Eyeworld

EW REFRACTIVE SURGERY 42 June 2015 by Maxine Lipner EyeWorld Senior Contributing Writer Correcting astigmatism and more I n cataract patients with pre- existing corneal astigmatism, the TRULIGN toric lens (Bausch + Lomb, Bridgewater, N.J.) can correct for this, while also offer- ing enhanced vision in the interme- diate range in particular, as well as functional near acuity with excellent distance vision, according to Jay Pepose, MD, PhD, medical direc- tor of Pepose Vision Institute, and professor of clinical ophthalmology, Washington University School of Medicine, St. Louis. "The intermediate vision is almost double that seen in the stud- ies with standard toric lenses," Dr. Pepose said. "So patients are going to get much better intermediate vision, which is important for using a cell phone, for a computer, and for seeing the dashboard of a car." Building on the Crystalens platform This lens has the distinction of be- ing the first toric presbyopia-correct- ing IOL in the U.S. The TRULIGN uses a Crystalens (Bausch + Lomb) platform but also has a toric com- ponent on the posterior surface of the lens to correct for astigmatism, Dr. Pepose explained. It includes a hinged optic haptic junction that was originally thought to play a key role in providing improved vision across the natural range of focus. "There have been multiple mechanisms of action studied, which have shown enhanced range of vision," Dr. Pepose said. "These include axial translational move- ment of the lens and theoretical deformation of the lens (accom- modative arching) creating central depth of field." Dr. Pepose views the TRULIGN lens as best suited for patients who have preexisting corneal astigmatism and are also interested in a greater depth of field. This is especially true for those who would like to avoid the photic phenomenon (nighttime glare or halos) that sometimes occur with multifocal lenses, he noted. Studying the lens In a recent prospective, randomized study published in the February 2015 issue of the Journal of Cataract & Refractive Surgery, investigators evaluated the safety and efficacy of the lens. Patients were stratified based on their corneal astigmatism. The TRULIGN comes in 3 different powers of toricity at the IOL plane, 1.25 D, 2 D, and 2.75 D, Dr. Pepose said. During the study, 229 patients were placed in one of 4 groups: high, intermediate, and low astig- matism groups or a low astigmatism control group. Those in the low astigmatism control group received a Crystalens, Dr. Pepose said. "For the high toric [patient], we didn't have a control because that would not be ethical—we would still have high corneal astigmatism (left) un- treated," he said. Of these patients, 74 received the low-powered toric lens while 68 received the non-toric Crystalens, he said. "There was no attempt to reduce the astigmatism in the control group other than the primary corneal incision for phacoemulsification," he said. Postoperatively, investigators found that there was a statistically greater reduction in astigmatism in the group that received the toric lenses versus the controls, Dr. Pepose noted. With the lens, the mean residual astigmatism was less than 0.5 D in all of the groups, even for those with the highest preoperative astigmatism, he said. "Even the high preexisting corneal astigmatism was effective- ly reduced, and the TRULIGN had great rotational stability," he said, adding that approximately 96% of patients had postoperative rotation of the lens of less than 5 degrees. Not all toric lenses could boast such stability, he said. "A lot of standard toric lenses do rotate postoperative- ly, and with every degree of rotation away from the optimum axis you're losing about 3% [of toric effect]—so if the lens rotates 10 degrees, you've lost 30% of the effect of the toric lens," Dr. Pepose said. Investigators found that with the TRULIGN lens patients enjoyed excellent distance vision, great intermediate and functional near, together with reduced astigmatism, Dr. Pepose reported, adding that this was true for those with both lower and higher magnitudes of preexisting astigmatism. "The toric component didn't seem to produce any new safety concerns," he said. "There wasn't any increase in glare or any of those issues." Still, to ensure the best results with the TRULIGN, attention to detail is needed. "You do have to polish the capsule," Dr. Pepose said. "It requires a meticulous cortical cleanup." Also, with this type of lens, creation of a nice, round rhexis is important, he stressed, adding that this is true with the Crystalens as well. In addition, if a practitioner sees any capsular striae, Dr. Pepose advised doing an early YAG, as left alone this could create a change in the position of the lens. Overall, Dr. Pepose pointed out that the TRULIGN offers an advan- tage with astigmatism improvement and some presbyopia correction. "I think for most patients when comparing it to a standard toric lens, you get something extra," he said, adding that with the lens patients get uncorrected distance of about 20/25 and intermediate vision of about 20/22. While near acuity is in the 20/39 range offering about 1 D of through focus, that is just with correction in one eye, Dr. Pepose said. "In the second eye, you can create a little bit of monovision," he said. "Even if you target –1 D, most people can tolerate a diopter of monovision and you're getting good depth of field, so that works out well." EW Reference Pepose J, et al. Safety and effectiveness of a new toric presbyopia-correcting posterior chamber silicone intraocular lens. J Cataract Refract Surg. 2015 Feb;41(2):295–305. Editors' note: Dr. Pepose has financial interests with Bausch + Lomb. Contact information Pepose: jpepose@peposevision.com Aligning the stars with TRULIGN Schematic of the TRULIGN lens Source: Jay Pepose, MD, PhD

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