Eyeworld

48 | EYEWORLD | MARCH 2021 ATARACT C Relevant disclosures Cummings: Alcon, RxSight, Vivior Donnenfeld: Alcon, BVI, Johnson & Johnson Vision, LensGen Garg: Alcon, Johnson & Johnson Vision, LensGen McCabe: Alcon, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision Vukich: AcuFocus, Johnson & Johnson Vision who really desire accurate outcomes, he said it is a good option. Accommodative The IOL holy grail is a lens that functions like an emmetropic 20-year-old's with accommoda- tive abilities. While much work is being done to- ward this goal, nothing has quite met the mark. "I think aside from tuning the distance vision perfectly, being able to have that smooth transition from distance to near that happens with your intention to focus at different dis- tances would be fabulous," Dr. McCabe said. "I think there are many great ideas being put forward. There [are] just always challenges and compromises that come with these designs. I don't know what will rise to the top of this, but I think we want to continue to innovate in those areas." There are many different approaches being looked at. Juvene (LensGen) is a two-part IOL that works off a biomimetic principle to shift fluid to direct accommodation, Dr. Donnenfeld said, adding that data shows the majority of patients achieve 20/20 or better at distance, 20/25 at intermediate, and 20/40 at near. There are a number of other accommoda- tive IOLs at different stages of development. FluidVision (Alcon) is an IOL that uses the ciliary body's existing accommodation to move fluid in and out of different areas of the IOL. Tek-Clear Accommodative Lens (Tekia) also takes advantage of the eye's ciliary body with a haptic-optic design that bends with this muscle movement. Tekia calls this a "bending-beam" approach. ForSight Labs is creating Opira, which according to a company presentation at the 2019 Ophthalmology Innovation Summit, is a sulcus-based lens with haptics fixated in the capsulorhexis that uses the ciliary body to create a "dynamic anterior surface." Lumina (AkkoLens) is composed of two progressive, flexible optics and is fixated in the ciliary muscle. The company stated that the amount of accommodation achievable depends on the existing strength of the ciliary muscle. Atia Vision Modular Presbyopia Correcting IOL (Atia Vision) has a stationary refractive optic and an accommodative base that is driven by the ciliary muscle. TetraflexHD (Lenstec) is approved out- side of the U.S. and features a slightly angled Dr. Vukich has been working with the LAL for more than a year and said it has become his predominant premium IOL. Other options in the works for adjustabil- ity of lenses include refractive index shaping and modular IOLs. Perfect Lens is a company working on the former technique, which uses a femtosecond laser to induce a change in the refractive index of an IOL's material. Some mod- ular IOLs, which consist of a stationary base and an exchangeable optic, are making advances outside the U.S., such as Harmoni (Alcon), as well as in development, such as the Precisight Lens (InfiniteVision Optics). Dr. Vukich thinks adjustable lenses, like the LAL, can help grow the premium IOL market. Despite upgrades to premium IOLs in terms of performance, the adoption of presbyopia-cor- recting IOLs is about 15%, he said. "The fundamental reason for that is there has never been a lens with a refractive outcome in mind that has a zero enhancement rate. There is always going to be a small percentage of individuals who will need to have a touch-up or some adjustment to achieve a desired result and to achieve satisfaction, which is critical for someone who has become a consumer, in addition to being a patient," Dr. Vukich said, explaining that he thinks this is a major disin- centive among ophthalmologists for adopting these lenses. From a patient perspective, the adjustments afterward are just part of the procedure and they understand this up front, whereas enhance- ments, even when discussed preop, can be seen as a complication by patients. "[The LAL], in my opinion, creates the opportunity for every cataract surgeon to be a refractive cataract surgeon. All of those other things that are barriers to entry or disincentives to participate or challenges that are created with other lenses are simply not present with the LAL," Dr. Vukich said. Some surgeons, though lauding the LAL technology, have not found it essential to their practice. Dr. Cummings, for example, said his enhancement rate is so small, and with access to an excimer laser for these enhancements, it doesn't make sense to bring in the LAL, which requires more intense follow-up and essential patient compliance. Dr. Donnenfeld offered a similar perspective, citing his low enhancement rate. For a small group of patients and those continued from page 46 continued on page 51

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