Cataract: Hot topics in ophthalmology
December 2022
by Liz Hillman
Editorial Co-Director
While the concept of monovision to enhance distance vision in the dominant eye and provide functional near vision in the non-dominant eye—the goal being to reduce dependence on spectacles and contact lenses—is not new, advances in IOL technologies are providing a more coordinated visual experience compared to prior monovision options.
In fact, Lance Kugler, MD, said there’s a shift in how the field is talking about monovision produced with IOLs at the time of cataract surgery.
“We’re moving toward the term ‘blended vision,’ which seems to be a more inclusive term than monovision,” he said. “With monovision, people think about wearing their contact lenses and a huge difference between the two eyes, and there is a negative connotation to that. Blended vision is more the eyes blending together. With some of these technologies that provide an extended depth of field, whether it’s the IC-8 Apthera IOL [AcuFocus] or different IOLs, you get a completely different experience than what someone might have with monovision contacts.”
What does ‘monovision’ look like in your practice?
Eric Donnenfeld, MD, said monovision is one of the most common treatments he uses for his cataract patients.
“I don’t do a full monovision; I do a micro-monovision of about 0.75–1 D, and that gives patients enough near that they are comfortable without having problems with distance. I like using the extended depth of focus [EDOF] lenses with monovision. I think that’s been the biggest breakthrough that we’ve had in our practice over the last several years, and I think mini-monovision with the added value of an EDOF lens has been a terrific advancement for our patients,” he said. “I like the Eyhance [Johnson & Johnson Vision], the RayOne EMV [Rayner], and Vivity [Alcon].”
Dr. Donnenfeld said he’ll usually use an EDOF in both eyes because the biggest risk of monovision is not hitting the distance target.
“The significant change in my practice has been that I no longer aim for the first myopic lens because I don’t want to leave anyone myopic in the dominant eye,” he said, explaining that he aims for the first plus lens, knowing that with the EDOF technology, even if the patient is +0.25–0.5, they’ll still see 20/20 at distance. “The IC-8 Apthera IOL is a pinhole IOL that can provide as much as 1.5 D of near vision without splitting light and maintaining 20/20 vision at distance. It’s ideal for post-refractive cornea patients who wish to be spectacle independent but are not good candidates for multifocal IOLs,” he said.
Source: Bryan Lee, MD, JD
Bryan Lee, MD, JD, said he achieves monovision in three ways: with a monofocal or monofocal toric, with the Vivity IOL, or with the Light Adjustable Lens (LAL, RxSight).
“I explain to [patients] that with the monofocal, you have two points that are clear, while the Vivity provides more range for each eye. The Light Adjustable Lens is the most accurate both for distance and for near, which is the harder eye to target,” he said.
Dr. Kugler said he also uses the LAL as his “go-to option” for monovision in patients who have had previous corneal refractive surgery. He said some of his blended vision patients receive a monofocal lens in the dominant eye and an EDOF or trifocal in the non-dominant eye.
“It’s a different kind of blended vision but it has a very high satisfaction rate in the right patients,” he said.
Dr. Kugler added that the IC-8 Apthera IOL will be useful in some monovision cases.
“If you’ve got a case where you want to avoid multifocality, but you want to give them a nice range of vision, it allows you to do that without the downsides of multifocality and without the limited range of vision that a fixed monofocal has. I think it fills an interesting niche,” Dr. Kugler said.
Assessing candidates
Dr. Donnenfeld said he employs monovision because any residual dysphotopsias that might occur can be solved with a pair of glasses and because it preserves distance vision. Trifocals, Dr. Donnenfeld continued, come with a little bit of distance vision compromise.
Source: Eric Donnenfeld, MD
“For patients who say they want to reduce their dependence on glasses and wear them infrequently, I want to be able to not have dysphotopsias, or if they’re not a great candidate for a trifocal … they can still be a good candidate for monovision,” Dr. Donnenfeld said.
Dr. Lee said he will consider monovision for a patient who has had vision corrected with this technique before and was happy with it.
“If a patient likes monovision, I would continue it and never switch to a trifocal. At the same time, the only way I would do monovision in someone with no prior experience but too much cataract for a monovision contact lens trial would be with the Light Adjustable Lens,” he said.
In general, Dr. Lee said that monovision can give better reading vision than a presbyopia-correcting IOL in both eyes. He also said that some patients who are not good candidates for a trifocal IOL, due to ocular comorbidities, can still be a candidate for monovision.
“Monovision avoids the halos associated with a diffractive IOL, and you can optimize night vision with a pair of glasses,” he said.
Some ocular comorbidities rule out monovision/blended vision as a viable option. These, according to Dr. Donnenfeld, include patients with amblyopia, macular degeneration, or other pathology in one eye to the extent where the vision has deteriorated, and the patient thus would not be happy with vision in that eye for near or far. Dr. Donnenfeld said he’ll also steer away from monovision in patients who are athletes and need depth of focus. Golfers, for example, can’t see the greens well with monovision, he said.
Dr. Donnenfeld doesn’t specifically trial monovision with contact lenses in patients who are cataract surgery candidates because they won’t get a true experience due to the cataract.
Dr. Kugler also cautioned against monovision/blended vision in eyes that are compromised in any way because “each eye has to be able to carry the weight of a certain distance by itself.” Additional examples include eyes with strabismus or keratoconus.
“I think you need to be very careful with blended vision because you’re asking each eye to function independently. If the eye is not capable of doing that, it’s probably not going to be a successful result,” he said. Dr. Kugler also said there are patients who simply cannot adapt to monovision. “There are patients who I think aren’t great candidates for blended vision but they are good candidates for bilateral multifocals. That’s absolutely on the list of options.”
ARTICLE SIDEBAR
IC-8 Apthera makes U.S. debut
The IC-8 Apthera IOL was approved by the FDA in July 2022. When EyeWorld spoke with Dr. Donnenfeld, Dr. Kugler, and Dr. Lee, it was not yet available commercially in the U.S., but they shared their insights on how this IOL would benefit patients with EDOF capabilities as well as some therapeutic uses.
Dr. Donnenfeld noted that the IC-8 Apthera was approved as an EDOF IOL.
“It was approved on virgin eyes that had good visual potential, and the patients did very well in the FDA trials. The nice part about the lens is it doesn’t split light. It’s a true EDOF lens. It gives dramatically more near than the Vivity, Eyhance, and RayOne EMV, so it gives patients that extra near that they want, and it doesn’t compromise distance. In fact, it very commonly improves distance. I think there is a significant opportunity to add this lens to your portfolio. I think it’s a good consideration for people who want monovision. You will get more reading from this lens than you will from the other EDOF lenses that we generally think about.”
The biggest opportunity, however, that he and other physicians consider for the IC-8 Apthera is in irregular corneas.
“I think this will be one of the more important new technologies that we add to our armamentarium for the most challenging patients in our practice. This lens is going to solve problems that previously were unsolvable for many patients,” Dr. Donnenfeld said.
Dr. Lee, who participated in the clinical trials for the IC-8 Apthera, said that the lens will be helpful for monovision, even when set for –0.75 to –1 D, but he is also looking forward to its use for irregular corneas.
“Additionally, the IC-8 Apthera will allow for continued RGP wear for patients, unlike a toric IOL or Light Adjustable Lens. Irregular corneas will be an off-label use because those patients were excluded from the trial, so I expect that surgeons will start using it and see how their patients do, just as with any new technology. However, it will be important for us to have reasonable expectations for the IOL because it would be unfair to expect miraculous results in abnormal, highly aberrated eyes,” Dr. Lee said.
Dr. Kugler, also an investigator in the IC-8 Apthera trial, said this lens might be attractive for surgeons who have been hesitant to offer multifocals due to the management or enhancement needed for them.
“For cataract surgeons who don’t have access or capability to enhance those patients, multifocals are very difficult to use successfully. You tend to get frustrated with them and stop offering them. I think that’s a huge complexity to multifocal IOLs, whereas the IC-8 Apthera is very forgiving. The enhancement rate is not zero but it’s lower than what you would have with a multifocal,” Dr. Kugler said.
He noted that while he doesn’t have experience with post-refractive eyes and the IC-8 Apthera, if you look at the work of international ophthalmologists, the IC-8 Apthera is a common solution for post-refractive eyes.
“I do wonder how it’s going to fit into what we’re doing for post-refractive IOLs. The Light Adjustable Lens is great, but it also has its downsides,” Dr. Kugler said, adding that looking at international experience, he thinks it will be an especially good option for post-RK eyes.
About the physicians
Eric Donnenfeld, MD
Ophthalmic Consultants of Long Island
Garden City, New York
Lance Kugler, MD
Kugler Vision
Omaha, Nebraska
Bryan Lee, MD, JD
Altos Eye Physicians
Los Altos, California
Relevant disclosures
Donnenfeld: AcuFocus, Alcon, Johnson & Johnson Vision, Rayner
Kugler: None
Lee: None
Contact
Donnenfeld: ericdonnenfeld@gmail.com
Kugler: lkugler@kuglervision.com
Lee: bryan@bryanlee.pro
