the Precizon Presbyopic NVA Toric lens (Ophtec BV, Netherlands), which was implanted in both eyes. The formula used for IOL power calculation was the Barret formula, with an intended IOL position of 97° and 61° for the right and left eye, respectively.
This presbyopia-correcting IOL presents an aspherical segmented refractive optic divided into three concentric sectors with 11 segments (Figure 1II). The smooth transition of power between segments creates a continuous transitional focus (CTF) optic [16,17]. CTF technology provides a smooth transition of focus from far to near distances, reducing visual disturbances by avoiding distinct focal zones. Additionally, the unique feature of Precizon Prebyopic NVA is its far-distance butterfly-shaped central area of 1.4 mm × 2.6 mm. Theoretically, for angle kappa with visual axis decentration up to 0.7 mm, the visual axis passes through the smooth central part of the lens regardless of IOL orientation. On the other hand, for large angle kappa patients, the IOL can be oriented so that the visual axis passes through the wider part of the central segment, which can then accommodate a decentration of up to 1.3 mm at the extreme (Figure 1III). In this way, it should be expected that large values of angle kappa and lens decentrations would be better tolerated compared to other designs, potentially minimizing photic phenomena.
After implantation, follow-up visits were at 1 month and 10 months (last visit). The postoperative IOL position was 96° and 60°, with a difference of 1° from the intended position. The lens position was captured with the anterior segment optical coherence tomography (AS-OCT) CASIA2 (Tomey Corporation, Nagoya, Japan), as shown in Figure 2A,B. Postoperative angle kappa values were 0.6 mm for the right eye and 0.7 mm for the left eye at the last visit. Corneal ocular aberrations were measured by Sirius topography (CSO, Firenze, Italy) for a 5 mm pupil diameter (Table 1). Spherical aberration, coma and higher order aberration (HOA) root mean square (RMS) decreased after implantation, whereas trefoil was slightly higher at the last visit.
Postoperative refraction at the last visit was −0.25D of cylinder at 80° for the right eye and +0.25D sphere −0.50D cylinder at 170°. Moreover, visual acuities at various distances were evaluated (Table 1). Corrected distance visual acuity (CDVA) at the last visit was −0.1 logMAR monocular and binocularly. Binocular uncorrected distance visual acuity (UDVA) reached −0.1 logMAR at the last visit. Binocular uncorrected intermediate (UIVA) and near visual acuity (UNVA) were both 0.1 logMAR, with a binocular corrected near visual acuity (CNVA) of −0.2 logMAR. Figure 2C shows the corrected binocular defocus curve at the last visit, exhibiting outstanding vision at the 0.00D defocus level and showing a continuous range of functional vision from distance to near.
Additionally, the patient completed a custom set of questions to evaluate satisfaction at the last visit. Frequency of symptoms (never/rarely/occasionally/frequently/always), intensity (none/mild/moderate/severe/extreme) and the final level of patient satisfaction (very dissatisfied/dissatisfied/neutral/satisfied/very satisfied) were assessed. The results are presented in Table 1, with an overall excellent satisfaction. No dysphotopic phenomena, such as glare, haloes, reduced contrast sensitivity or reduced quality of vision at night were experienced by the patient. Spectacles were only needed occasionally to do detailed work (such as reading a label) and not for prolonged visual tasks. The patient reported complete satisfaction with the implanted IOLs.

3. Discussion and Conclusions

Several factors are known to affect visual performance after IOL implantation. Among those factors, the role of ocular axes has been studied, but evidence regarding this matter remains unclear. Patients with large angle kappa values have been traditionally considered poor candidates for presbyopia-correcting IOL implantation due to a potentially higher risk of experiencing postoperative visual disturbances. Nevertheless, presbyopia-correcting IOLs have advanced over the past decade to provide better outcomes and optimal visual quality after cataract extraction or refractive lens exchange surgery. Thus, it is important to assess the visual performance of this specific population after IOL implantation.
Some authors reported an influence of angle kappa on postoperative outcomes [4,5,6,7,8]. A positive significant correlation was found between preoperative angle kappa and postoperative haloes and glare [4,5], decreased visual quality [6,8] and narrower depth of focus [7]. However, there is also significant evidence showing no clinically meaningful or predictable correlation between angle kappa and visual performance after IOL implantation [9,10,11,12,13]. Nevertheless, it is important to note that these studies were performed in patients with values of angle kappa within a normal range, which might be a potential reason why no effect on IOL performance was observed.
Wallerstein et al. [18] did perform a large-scale analysis of the influence of preoperative angle kappa on multifocal IOL outcomes in eyes with a mean value of 0.64 ± 0.27 mm. Their findings suggested no clinically meaningful relationship between this variable and postoperative visual acuity, refraction and patient satisfaction. However, it is worth highlighting that they included two different multifocal IOL designs (the AcrySof IQ PanOptix Trifocal IOL and the FineVision Trifocal IOL), which makes it difficult to isolate the effect of a specific design. Thus, different lens designs will have varying levels of tolerance to high kappa angle values, making it essential to assess new lenses as they are introduced to the market.
The present case report describes a patient with larger angle kappa values according to the literature [14,15], who initially would represent a challenge for presbyopia-correcting IOL implantation. The patient was implanted with the Precizon Presbyopic NVA IOL. This design offers a butterfly-shaped central area that can be oriented so that the visual axis passes through the wider part of the central segment. Additionally, given that the final IOL location was found to be the factor affecting postoperative photic phenomena [9], both the axis of the cylinder and the angle kappa of the patient were coincident, thus allowing the IOL to be oriented so that the visual axis fell within the larger diameter of the central area. Hence, large preoperative angle kappa values would theoretically be better tolerated.
This design has been previously evaluated by both optical bench and clinical analysis. The outcomes revealed comparable optical performance to a standard trifocal IOL [19] and satisfactory visual acuity at far, intermediate and near distances [16,20]. Additionally, this IOL design was evaluated in a multicentre European clinical trial (Clinical Trial NCT02409771) with 60 patients who were followed up at 3 months [21]. The outcomes showed great visual performance and low haloes and glare perception rates. Moreover, other investigators evaluated this IOL in patients with low values of angle kappa (<0.4 mm) and obtained satisfactory results in terms of wavefront aberrations, PSF Strehl ratio and refractive outcomes, although they showed a significantly poorer retinal image quality compared to other designs [22]. Thus, it was of great interest to evaluate this IOL design in a large angle kappa patient (0.6 and 0.8 mm).
The results revealed good visual performance along with excellent patient-reported satisfaction. Both objective and subjective measurements meet the needs and visual expectations after presbyopia-correcting IOL implantation. The defocus curve showed a continuous range of functional vision from distance to near, along with minimal levels of associated photic phenomena, as previously reported in a case series implanted with this IOL design [16]. Additionally, the postoperative reduction in spherical aberration, coma and RMS HOA, associated with better image quality, likely contributed to the patient’s positive visual outcomes and high level of satisfaction.
It also should be noted the inherent limitations of a case report, such as the potential for selection bias and the lack of control groups, which do not allow for generalization. Although limited to a single case, this report highlights the potential of Precizon Presbyopic NVA IOL as an option for patients with high angle kappa. These findings may help in future clinical decision-making. Future research is needed to confirm these outcomes through larger prospective cohorts or randomized controlled trials.
In conclusion, Precizon Presbyopic NVA IOL provided satisfactory vision and low levels of photic phenomena in a high angle kappa patient who would potentially be excluded from presbyopia-correcting IOL implantation.

Author Contributions

C.B.: performed the surgery, conceptualization and study design, supervision, final approval; S.D.: data collection, literature review, final approval; A.B.: data collection, literature review. final approval; I.M.-A.: data analysis and interpretation, manuscript writing, literature review, final approval. All authors have read and agreed to the published version of the manuscript.

Funding

Ophtec BV provided funding for the publication of this article. The funder had no role in the design, conduct, analysis, or reporting of the study.

Informed Consent Statement

Written informed consent for the publication of this case was obtained from the patient.

Data Availability Statement

All data generated or analysed during this study are included in this article.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

AS-OCTanterior segment optical coherence tomography
CDVAcorrected distance visual acuity
CTFcontinuous transitional focus
HOAhigher order aberration
IOLintraocular lens
logMARlogarithm of the minimum angle of resolution
RMSroot mean square
UDVAuncorrected distance visual acuity
UIVAuncorrected intermediate visual acuity
UNVAuncorrected near visual acuity

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Figure 1. (I) Angle kappa representation, defined as the difference between the pupillary and the visual axis. (II) General overview and segment distribution of the Precizon Presbyopia NVA. (III-A) Real image of the angle kappa. (III-B) Representation of Precizon Presbyopia NVA implanted so the visual axis does not pass through the optic zone. (III-C) Reorientation of the lens to match up the visual axis and the wider diameter of the optic zone.
Figure 1. (I) Angle kappa representation, defined as the difference between the pupillary and the visual axis. (II) General overview and segment distribution of the Precizon Presbyopia NVA. (III-A) Real image of the angle kappa. (III-B) Representation of Precizon Presbyopia NVA implanted so the visual axis does not pass through the optic zone. (III-C) Reorientation of the lens to match up the visual axis and the wider diameter of the optic zone.
Jcto 03 00018 g001
Figure 2. Lens analysis report automatically calculated with the CASIA2 AS-OCT, showing IOL position, tilt and decentration of the right (A) and left (B) eyes. The red dot represents the center of the IOL, the orange arrows indicate the measurement of decentration relative to the reference axis, and the green curved lines outline the anterior and posterior surfaces of the IOL used for tilt and decentration calculations. Binocular defocus curve for the continuous transitional focus Precizon Presbyopic NVA intraocular lens (C).
Figure 2. Lens analysis report automatically calculated with the CASIA2 AS-OCT, showing IOL position, tilt and decentration of the right (A) and left (B) eyes. The red dot represents the center of the IOL, the orange arrows indicate the measurement of decentration relative to the reference axis, and the green curved lines outline the anterior and posterior surfaces of the IOL used for tilt and decentration calculations. Binocular defocus curve for the continuous transitional focus Precizon Presbyopic NVA intraocular lens (C).
Jcto 03 00018 g002
Table 1. Preoperative and postoperative data and satisfaction questionnaire.
Table 1. Preoperative and postoperative data and satisfaction questionnaire.
Preoperative DataODOS
Refractive sphere (D)+6.0+7.75
Refractive cylinder (D) and axis−1.50 at 20°−3.50 at 160°
Monocular CDVA (logMAR)0.00.0
K1 (D)39.2938.72
K2 (D)40.5941.25
ACD (mm)3.103.11
AL (mm)23.2022.86
Angle kappa (mm)0.60.8
Photopic pupil diameter (mm)2.722.33
Mesopic pupil diameter (mm)2.983.33
Scotopic pupil diameter (mm)4.614.58
Spherical aberration (µm)0.260.25
Coma (µm)0.290.36
Trefoil (µm)0.100.10
RMS HOA (µm)0.430.46
Postoperative data (last visit)ODOS
Refractive sphere (D)0.0+0.25
Refractive cylinder (D) and axis−0.25 at 80°−0.50 at 170°
Monocular/binocular CDVA (logMAR)−0.1/−0.1−0.1/−0.1
Monocular/binocular UDVA (logMAR)−0.1/−0.10/−0.1
Monocular/binocular UIVA (logMAR)0.2/0.10.3/0.1
Monocular/binocular UNVA (logMAR)0.3/0.10.3/0.1
Monocular/binocular CNVA (logMAR)0/−0.20/−0.2
Spherical aberration (µm)0.080.07
Coma (µm)0.200.20
Trefoil (µm)0.150.17
RMS HOA (µm)0.280.29
Satisfaction questionnaire
ItemAnswer
Since you have had your implants, have you been subject to glare?Never
Do you experience haloes?Never
Are you bothered by the quality of your vision at night?Never
Do you see contrasts less well since you had implants?No
Do you observe a duplication of images?Never
Do you notice fluctuations in your vision?Occasionally
Can you quantify the discomfort caused by these fluctuations?Mild
Do you need spectacles occasionally? (e.g., to read a price/a label)Occasionally
Do you need glasses for prolonged visual effort? (e.g., reading a book, watching television)No
How satisfied are you with your vision since surgery?Very satisfied
ACD: anterior chamber depth; AL: axial length; HOA: higher order aberration; K1: flat keratometry; K2: steep keratometry; OD: right eye; OS: left eye; RMS: root mean square.
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MDPI and ACS Style

Bosc, C.; Delaunay, S.; Barrucand, A.; Martínez-Alberquilla, I. Presbyopia-Correcting Intraocular Lens with Butterfly-Shaped Central Area Implanted in a Large Angle Kappa Patient: A Case Report. J. Clin. Transl. Ophthalmol. 2025, 3, 18. https://doi.org/10.3390/jcto3030018

AMA Style

Bosc C, Delaunay S, Barrucand A, Martínez-Alberquilla I. Presbyopia-Correcting Intraocular Lens with Butterfly-Shaped Central Area Implanted in a Large Angle Kappa Patient: A Case Report. Journal of Clinical & Translational Ophthalmology. 2025; 3(3):18. https://doi.org/10.3390/jcto3030018

Chicago/Turabian Style

Bosc, Camille, Sandra Delaunay, Anne Barrucand, and Irene Martínez-Alberquilla. 2025. "Presbyopia-Correcting Intraocular Lens with Butterfly-Shaped Central Area Implanted in a Large Angle Kappa Patient: A Case Report" Journal of Clinical & Translational Ophthalmology 3, no. 3: 18. https://doi.org/10.3390/jcto3030018

APA Style

Bosc, C., Delaunay, S., Barrucand, A., & Martínez-Alberquilla, I. (2025). Presbyopia-Correcting Intraocular Lens with Butterfly-Shaped Central Area Implanted in a Large Angle Kappa Patient: A Case Report. Journal of Clinical & Translational Ophthalmology, 3(3), 18. https://doi.org/10.3390/jcto3030018

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