EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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36 EW FEATURE February 2011 2013 Presbyopia June Eyeing accommodative and multifocal IOLs in the pipeline by Maxine Lipner EyeWorld Senior Contributing Writer AT A GLANCE ¥ The Lentis Mplus lens uses a new approach to attain multifocality and is visually forgiving. ¥ An innovative trifocal, the AT LISA tri 839MP, offers patients computer range as well as near vision. ¥ The FluidVision Lens, which is filled with ophthalmic-grade silicone oil, has been known to attain up to 5 D of accommodation. ¥ A new electromechanical lens in prototype, the Sapphire, works independently of the muscles and is not constrained by capsular bag hardening. Continued quest for full range of presbyopic vision W hile options have grown among accommodative and multifocal lenses, so far no perfect replacement for the young natural lens exists. "It remains the Holy Grail," said Louis D. "Skip" Nichamin, MD, medical director, Laurel Eye Clinic, Brookville, Pa. "I think that it is the most sought-after technology that we currently don't have." Yet new technologies such as innovative multifocal lenses available outside of the U.S. as well as unique accommodative approaches still in prototype are moving the prospect closer. There would be a huge market for such a lens that truly mimics human accommodation, said Eric D. Donnenfeld, MD, professor of ophthalmology, New York University, New York. "Accommodative and multifocal lenses right now constitute about 7% of all cataract surgeries done in the United States, and that's with lenses that are good but not great," Dr. Donnenfeld said. "If we could come up with a lens that was significantly better, that reduced side effects and had reproducible excellent reading vision, the demand for that lens would be almost limitless." Indeed, despite available options, the need remains. Unhappy with current lenses, Michael Lawless, MD, Vision Eye Institute, Chatswood, New South Wales, Aus- tralia, has currently stepped back from the accommodative market altogether. "I used the Crystalens HD [Bausch + Lomb, Rochester, N.Y.] for two years from 2009 to 2011 and stopped using it because the enhanced reading available with this lens was minimal in my hands, giving an effect of approximately 0.75 diopters," he said. "This was outweighed by the fact that the YAG capsulotomy rate was very high, at 75% in my cases." Likewise, he does not use other accommodative lenses since he has not found them to be an improvement over the Crystalens. Dr. Lawless does, however, use multifocal lenses in about 35% of patients. He relies on ingenuity to bring patients the full range of vision here. Since May 2011 he has been using the ReSTOR +2.50 multifocal (Alcon, Fort Worth, Texas) in patients' dominant eye, aiming for plano. "It gives excellent distance quality with little or no photic phenomena, glare or haloes," he said. In the nondominant eye he uses the ReSTOR +3.0. "This does give some reduction in contrast and patients are aware of photic phenomena, but because it is the nondominant eye and because the dominant eye has excellent quality, they seem to adapt very well." Patients also pick up some intermediate vision in the 50to 60-centimeter range because of the transition between the +3.0 multifocal and the +2.5. While some patients do still need to wear +1.50 reading glasses in poor light, this seems to be a good overall compromise, he thinks. New multifocal lenses While such innovative approaches can help some to approximate a full range of vision, many practitioners are pinning their hopes on new lenses. One new multifocal IOL gaining ground outside of the U.S. is the Lentis Mplus (Oculentis, Berlin). David G. Kent, MD, Christchurch, New Zealand, uses this segmented, visually forgiving multifocal lens for many of his patients. "With the lens in the recommended position, the distance segment of the lens is (located) superiorly and the reading and intermediate segment is inferiorly," Dr. Kent said. The Lentis is based on the concept of rotational The FluidVision Lens Source: PowerVision asymmetry with a distinct sector for near and the rest dedicated for distance. This is unlike typical diffractive or refractive multifocal lenses, made with concentric circles, which scatter the light over the entire lens. The Lentis allows for more transmission of light because it is not using a diffraction grating, Dr. Kent explained. Dr. Kent reported that his results with the Lentis Mplus have been outstanding, with 100% of his patients able to read well without glasses. The few night vision disturbances that do occur are different than the typical haloes experienced with other multifocal lenses. "Most people with the lens describe it as a street light or car headlight having light rays radiating downward like fingers or whiskers," Dr. Kent said. As a rule, patients tend to find this far less disturbing than typical night vision problems, he thinks. "But there are definitely reports of patients who have clear problems with the lens, which require either removal of the lens or in some cases can be solved by rotating the lens up the opposite way," Dr. Kent said. This reverses the situation, putting less of the reading segment in the pupil area and enabling patients to block some of that area if they close the eye a bit. A customized toric version of the lens is also available. Dr. Kent's experience has been so positive with the Lentis that he finds that he is using fewer diffractive multifocal IOLs. Marc E. Wei, MBBS, FRANZCO, in private practice, Laser Sight, Brisbane, Australia, also finds that the Lentis works well. "I've been getting J2 reading with those lenses with 20/20 distance vision as well," Dr. Wei said. The clarity of the distance vision is good, he finds. "They don't get so much of the waxy, blurry vision for distance," he said. A small portion of people experience flaring from lights, however. As a result, he does not recommend the Lentis for those who may be required to drive at night. Dr. Wei has also begun using the AT LISA tri 839MP (Carl Zeiss Meditec, Dublin, Calif.), a trifocal lens that promises to better fill in intermediate vision. This Dr. Wei described as a diffractive lens with a number of rings on the surface, with a unique light distribution. "The lens splits the light 20% at interme-