March 2019


Refractive corrections
Premium IOLs continue to gain popularity

by Michelle Stephenson EyeWorld Contributing Writer

A low add multifocal IOL showing good centration and capsular overlap
Source: Michael Greenwood, MD

This trend is expected to continue when trifocals come to the U.S. market

Today’s patients desire and expect spectacle independence at near, intermediate, and distance, and premium IOLs are a popular choice for helping patients reach their vision goals. Until trifocals are available in the U.S., surgeons have several different methods for achieving spectacle independence at all three distances. Some surgeons mix and match multifocal and extended depth of focus lenses, while others choose monovision.
“In the U.S. market today, none of the currently available lenses hit all three of those distances perfectly,” said Russell Swan, MD, Bozeman, Montana. “I’ve found mixing and matching to be the most successful in this situation. We most commonly use an extended depth of focus lens in the dominant eye and a mid-add multifocal in the nondominant eye. If a patient has significant astigmatism, we look for a toric multifocal option. Our tendency would be to lean toward the ReSTOR with ACTIVEFOCUS [Alcon, Fort Worth, Texas] because it is available in a toric platform. For lesser degrees of astigmatism, we may still do an extended depth of focus Symfony lens [Johnson & Johnson Vision, Santa Ana, California] and a ZLB00 [Johnson & Johnson Vision] and make some astigmatic keratotomy or limbal relaxing incisions to get the lower degree of astigmatism. Our hope is that patients can do 90% to 95% of their activities without glasses.”
Michael Greenwood, MD, Fargo, North Dakota, uses the mix and match approach with low add multifocals. “In the dominant eye, I’ll use either an extended depth of focus lens or the lowest add power. Then in the nondominant eye, I’ll use a low add multifocal, but one that gives a little bit more near vision,” he said.
To achieve spectacle independence at all three distances, Michael Gordon, MD, San Diego, typically implants a ReSTOR 2.5 in the dominant eye and a ReSTOR 3.0 in the nondominant eye. “I have done the same with the ZK in the dominant eye and the ZL in the nondominant eye. I think that works well. Patients get the widest range of functional vision. I think the Symfony is a good lens, but I don’t use it much anymore because of glare issues,” he said.
Dr. Gordon has had success using modified monovision. He leaves the nondominant eye at –1 D to –1.25 D, while attempting plano in the dominant eye. “These patients are extremely happy. They don’t have the potential for the serious glare that you can get with multifocal or extended depth of focus lenses, and it’s a simple, safe, cost-effective way of minimizing dependence on glasses. Usually, all they need is a pair of glasses for fine print, and most people don’t mind that. I find that to be the safest approach,” he said.
Glare and halos are well-known issues with multifocal lenses. “All of the companies are working on optical solutions to that,” Dr. Gordon said. “I’m not sure they are ever going to eliminate that as a potential risk, but I know they’re working to minimize it. In individuals who are not looking for 100% glasses-free, I think that a modified monovision approach seems to work very well. You can look at the Q value of the patient and choose lenses that will increase negative spherical aberration in the nondominant eye. This will provide better depth of focus. By using different lenses, you can maximize the effect of modified monovision. I like this approach. It’s time-tested and cost-effective for the patient.”

Trifocals on the horizon

European surgeons have embraced trifocals and have had good success with them. They are expected to be approved for use in the U.S. soon. “Some people are leaning toward mixing and matching, but a lot of people are moving toward the PanOptix [Alcon], which will likely be the first one available here in the U.S.,” Dr. Swan said. “There is a lot of excitement because it allows us to hit all three of those distances in both eyes. I think some surgeons may still stick with mixing and matching because of concerns about glistening and other issues. I think probably 50% of that market may continue to do an extended depth of focus and a multifocal or bilateral extended depth of focus lenses. But I think trifocals will have a significant impact on the market.”
According to Dr. Greenwood, these lenses perform slightly better than mix and match at all three distances. “I think they will make a big impact when they become available in the U.S. but like any new technology, it will take a little bit of time to figure out some of the nuances and see where they fit best. My hunch is that they will work well at all three distances. It’ll be another nice thing for surgeons to have available for patients,” he said.

Light Adjustable Lens

The approval of the Light Adjustable Lens (RxSight, Aliso Viejo, California) offers another option for surgeons. “While it may be limited more toward distance-only vision or titrated monovision, patients being able to try out different types of monovision and decide exactly what they want is exciting,” Dr. Swan said. “We can show patients that we can improve their refractive result at 2 to 3 weeks after surgery by dialing and locking it in. They can then make a decision based on that level of improvement, if that’s something that they want to do.”

Patient expectations

Patient expectations can be managed both preoperatively and postoperatively to ensure patient satisfaction. Dr. Swan said that preoperatively, he makes sure patients know all of their options. “It’s also giving them realistic expectations that it’s a journey. They might have some glare and halos in the beginning that usually get better with time. Additionally, they may still need reading glasses for certain activities. If you frame it in a realistic manner, patients go in knowing that,” he said.
Additionally, Dr. Swan builds a laser fine-tune into the process. “One of the biggest issues that patients can have with these lenses is residual refractive error. If you’re not treating that residual refractive error, it’s going to be hard to meet patients’ expectations. At 3 months after refractive cataract surgery, we do an advanced visual analysis where we bring patients back, dilate their eyes, and look for posterior capsule opacification and check their refractive error. If they have significant refractive error and would benefit from a fine-tune, we’ll do a laser fine-tune and get them perfect,” he said.
“I think that by educating and screening patients well, we can pick up on problems on the front end and achieve success with the lenses that we have today,” Dr. Swan said.
Dr. Greenwood agreed. “We discuss that cataract surgery is a multi-step process. The first step is taking out the cataract and putting in a new lens. The second step is removing any capsule opacity, if any occurs during the healing phase. Then, if there’s any leftover refractive error, whether it’s sphere or cylinder, we need to fine-tune that, usually with LASIK or PRK. Once we’ve done all of that, it can take a little time for neural adaptation to occur. We let them know that it’s a journey, and there’s no magic bullet,” he said.
Dr. Greenwood thinks that the popularity of premium lenses will continue to increase as surgeons become more comfortable implanting them. “The technology has advanced so much just in the past 5 years that surgeons have more confidence in using these lenses because they perform a little bit better, especially with the advent of the low add multifocals and extended depth of focus lenses. As patients keep demanding more, surgeons keep pushing for more, and industry keeps developing more, I think more patients will ask for them. As the technology gets better, the margin of error gets a little more forgiving, and that’s why we’re able to have more success with these lenses in more patients,” he concluded.

Editors’ note: Dr. Gordon has financial interests with Alcon. Dr. Greenwood has financial interests with Alcon and Johnson & Johnson. Dr. Swan has financial interests with Alcon, Allergan (Dublin, Ireland), Equinox, and Glaukos (San Clementine, California).

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