New IOLs expand patient options, but selection remains crucial
IOL technology has made giant steps in recent years.
Through progressive, continuous improvement, many challenges have been met, drawbacks minimized and goals achieved, and the market today offers a wide variety of options to suit the needs of every patient. Still, the key to success with a lens implant lies in making the right choice.
“Not every IOL is good for every patient, and this is a very important point to understand. Having one lens that fits everybody would make our job easier but will never be possible because not only are needs and expectations different, but also every visual system and optical neuro setup are different, and therefore you have to customize your IOL choice to each patient,” OSN Cornea/External Disease Board Member Marjan Farid, MD, said.
Preoperative assessment requires three actions, according to Farid. First is talking to patients to understand who they are, what their lifestyles are and what they expect. Second is performing a thorough examination to detect any ocular pathology.
“I have added posterior segment OCT to my preoperative standard regimen because even subtle changes in the macula and optic nerve can make a big difference in terms of IOL choice. Something else I always do is a topography to look at the ocular surface because dry eye disease and even subtle irregularities in the cornea can degrade the patient’s optical quality,” she said.
The third important step is educating patients and involving them in the final decision-making.
“I don’t necessarily present all IOL options to every patient. In my mind, I narrow down the choice to two, and based on that, I make my recommendation. I have a detailed discussion with the patients so that they are part of the final decision,” Farid said. “It really helps them to be motivated and to buy into whatever choice they have made.”
Additionally, patients should be asked what they expect in terms of spectacle independence and what visual problems trouble them the most, according to Nicole R. Fram, MD.
“When I was in residency, we often assumed patients would like a distance aim. This was my strategy until I had a patient come back to me and say, ‘I’m miserable. I used to be able to read and can no longer read without glasses.’ It’s very important to understand what patients are currently able to do visually, as we want to meet expectations, not create a new problem,” she said.
Similarly, if patients are bothered by nighttime symptoms such as glare and halos, a diffractive IOL platform may worsen rather than alleviate these symptoms. Patients should understand this possibility and be counseled accordingly.
“With patients with a main complaint of nighttime glare and halos, an EDOF may be a better approach than a fully diffractive IOL. I ask patients if they are willing to wear reading glasses some of the time, and if they say yes, I feel much more comfortable with this strategy,” Fram said.
Multiple factors influence the decision-making process. Looking at eye health and corrective needs and asking patients questions about their lifestyle, habits, likes and dislikes help to filter out options and narrow down the choices.
“In our practice, we take the time to understand their lifestyle needs and day-to-day routines. I do not delegate this discussion as I like to really understand what the patient values. We then tailor the options to fit these needs. We do not generally present all IOL options and say, ‘Here is a menu, you pick.’ We try to guide them because they are coming to us for our experience and expertise,” Fram said.
Wide variety of options
The U.S. IOL market offers a wide variety of options to satisfy all needs. In recent years, the FDA has granted approval to two trifocal diffractive lenses, the AcrySof IQ PanOptix (Alcon) and the Tecnis Synergy (Johnson & Johnson Vision), and two extended depth of focus lenses, the Tecnis Symfony (Johnson & Johnson Vision) and the AcrySof Vivity (Alcon). All four are also available in toric designs. Another newcomer in the Tecnis platform is the Eyhance monofocal “plus” (Johnson & Johnson Vision), with slightly extended depth of focus and also available in a toric model. A unique new tool is the RxSight Light Adjustable Lens (LAL), which can be customized to the desired power after cataract surgery. Fairly close on the horizon are two more lenses: the IC-8 small aperture IOL (AcuFocus) and the accommodative Juvene (LensGen).
Trifocal IOLs have overcome the limitations of earlier-generation multifocals, filling in the gap of intermediate vision. They are for patients who “want it all” and are not concerned about the possibility of night-vision disturbances.
“I am a bit conservative in this respect because we still don’t know how to preoperatively predict who is going to have severe nighttime vision problems with the diffractive lenses. Most people, up to 97%, have little problems, but 3% report medium or severe glare and halo at night. So, we have to be very selective,” Fram said.
It is important to understand patient needs for nighttime driving and to be cautious with patients with a personality type that would potentially fixate on side effects, according to OSN Cornea/External Disease Section Editor Elizabeth Yeu, MD.
“People who tend to fixate on things, like a new watch on their wrist or the rim of new glasses or floaters, may not be good candidates for any diffractive lens,” she said.
For these patients, an EDOF implant such as the Vivity is a better choice, with the specification that the patient will need spectacles for near vision.
“Patients need to be told they will have good distance and will get computer vision, but absolutely for anything within elbow length, in the 32 cm to 40 cm region, they will require reading glasses. Making this clear is very important if they are looking into presbyopia-correcting options,” Yeu said.
It is important to consider that Synergy provides a long range of vision, with more near vision and a more continuous range rather than three distinct focal points.
“The Synergy is an interesting lens. J&J blended its technology of the Symfony EDOF lens with multifocal technology, so you have a continuous range of vision between those focal points. In addition, the Tecnis platform actively reverses chromatic aberration, so you get a sharper quality and excellent contrast,” Fram said.
The Symfony IOL is a diffractive EDOF that has been available for some time in the U.S. It provides “a nice 1.5 D range of continuous vision from distance to intermediate” but has the visual disturbance profile that is typical of diffractive IOLs, according to Farid. Vivity, on the other hand, has a nondiffractive, wavefront-shaping optic design that meets the goals of the EDOF category and has a visual disturbance profile similar to a monofocal IOL.
“In my experience, the halo profile at night for the Vivity IOL is very tolerable. I find it helpful to explain that every IOL if plastic may result in some glare and halos at night. Diffractive IOLs give the most, a nondiffractive IOL such as the Vivity gives a small amount, and a standard monofocal will likely give the least,” Fram said.
“If patients want some increased depth of focus, have healthy eyes and don’t want halos or glare at night, maybe because they drive a lot, the Vivity works very well. They get good computer distance, and with both eyes they can often read their cell phone and even do some reading of books,” Douglas D. Koch, MD, said.
Patients with ocular comorbidities
Monofocal IOLs are still the most sensible option in patients with sight-threatening or sight-altering pathologies, such as glaucoma with field loss, macular degeneration and Fuchs’ dystrophy, according to Koch.
“In all of those cases, I tend to prefer monofocal IOLs. I might use a Symfony if I think that the prognosis is excellent for many years,” he said.
In patients with mild glaucoma, with minimal preperimetric nerve fiber layer thinning but no field loss, Yeu might consider a presbyopia-correcting lens combined with MIGS to minimize the use of topical medications.
“I want to maintain the ocular surface as healthy as possible, avoiding progressive dry eye disease,” she said.
Subtle ocular comorbidities such as a few drusen or mild to moderate dry eye may be compatible with an Eyhance, but also with a Vivity, in Yeu’s opinion.
In patients with well-controlled diabetes who wish to have more than just distance vision, an EDOF is a reasonable choice, according to Fram.
“It is important to monitor their overall health and to communicate with the retina specialist. If they have been stable for years, I do consider an EDOF. However, since contrast in this population matters, we want a lens with the best contrast sensitivity profile. The Tecnis platform has such a good track record with maintaining contrast that that is the place I would lean toward in this patient population,” she said.
For patients who have had prior refractive surgery, the choice is often a monofocal or toric monofocal IOL or a toric Eyhance, but a Vivity or even a trifocal could be used in selected cases, according to Yeu.
“Post-hyperopic patients have a lot of negative spherical aberration within the cornea, and I don’t want to add to that. Therefore, I usually implant a zero sphericity toric lens, like an enVista (Bausch + Lomb) or a spherical monofocal. However, depending on the K values, on how good the bed of ablation is, on how stable the patient’s vision has been and on how happy the patient was after LASIK, I might consider a Vivity. In a very selected group of post-myopic LASIK patients with perfectly centered and not too flat ablation beds, who had no glare after LASIK and are not fearful of potentially exchanging the lens but really want to have the full range of vision, I consider moving forward with a trifocal,” she said.
Koch often uses Symfony in post-LASIK patients.
“I like it in these patients. It provides the best quality of vision among all IOLs, EDOF and trifocal, and often leads to excellent vision in this population, probably because they already have a somewhat multifocal cornea. It has a large landing zone, so patients are more likely to get better uncorrected distance vision. Because I am a bit wary of the problems of glare at night, I start with the nondominant eye. If they have excessive glare, I put an Eyhance in the dominant eye,” he said.
The LAL is another good option for post-refractive surgery eyes, according to Koch.
“We have been the first academic center to use the LAL in the U.S. I have used it in post-RK and post-LASIK patients, particularly those who had monovision with LASIK. I am excited about the opportunity to offer them a precise correction by doing monovision. You generate a little extra negative spherical aberration in the IOL for the near eye, enhancing depth of focus,” he said.
“The LAL has been a big boost in our practice for IOL calculations in challenging eyes,” Fram said. “In post-LASIK and post-RK patients, the literature reports that we are hitting our target ±0.5 D 69% to 74% of the time. These post-refractive patients want it all. However, the current formulas cannot reliably meet these refractive expectations. This is why we would prefer a technology we can customize. With the Light Adjustable Lens, we are hitting our target in 93% of the cases post-LASIK at 6 months, which is unheard of, and in 83% post-RK, although it fluctuates during the day in RK patients. I also use this lens with mini-monovision in patients who may not qualify for a multifocal or EDOF and want more depth of focus.”
Toric versions and mix and match
The toric version of EDOF and diffractive lenses is an example of how industry listened and met the needs of surgeons and patients, according to Fram.
“They opened up presbyopia correction to surgeons who may have been apprehensive to take on a patient who wanted an EDOF or multifocal who had high astigmatism. It started with Tecnis low add multifocal and then expanded to Symfony, Vivity, PanOptix and Synergy — all of these lenses have toric options to correct astigmatism. We no longer need to do enhancements for residual uncorrected astigmatism and can perform surgery with a level of confidence and almost gratification,” she said.
“I use toric presbyopia-correcting or toric monofocal IOLs in 60% of my patients. They are fabulous. They make all the difference in the world,” Koch said.
Mixing and matching IOLs has become less common nowadays because patients tend to like the current IOLs well enough to want them implanted in both eyes, Koch said.
“I have done mix and match with trifocals and Vivity in patients who were not happy with one technology, but it is not usually my strategy. I think patients do better with the same lens or at least the same platform, but I have colleagues who have great success with it,” Fram said.
Yeu likes mixing and matching in patients who want the best of all words but are afraid of glare and starburst at night.
“I start with a PanOptix in the nondominant eye, and if they are a little concerned of that, I implant a Vivity in the other eye, and patients do very well. I have done the same in patients with subtle retinal pathology in one eye, like a peripheral [epiretinal membrane], but the other eye is totally healthy,” she said.
Expanding lens use
Overall, latest-generation IOLs have greatly expanded the use of premium technologies.
“I implant presbyopia-correcting lenses in about one in five patients now, and the numbers will continue to increase, particularly as we are waiting for the IC-8 small aperture IOL to be approved by the FDA. This implant will have an indication for presbyopia correction in patients who have up to 1.5 D of astigmatism and is also indicated for monovision,” Yeu said.
“When I started doing premium IOLs, I was implanting 10% to 20%, and now it has gone up to at least 50%, quite a high number for a tertiary referral center where we see a lot of pathology. Improved formulas, improved IOL technology and improved confidence have all played their part,” Farid said.
Fram said the PanOptix marked this transition in her office.
“It was with the Tecnis ZLB00 and ZKB00 (Johnson & Johnson Vision) that we started to understand that patients were satisfied with a focal point that was a little bit further out from near, and when the PanOptix came out, and then Vivity and Eyhance, they took us up to 60% presbyopia-correcting IOLs — a level that was never seen in the market, which was stuck at 5%. Our office was stuck at 15%, and then it jumped,” she said.
Koch said, however, that better IOLs and more savvy surgeons have not completely ruled out the chance that patients might end up unhappy, mainly because of visual disturbances and quality of vision.
“Despite the quality of these lenses, they just don’t work for some patients, and often it is someone you might least suspect. As a referral center, we take out or exchange a lens nearly every week,” he said.
What would surgeons choose for themselves?
Koch has direct experience with the Eyhance IOL, as he had it implanted in his eyes.
“I inherited my mother’s glaucoma, so I had to be cautious and wanted a high-quality monofocal with a little extended depth of focus. I am very happy with my choice. I can read on the computer and on my phone, and I can work in the office without glasses. And this with zero problems of glare,” he said.
For the same reason, Yeu would also choose an Eyhance, in the toric design, because she has a fair amount of astigmatism.
“There is a history of glaucoma in my family, and so I am concerned about contrast sensitivity and using any form of presbyopia correction for my future. So, I would want to optimize as much of the ability of a monofocal as possible, and I have seen excellent results with this IOL in my patients,” she said.
“I would want the best contrast and the ability to at least see my phone. So, I would probably choose an Eyhance, with just a touch of –0.75 D in the nondominant eye,” Fram said.
She would also happily choose a Vivity but is waiting for the company to change the lens material, which Alcon is in the process of doing.
Based on her lifestyle and her eye health, Farid would choose a Synergy.
“I want to enjoy a full range of vision with excellent contrast sensitivity and quality of vision,” she said.
- Alsetri H, et al. J Cataract Refract Surg. 2021;doi:10.1097/j.jcrs.0000000000000815.
- Arrigo A, et al. Graefes Arch Clin Exp Ophthalmol. 2021;doi:10.1007/s00417-021-05245-6.
- Kohnen T, et al. J Cataract Refract Surg. 2021;doi:10.1097/j.jcrs.0000000000000364.
- Kohnen T, et al. J Cataract Refract Surg. 2021;doi:10.1097/j.jcrs.0000000000000826.
- Lwowski C, et al. J Cataract Refract Surg. 2021;doi:10.1097/j.jcrs.0000000000000780.
- Masket S, et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2020.08.009.
- Modi S, et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2020.07.015.
- Moshirfar M, et al. J Refract Surg. 2020;doi:10.3928/1081597X-20201002-01.
- Rampat R, et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2020.09.026.
- Schallhorn JM. J Refract Surg. 2021;doi:10.3928/1081597X-20201111-02.
- Schmid R, et al. Graefes Arch Clin Exp Ophthalmol. 2021;doi:10.1007/s00417-021-05362-2.
- Tognetto D, et al. Graefes Arch Clin Exp Ophthalmol. 2021;doi:10.1007/s00417-021-05426-3.
- Yeu E et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2020.08.025.
- For more information:
- Marjan Farid, MD, can be reached at Gavin Herbert Eye Institute at the University of California, Irvine, 850 Health Sciences Road, Irvine, CA 92697; email: firstname.lastname@example.org.
- Nicole R. Fram, MD, can be reached at Advanced Vision Care, 2080 Century Park East, Suite 911, Los Angeles, CA 90067; email: email@example.com.
- Douglas D. Koch, MD, can be reached at Baylor College of Medicine, Department of Ophthalmology, 6565 Fannin, NC205, Houston, TX 77030; email: firstname.lastname@example.org.
- Elizabeth Yeu, MD, can be reached at Virginia Eye Consultants, 241 Corporate Blvd., Suite 210, Norfolk, VA 23502; email: email@example.com.
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