Article

CLINICAL: CORNEA

PREMIUM IOL PROFICIENCY

DO YOU HAVE IT? PATIENTS DEPEND ON YOUR KNOWLEDGE

AS OPTOMETRISTS, we are our cataract patient’s entry to care: We diagnose the condition, prepare them for surgery and oversee their post-op care. Preparing our patients for surgery includes performing a comprehensive exam (refraction, glare testing, dilation) and discussing the two types of cataract surgery and the IOL options relative to each patient. Regarding the latter, several recent notable advances have been made in the premium realm. To ensure patients are educated about all their choices and what we feel is best for them, we must stay up-to-date on these latest offerings.

Here, I discuss the premium IOLs available by category,

TORIC IOLS

These are ideal for patients who have 1.00D or more of corneal astigmatism, though patients with less than 1.00D of astigmatism may benefit from a toric IOL, as lenticular astigmatism can counteract corneal astigmatism, and more astigmatism can be unmasked after cataract surgery. (Obviously, accurate biometry and topography is critical to help surgeons decide the best course of action.)

Toric IOLs provide excellent outcomes and decreased dependence on spectacles and contact lenses for distance vision post surgery. Available on the market: AcrySof IQ Toric (Alcon) and the TECNIS Toric (AMO) and the TECNIS symfony (AMO).

PRESBYOPIA-CORRECTING IOLS

This category includes multifocal, accommodating and extended depth of focus (EDOF) IOLs.

To start, multifocal IOLs decrease the need for spectacle dependence on distance and near vision for these patients. Specifically, light is split into two separate focal points for distance and near. The splitting of light can make these IOLs contraindicated in patients who have optic nerve disorders, retinal issues and amblyopia, as these conditions limit vision. Also, caution should be used in patients who have other glare issues.

Designs are available in high add powers, providing close near points, and in low and mid add powers. The former are ideal for patients who do a lot of close near work, such as needlework. The second is ideal for those looking for overall functional vision. The latter provide a farther near point, enabling enhanced functional intermediate and near vision, making them ideal for patients who work on computers.

IOLs in the Pipeline

The following IOLs are currently in Phase 3 clinical trials in the U.S.

  • AcrySof IQ PanOptix Trifocal
  • FineVision IOL Trifocal
  • AcuFocus IC-8 IOL

Presbyopic “Type A” personality patients usually do better in lower add power designs because they have a lower number of diffractive rings, which results in less symptoms of glare and halos.

Some surgeons take a “blended” or “mix and match” approach when it comes to correcting presbyopia in cataract patients. This entails inserting a high or mid add power multifocal IOL in one eye for more near dominance and inserting a lower or mid add power multifocal IOL in the other eye for more distance and intermediate vision.

Similar to modified monovision, this technique offers visual customization based on the patient’s lifestyle visual demands. For example, patients who read at a further near point or work a lot at the computer have improved overall functional vision with less lost contrast sensitivity.

Patients who have high myopia tend to want to keep a close near point (high add powers), and most other patients do well with a low or mid add power. The multifocal designs available on the market: TECNIS +4.0,D +3.25D and +2.75D and the AcrySof IQ ReSTOR +4.0D, +3.0D and +2.5.D.

Overseeing post-op care: Cortex material limited the vision and caused chronic uveitis after cataract surgery. The residual cortex was removed with additional irrigation and aspiration.

Accommodating IOLs are monofocal IOLs that move and flex in the capsular bag and allow for good distance and intermediate vision, sans splitting light. They are ideal for patients who don’t want to risk experiencing glare and halos and prefer strong intermediate and distance vision with near vision not being as important.

Accommodating IOLs also work well for patients who don’t read at all or have a far out near point. Accommodating IOLs on the market: Crystalens AO (Bausch + Lomb) and Trulign Toric (Bausch + Lomb).

Finally, EDOF IOLs offer a great range of vision at distance, intermediate and near. Specifically, they provide dips in the defocus curve by creating an elongated focal point to increase the range of functional vision.

Since this is a new class of premium IOLs, the ideal patient is being determined. That said, EDOF IOLs provide good near, great intermediate and distance vision. The TECNIS Symfony (AMO) is the only EDOF IOL currently available.

KEEP THEM COMING BACK

When you take the time to educate cataract patients about the IOL choices relative to their prescription and personality type, they’ll return for your care because (A) you’ve shown you genuinely care about their visual outcome expectations and (B) you’ve given them the confidence to present to the surgeon with an informed decision. OM