Eyeworld

I INNOVATIONS IN LENSES N FOCUS 94 | EYEWORLD | APRIL 2019 by Chiles Aedam R. Samaniego EyeWorld Contributing Writer Contact information Chang: dchang@empireeyeandlaser.com Loden: lodenmd@lodenvision.com Wong: shannon@austineye.com Yeu: eyeulin@gmail.com Second are eyes with sensory complications such as epiretinal membranes, macular degener- ation, and glaucoma. "For an EDOF IOL that provides image quality and contrast comparable to a monofocal, like the Symfony, I still offer it to these patients," he said. He offers a surgical option since other solutions for presbyopia such as bifocal glasses can increase the elderly's risk of trips and falls. "I do make it clear to these patients that if their pathology progresses, their visual quality could likely decrease regardless of the IOL they receive." "Because the EDOF lens performs similarly to a monofocal lens in eyes with coexisting corne- al, retinal or optic nerve pathology, we use EDOF lenses in these patients but counsel them exten- sively preop about what to expect," Dr. Wong said. "Usually patients with an EDOF lens and coexisting macular pathology do not read up close as well as EDOF patients with normal maculas. The far vision seems to be equivalent to a mono- focal lens in patients with macular pathology." Dr. Loden, however, avoids complicated eyes altogether. Once the patient has paid for the upgrade, he said, their expectations are set for the superior vision they thought they "bought." "It seems that no amount of preop discussion can alleviate this tendency," he said. EDOF and refractive lens exchange Drs. Chang, Wong, and Yeu use EDOF IOLs for refractive lens exchange (RLE). "I see lens pathology to be a continuum of progression from a young healthy lens to a dysfunctional lens to a cataractous lens," Dr. Chang said. "Regardless of the condition of the phakic lens prior to removal, the patient will have the same potential vision postoperatively. Therefore, as long as I expect that the patient will be happy with the relative func- tional gains in their uncorrected vision acuity after surgery, I do not hesitate to offer EDOF IOLs as an option." Dr. Yeu, however, only performs RLE in hyperopic patients over the age of 45; she will not perform RLE in myopic patients until at least the age of 58. A s an increasingly popular option for presbyopia correction, extended depth of focus (EDOF) IOLs must contend with the challenges facing all premium IOLs. To date, premium IOLs have tended to be less than ideal options for non-routine cases. Given that the tar- get population consists significantly of aging and elderly eyes, it is not uncommon for these eyes to be complicated by comorbid conditions such as glaucoma or by previous refractive surgery. EyeWorld corresponded with Daniel Chang, MD, James Loden, MD, Shannon Wong, MD, and Elizabeth Yeu, MD, to find out how the lenses have fared against such conditions in their respec- tive practices. EDOF in complicated eyes Despite their superior light transmission and vi- sual quality, surgeons should still exercise caution when considering EDOF IOLs for complicat- ed eyes. "It is still important to have an overall healthy eye, and I do not place either the Tecnis Symfony [Johnson & Johnson Vision] or multi- focal IOLs in an eye that has macular drusen or ERMs," Dr. Yeu said. She still considers both EDOF and multifocal IOLs for glaucomatous eyes that have no visual field loss and a healthy ocular surface, but only an EDOF IOL—possibly combined with a concom- itant MIGS procedure—if there is some OSD as is common in stable early to moderate primary open angle glaucoma. "I do think that the Sym- fony IOL is more resilient to visual fluctuations associated with OSD," she said. Dr. Chang considers EDOF IOLs a potential benefit to two kinds of "complicated" eye. First are eyes with refractive complications such as OSD, anterior basement membrane dystrophy, corneal scarring, and post-refractive corneas. "Since EDOF IOLs provide a broader focal range than monofocal IOLs, they can be advantageous when refractive targeting and stability are diffi- cult," he said. "With the Symfony IOL, I fre- quently aim slightly (~0.5 D) plus to left-shift the defocus curve, thus utilizing the depth of focus for refractive stability (of distance vision) instead of range of vision." Challenging EDOF Extended depth of focus IOLs in non-routine cases At a glance • EDOF IOLs still require caution when being considered for complicated eyes, although the broader focal range confers a number of advantages, particularly in cases where refractive targeting and stability are issues. • EDOF IOLs can be used successfully for refractive lens exchange, but it must be made clear to patients that even these lenses may not be able to replicate the full visual acuity and quality of their crystalline lenses. • As always, preoperative coun- seling is essential in managing patients receiving EDOF IOLs.

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