Eyeworld

SEPTEMBER 2023 | EYEWORLD | 47 R Relevant disclosures Bafna: Bausch + Lomb Cummings: Alcon, Bynocs, NanoDrops, REVAI, Scope, TearLab, Vivior Stonecipher: Alcon, Bausch + Lomb, Johnson & Johnson Vision, Rayner Williamson: Bausch + Lomb Contact Bafna: sbafna@midwestvision.com Cummings: abc@wellingtoneyeclinic.com Stonecipher: stonenc@gmail.com Williamson: blakewilliamson@weceye.com the cataract was diagnosed, the visual symp- toms are likely from the cataract. Devices like the iTrace [Tracey Technologies] are useful for both patients and surgeons, making complicated optics understandable and showing both parties where the main issue lies. Is the greatest source of higher order aberrations external (cornea and tear film) or internal (lens and vitreous)? Address the source of greatest error first and explain to the patient that the vision will not be perfect until both have been addressed." In the case where further corneal surgery is either impossible or unwanted, using the IC-8 Apthera can improve the overall wavefront from internal and external sources, Dr. Cummings said. Dr. Cummings did note that someone with a perfect cornea might consider less light with the IC-8 Apthera to be an issue if they have not seen a significant reduction in glare and halos because there were no corneal higher order ab- errations to start with. "The IC-8 Apthera works well in cases with corneal aberrations, including keratoconus, post-RK, post-decentered corneal ablations, or cases with irregular astigmatism," he said. "I have also found that patients with amblyopia often gain more vision than I would have expected, perhaps due to addressing the 'crowding effect' with the small aperture IOL." Technique considerations Dr. Bafna said part of the approval process for surgeons who want to use this lens is they're required to read about how to do a YAG because it's a little different for this lens. The company asks you to YAG in a specific manner in these cases. "If you do it the normal way, patients will have floaters after the YAG," he said. "In these patients, because they're looking through this small, 1.6 mm aperture, if there are any floaters in the middle, it's going to have a bigger impact on the patient's overall vision." Dr. Cummings also said it's important to be very particular with the YAG laser, avoid- ing laser pulses in the center of the mask. "It is advised to laser outside of the mask with the hinge inferiorly, and after the YAG laser capsulotomy, ideally the posterior capsule will flop posteriorly and hang inferiorly out of the pathway of the incoming light beams," he said. "On occasion, this won't go entirely according to plan, then you must do the YAG through the aperture in the center of the mask to detach the posterior capsule from the IOL surface. A small nick in the IOL is more symptomatic here, so it is important to take extra care." He also said to determine your surgically induced astigmatism with this IOL, as the incision size is bigger than usual at 2.7 mm, and sometimes even larger. The IOL performs well if the final astigmatism is <1.5 D, so it is often prudent to do the surgery on axis to reduce the astigmatism. In terms of technique and implantation of the lens, Dr. Bafna said the process is straight- forward. There is an injector approved for use with the lens. He also mentioned the larger incision that might be needed with the IC-8 Apthera to avoid too tight of a fold that could damage the filter. Dr. Williamson said he often uses a 2.5-mm incision during surgery but uses a larger one for the IC-8 Apthera. "What a lot of people won't appreciate is it has to go through a 3-mm inci- sion," he said. "If I'm doing an on-label patient, I will typically use a 3-mm blade, larger sleeve, and surgery is the same. You just don't want to try to use a 2.4-mm sleeve in a 3-mm wound. It leaks and makes the surgery that much harder." Future advances In terms of future developments, Dr. Cummings said he would like to have a pre-loaded ver- sion of the IOL and a toric version. Often these aberrated corneas have significant amounts of astigmatism, he said. Dr. Bafna said he'd be interested in see- ing different aperture sizes for the lens in the future. Right now, it's one size fits all, but depending on the individual and based on what their pupil size is and how much irregularity they have in the cornea, he would want the surgeon to have options to choose lenses with different size openings. However, he noted that the current opening works well for the majority of patients. Dr. Stonecipher stressed that the IC-8 Apthera is another great tool in the toolbox, and he doesn't want to pigeonhole it in the complex corneas. "I think it's got an array of options available in the big picture. I find patients in whom I thought they would need something ad- ditional, and it's amazing how the pinhole effect makes a difference," he said.

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