Refractive
December 2023

by Karolinne Rocha, MD, PhD
Refractive Editor

With the beginning of 2024 in sight, it’s the time of year for reflection. One clinical theme that comes up as I review my 2023 year of refractive surgery is combating dysfunctional lens syndrome (DLS). DLS describes the advancement of the aging lens in stages, from loss of accommodation to decreased contrast sensitivity to clinically significant cataract.¹

I’ve learned that with a more precise management of young presbyopic hyperopes, we can better serve these patients’ visual needs, specifically by introducing lens replacement as an earlier alternative to corneal procedures. This is a trend that I’ve noticed, and the literature points to some benefits: avoiding hyperprolate corneas and decentered ablations that generate negative spherical aberration and coma, thus decreasing presbyopia-correcting IOL options in the future, and improvement in narrow angles after lens surgery. Thanks to Yan et al.,² we know that lens removal is more efficient than a laser peripheral iridotomy in opening up the angle, specifically for hyperopes. I’ve seen this in my own patient (see Figure 1).

What’s more, post-hyperopic LASIK patients have a multifocal cornea. Due to its inherent shape, these patients have extended depth of focus, and thus, an aberration-free monofocal IOL could allow the patient to reach optimal visual acuity and limit the previously discussed issues over the patient’s lifetime.³

There’s so much more to learn from the contributing physicians in this issue of EyeWorld.

In “Expanding experience with the EVO ICL,” Arjan Hura, MD, Amy Lin, MD, and Gregory Parkhurst, MD, detail two patient populations who they have found are good candidates for the EVO ICL (STAAR Surgical): patients who are high myopes and those for whom LASIK or PRK are not options. The doctors shared that they have seen more interest in ICLs and have been discussing it as an option for a broader patient base. Additionally, Dr. Parkhurst specifically said that he has seen fewer spikes in IOP with the lens since its FDA approval.

Our colleagues also shared their experiences with patients in “Assessing IOL tilt and decentration,” specifically following cataract surgery. Susana Marcos, PhD, discusses how new devices that allow her to quantify the lens tilt and decentration have made it an easier, better diagnosis when it does occur. Brandon Ayres, MD, walks us through the steps that he takes to pair each patient with the best lens, specifically as some lenses are more forgiving than others regarding tilt and decentration.

Finally, in “Toric troubles: postop rotation,” Brandon Baartman, MD, David R. Hardten, MD, Bryan Lee, MD, and Dagny Zhu, MD, review steps for preventing and managing toric IOL rotation. From choosing the right lens for the patient and using up-to-date tools and calculators to how to rotate the lens and offering PRK or LASIK, the physicians do an excellent job of discussing options for this somewhat infrequent occurrence in toric IOL patients.

Consider what lessons you have learned this year. It’s an interesting exercise that may produce solid results to take into the new year.

References

1. Waring IV GO, Rocha KM. Characterization of the dysfunctional lens syndrome and a review of the literature. Curr Ophthal Reports. 2018;6:249–255.
2. Yan C, et al. Long-term effects of mild cataract extraction versus laser peripheral iridotomy on anterior chamber morphology in primary angle-closure suspect eyes. Br J Ophthalmol. 2023. Online ahead of print.
3. Rocha KM, et al. Static and dynamic factors associated with extended depth of focus in monofocal intraocular lenses. Am J Ophthalmol. 2020;216:271–282.