Premium IOLs in imperfect eyes

Cataract
December 2021

by Liz Hillman 
Editorial Co-Director

There is often discussion about the conditions an eye should meet in order to be successful with a premium, advanced technology IOL, but what about patients who desire independence from spectacles but who have less than perfect eyes? 

According to Eric Donnenfeld, MD, Stephen Scoper, MD, and Blake Williamson, MD, there are some conditions that are complete no-go’s for any presbyopia-correcting IOL, but with more options available in the presbyopia-correcting IOL market, some can be suitable even if the patient has existing ocular pathology. 

“At least once a day I have a patient who wants a multifocal implant and has something going on that makes it so they probably wouldn’t be a candidate,” Dr. Williamson said, adding, however, that diabetic eye disease or glaucoma, for example, aren’t discussion stoppers. “It’s a severity scale,” he said. 

Patients with severe glaucoma, macular edema, uveitic disease, neovascularization, history of retinal detachments, moderate to severe amblyopia, or double vision are not suitable candidates for a presbyopia-correcting IOL in Dr. Williamson’s practice. Patients who have mild to moderate glaucoma, mild, insignificant epiretinal membrane, stable macular degeneration, or those who’ve had previous refractive surgery are patients who, in the past, wouldn’t have been considered for presbyopia-correcting IOLs. Newer technology, such as extended depth of focus (EDOF) IOLs and the AcrySof IQ Vivity (Alcon), which is a non-diffractive EDOF IOL, can offer the opportunity for presbyopia correction. 

“The biggest thing that I do is make sure they understand the different eye diseases they have and how those diseases add up to give them what they perceive to be their vision.”

Blake Williamson, MD

“I would lean toward Vivity and Symfony [Johnson & Johnson Vision] in these eyes because we know these are EDOF technologies and do not have multiple focal points. They can be more forgiving in eyes that are less pristine. EDOF as a category is a better solution than bifocal or trifocal in eyes such as this that are borderline,” Dr. Williamson said. “The biggest thing that I do is make sure they understand the different eye diseases they have and how those diseases add up to give them what they perceive to be their vision.”

Dr. Scoper said with multifocal lenses, such as PanOptix (Alcon), which became the first trifocal approved in the U.S. in 2019, significant ocular pathology will negatively impact lens performance. He said he won’t offer this lens to patients who have any macular pathology, moderate epiretinal membrane, or significant ocular surface disease. If dry eye is mild, he’s open to treating the patient with artificial tears, plugs, Xiidra (lifitegrast, Novartis), or Restasis (cyclosporine, Allergan). If after that course of treatment the surface improves, he’s comfortable offering them the trifocal. 

“But I remind them that dry eye can be a chronic disease and they’re going to have to commit to treating the dry eyes indefinitely for this trifocal lens to work its best for the rest of their life,” Dr. Scoper said. 

If a patient has more significant ocular surface disease, like epithelial basement membrane dystrophy, Dr. Scoper said he’ll do a superficial lamellar keratectomy to get the surface smooth. If after recovery it looks good, he’ll offer a multifocal. 

If patients are not candidates for “any lens with a ring in it” due to ocular conditions, Dr. Scoper considers Vivity a viable option to provide some independence from glasses. 

“The Vivity lens has no rings in it, so it’s not light splitting. Because it’s not light splitting, we don’t have to be as concerned about ocular pathology,” he said, describing it as a great lens for patients who wanted a multifocal. He still considers significant ocular pathology a contraindication for Vivity in his practice. 

As Dr. Donnenfeld put it, the more near vision a presbyopia-correcting IOL provides, the more dysphotopsias can be expected. He said clinical trials showed that dysphotopsias were reduced with lower add multifocal IOLs. Lower add EDOF lenses also showed improvements in dysphotopsias. Further, Vivity and Eyhance (Johnson & Johnson Vision), he said, provide 0.75 D–0.5 D of near vision, but he’s seen dysphotopsias associated with these lenses similar to that of monofocal IOLs. 

“These two presbyopia-correcting IOLs are refractive rather than diffractive and have become my IOLs of choice for patients who traditionally I would not consider candidates for a [presbyopia-correcting] solution,” Dr. Donnenfeld said. “I have placed them in post-LASIK, epiretinal membrane, and mild glaucomatous eyes with good success. The important conversation to have with these patients is the correct expectation of how much near vision they will receive, and I often will offer these patients mini-monovision of 0.50–1.0 D in their non-dominant eye, which provides them with an effective 1.0–1.75 D of near.”

In general, Dr. Donnenfeld said presbyopia-correcting IOL technologies over time have smoothed transition zones for decreased dysphotopsias in all patients, but especially in those less than perfect eyes. 

“Any IOL that splits light is going to increase dysphotopsias. The next major breakthrough in presbyopia-correcting IOLs will be true accommodating IOLs. These lenses will be ideal for less than perfect eyes. For patients with corneal irregularities, the pinhole IOLs will improve dysphotopsias in less than perfect eyes.”

Dr. Donnenfeld said he’s found post-LASIK patients to be among the most interested in presbyopia-correcting solutions. However, some patients in this population can fit in the category of “imperfect eyes.” 

“Eyes with low hyperopia or myopia corrections with modern ablation profiles and centered ablations do well with all the presbyopia-correcting options,” Dr. Donnenfeld said. “Patients with older ablation profiles that were more oblate, decentered ablation, or higher refractive corrections are at greater risk of dysphotopsias with a presbyopia-correcting IOL but I have found do well with the low-add refractive EDOF Vivity and Eyhance lenses.”

Toric IOLs, which are still out of pocket and considered premium IOLs, are far more forgiving in the face of other ocular conditions. In fact, Dr. Scoper said the only contraindication to toric IOLs is not having astigmatism. Dr. Donnenfeld said that patients with treatable corneal disease, such as EBMD or pterygia, should have this addressed first, be given time to heal/stabilize, then have measurements and selection of a toric IOL.  

“The specific condition that is a contraindication to a toric IOL is patients who wear a gas permeable or scleral contact lens for visual rehabilitation. Placing a toric IOL will place the cylinder in the eye and not allow it to be treated with a rigid contact lens,” Dr. Donnenfeld said. 

Finally, Dr. Williamson emphasized the importance of having the right toolkit preoperatively and diagnostically in order to confidently recommend advanced technology lenses. He said topography, an updated biometer, and OCT of the macular are important. He also stressed the importance of refractive touch-ups when needed or IOL explants when necessary. 

“These lenses aren’t for everyone. … If you have good skills for doing a lens exchange, that’s an insurance policy. You know in the back of your mind that if everything else fails, … you have the tools to get that lens out,” he said. 


About the physicians

Eric Donnenfeld, MD
Ophthalmic Consultants of Long Island
Garden City, New York 

Stephen Scoper, MD
Virginia Eye Consultants
Norfolk, Virginia

Blake Williamson, MD
Williamson Eye
Baton Rouge, Louisiana

Relevant disclosures

Donnenfeld: Alcon, Johnson & Johnson Vision
Scoper: Alcon
Williamson: Johnson & Johnson Vision

Contact 

Donnenfeld: ericdonnenfeld@gmail.com
Scoper: sscoper@cvphealth.com
Williamson: blakewilliamson@weceye.com