March 2018


Current and future IOL choices
Where we stand with MFIOLs

by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer

Source: Alcon

Watch Dr. Yeu align a multifocal IOL to the visual axis on EWAR


The latest models of MFIOLs bring patients closer to a full range of vision with fewer photic phenomena

The aim and challenge of multifocal intraocular lenses (MFIOL) is to provide clear vision to patients for a full range of distances, from far to near. Physicians want to provide patients with the best possible vision, suited to their preferences and lifestyle, without compromising all that much on any one end of the spectrum. The evolution of multifocal lenses is ongoing and always improving, so it is important to keep abreast of what is new and how experienced surgeons are incorporating the latest devices into their practice. EyeWorld spoke with Tal Raviv, MD, associate clinical professor of ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine, New York, and Elizabeth Yeu, MD, Virginia Eye Consultants, Norfolk, Virginia, about which multifocal lenses they choose and why.

Who are MFIOLs best suited for?

The current generation of multifocal IOLs, particularly the lower add versions, as well as the extended depth of focus (EDOF) IOLs, provides consistently higher quality vision than their predecessors. Toric multifocal and EDOF IOLs have expanded the inclusion criteria for whom physicians are able to offer presbyopia correction to, so more than ever, physicians have excellent choices to offer patients a fuller range of vision. Still, multifocal IOLs are not for everyone. According to Dr. Yeu, a good candidate needs to have some flexibility. “The right candidate for multifocal IOLs has healthy eyes and is motivated to have spectacle independence with realistic goals regarding potentially adjusting their arm span for the best vision. Someone interested in a MFIOL needs to understand that complete spectacle independence is unrealistic,” she said. “Patients can have controlled mild dry eye disease, at worst, and no retinal or macular pathology.”
Dr. Raviv agreed. “A healthy eye with good visual potential is the most important factor. Furthermore, the patient should understand the benefits and limitations of multifocal technology. I explain that 100% spectacle independence may be impossible as well as describe the possible photic phenomenon associated with multifocals. The old warning about avoiding the exacting or type A engineering patients I find inaccurate, as they are usually the most aware of the IOL limitations and the limits of physics and optics when it comes to splitting light energy. Sometimes the most laid back patient with the least understanding can be the most disappointed,” he said.
Photic phenomena are far less frequent and bothersome than with early MFIOL versions, however, they can still occur and warrant mention. Dr. Raviv takes a lot of time in counseling his patients and educating them about potential side effects before deciding if it is the right choice for them. “I discuss all the surgical options I deem appropriate to patients to meet their visual outcome desires, and that includes ways to manage the ‘absolute presbyopia’ that bilateral plano targeted monofocal IOLs induce. I explain that presbyopia correcting IOLs such as MFIOL and EDOF can greatly improve spectacle independence, but they may have night time artifacts around point sources of light, and I describe those. I also explain that today’s fourth and fifth generation multifocals have far less aberrations than the earlier versions that gave the technology a rough start,” he said.
Although patients need to be fully aware of the potential imperfections of MFIOL vision, current MFIOL options provide sophisticated solutions to individual visual needs, particularly when combined as needed. Blended vision and mini-monovision are IOL combinations that have been used successfully to maximize the visual range through the use of monofocal IOLs of different strengths. Blended vision, or monovision, describes focusing one eye for distance (usually the dominant eye) and the partner eye for near (the non-dominant eye), which allows patients a large degree of spectacle independence. Mini-monovision uses IOLs with a maximal difference of roughly 0.75 D, targeting the patient’s dominant eye for emmetropia while the non-dominant eye is set for –0.5 D or –0.75 D. The idea is that a greater difference between the two eyes may lead to reductions in contrast sensitivity, stereopsis and binocular visual acuity. Both options have the potential to cover the full range of vision and offer spectacle freedom.

IOL combinations

According to Dr. Raviv, MFIOL combinations can enhance vision and reduce visual side effects. He explained, “For me, every combination is on the table. Until recently, the most common combination was a pairing of either a ReSTOR [Alcon, Fort Worth, Texas] +2.5 with a ReSTOR +3.0, or toric multifocal [TMF] +3.25 with a TMF +2.75. With EDOF, I frequently start with that IOL and can add a low add TMF in the other eye, if more add is needed. Alternatively, I’ve mixed low add multifocals and EDOF with a monofocal IOL as well. I’ve found that mini-monovision with multifocals doesn’t work out well. The multifocals combined with EDOF IOLs have the least glare and halo when plano is achieved. That being said, the EDOF can tolerate micro-monovision of maybe –0.35 D in one eye, which can significantly enhance the binocular near vision. If I think more near is needed on the second eye, I typically will switch to a low add multifocal such as the TMF +3.25.”
For Dr. Yeu, not all multifocal combinations are suitable in the monovision or mini-monovision context. “Blended vision depends on a few factors, including near vision needs, height, and prior use of multifocal or monovision soft contact lens,” she said. “I have not used a 4.0 add multifocal IOL since the mid and low add versions became available. In order of frequency of presbyopia correcting IOLs, I use the EDOF IOLs bilaterally most frequently (plano dominant eye, –0.25 to –0.50 non-dominant eye). I always aim to place the lowest add possible in the dominant eye, as night vision symptoms are also lower. In the non-dominant eye, I am a fan of the mid add multifocal for those who have shorter arm spans or prefer to read books/magazines over e-readers or computers. I will do a mini-monovision approach when I use EDOF IOLs in both eyes, particularly for those who have been successful monovision patients in the past. I generally prefer a near emmetropia goal, mixing two add powers with multifocal IOLs or an EDOF dominant eye/mid add multifocal IOL in the non-dominant eye. I generally do not implement mini-monovision with multifocal IOLs, but I do mix add powers.”
When it comes to multifocal toric options, the rules for Dr. Yeu are becoming better understood. For corneal astigmatism that is with-the-rule more than 1.25 D or against-the-rule more than 0.75 D anteriorly, she uses toric MFIOL versions. “This is the best way to proceed in cases of corneal astigmatism,” she said. “I will regularly treat any astigmatism more than 0.2 D, and for lower amounts of corneal astigmatism, by doing femto astigmatic keratotomy at the time of surgery. I correct low levels of postop residual mixed astigmatism with manual limbal relaxing incisions [LRIs] in the office,” she said.
Dr. Raviv opts for toric multifocal IOLs in his patients with corneal astigmatism whenever feasible. “The published literature has proven the superiority of toric IOLs over LRIs with regard to accuracy, so I use a toric multifocal or toric EDOF whenever indicated,” he said. “Using what we know about posterior corneal astigmatism and new thinking about using 0.1 D for our surgically induced astigmatism in the Barrett Toric Calculator, I typically use a toric for against-the-rule astigmatism of greater than 0.4 D and for with-the-rule astigmatism greater than 1.5 D. I use femtosecond laser arcuate incisions for the rest.”

Models are physicians using

The evolution among MFIOLs has been a 20-year process of learning from mistakes and incorporating the latest technologies. Lower add versions of existent MFIOLs and the development of EDOF lenses now provide excellent options for implantation in cataract surgery. “In the U.S., FDA-approved multifocal IOLs include the ReSTOR multifocal IOL [Alcon], Tecnis Multifocal [Johnson & Johnson Vision, Santa Ana, California], and Tecnis Symfony EDOFs [Johnson & Johnson Vision],” Dr. Raviv said. “The AcrySof ReSTOR lens was the first diffractive IOL in the U.S. market in 2005 with a +4.0 add, followed by the ReSTOR +4.0 aspheric in 2007. More recently the ReSTOR +3.0 and +2.5 with ACTIVEFOCUS (also toric) were released and are currently the most commonly used ReSTOR IOLs. The Array refractive multifocal IOL [Johnson & Johnson Vision] was introduced back in 1997, followed by the ReZoom in 2005, and the Tecnis multifocal +4. In 2015, the low add Tecnis multifocals +2.75 and +3.25 adds were released, and in 2016 the EDOF Symfony (and toric version) became available. In 2018, most surgeons utilize the low add multifocals or EDOF IOLs, although the older +4.0 add multifocals are still available.”
Continuous product development and improvements over the years have built a great deal of confidence. Eye surgeons have an array of devices to choose from to personalize treatment and are able to come through on their promises. According to Dr. Yeu, “Presbyopia correcting IOLs, both low add MFIOLs and EDOF IOLs, provide an expanded range of vision, which in turn truly leads to greater spectacle independence. The technologies available now are the best versions out there. I trust them enough that I placed such technologies in my mother-in-law. You will still need reading glasses for very small print and will need extra light to read in dimly lit rooms. While the advanced optic provides great benefits to range of vision, no technology is without its side effects. At night, you will notice halos, glare, or streaks around point light sources, such as a street lamp, but it is distracting in less than 3% of patients. If a patient encounters this, I will stop after the first eye, and together we will figure out the best plan moving forward.”

Editors’ note: Dr. Raviv has financial interests with Johnson & Johnson Vision. Dr. Yeu has no financial interests related to her comments.

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