Eyeworld

EW FEATURE 62 Refractive corrections • March 2019 AT A GLANCE • Premium IOL use is on the rise. • Patients need to understand that cataract surgery is a multi-step process. • Trifocal lenses perform slightly better than the mix and match of multifocals at all three distances. by Michelle Stephenson EyeWorld Contributing Writer 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 pow- er. 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 indepen- dence at all three distances, Michael Gordon, MD, San Diego, typically implants a ReSTOR 2.5 in the dom- inant 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 op- tical solutions to that," Dr. Gordon said. "I'm not sure they are ever go- ing 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 aberra- tion 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 This trend is expected to continue when trifocals come to the U.S. market T oday's patients desire and expect spectacle indepen- dence at near, intermediate, and distance, and premi- um 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 achiev- ing 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 ten- dency would be to lean toward the ReSTOR with ACTIVEFOCUS [Alcon, Fort Worth, Texas] because it is avail- able 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 keratot- omy or limbal relaxing incisions to get the lower degree of astigmatism. Our hope is that patients can do 90% to 95% of their activities with- out glasses." Michael Greenwood, MD, Fargo, North Dakota, uses the mix 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 signifi- cant 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 Adjust- able 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 man- aged both preoperatively and postoperatively to ensure patient satisfaction. Dr. Swan said that pre- operatively, 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 begin- ning that usually get better with time. Additionally, they may still need reading glasses for certain ac- tivities. If you frame it in a realistic manner, patients go in knowing that," he said. Premium IOLs continue to gain popularity A low add multifocal IOL showing good centration and capsular overlap Source: Michael Greenwood, MD

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