Eyeworld

EW NEWS & OPINION 32 November 2016 initial skepticism, he said, "I have been pleasantly surprised of what is essentially a diffractive IOL with two main focal points of distance and in- termediate." He noted great distance vision, excellent intermediate vision, minimal halos, and that patients can read to about J3 binocularly. It now comprises 50% of Dr. Wei's multi- focal IOL use (especially males) and is his go-to IOL for young pre-pres- byopic unilateral eyes requiring cataract surgery. Dean Corbett, MD, Auckland, New Zealand, has been involved in some of the earliest clinical trials. He commented, "This IOL is now my 'go-to' IOL for patients wishing to reduce and perhaps eliminate spec- tacles. Surgeons must be very clear about this distinction. Most patients I see are happy to have excellent dis- tance photopic quality … and have good intermediate and near, but are happy to wear spectacles for diffi- cult near tasks. They still have some night dysphotopsias, but these are a significant level below diffractive multifocal IOLs and almost always non-bothersome. About 30% to 50% of patients have no night symptoms. "The reason for my enthusiasm for this IOL is that it makes it fun for the surgeon and the patient: great vision, good range of vision, non-bothersome night visual symp- toms. Using the micro-monovision approach allows a surgeon to target excellent visual performance." Mun Lee, MD, Ipoh, Malaysia, noted that patients with Symfony "still have glare and halos, but most- ly [are] not bothered by that. I still make it a point to tell them about it especially if they drive at night. The contrast is better than the tradition- al multifocal IOL, but not quite like a monofocal." Dr. Lee observed that it's "not a great lens for the avid reader" but also that "intermediate and distance is wonderful." Many doctors weighed in with questions based on their practices and experiences with other IOLs and received responses from those who have worked with this lens. Among the responses, Dr. Waltz comment- ed, "There are no specific disadvan- tages of the Symfony or Symfony Toric. Essentially, you can treat them like high quality monofocal IOLs that also treat presbyopia or presby- opia/astigmatism, respectively. That was the design criteria for the lens, and it was demonstrated to be the case during the trial. On the other hand, just like a high quality monofocal, the Symfony can have some glare and halos and positive or negative dysphotopsia. The Symfony is not a perfect IOL, it is just no more problematic than a high quality monofocal." He also noted, "The Symfony Toric should rotate at the same rate as a Tecnis Toric. Their outer dimensions are identical. However, the Symfony Toric patient will not experience a significant drop in unaided vision unless the net refractive astigma- tism postop is greater than 1.5 D." Furthermore, "You can use the Tecnis Toric calculator to calculate the Symfony Toric. The A constant for the Symfony Toric is the same as that of the Tecnis Toric. The astig- matic options are almost the same. If you have an optimized A constant for Tecnis Toric, you should be able to use that seamlessly with the Symfony Toric." Randall Cole, MD, FACS, Rogers, Arkansas, said that he was an Abbott Medical Optics inves- tigator for both the Symfony and Tecnis low add multifocals. "My early impression," he noted, "is that the Tecnis ZKB00 gives much better reading vision, and the complaints of halos or glare are infrequent with either lens but about the same. I am interested in the Symfony Toric and will still use the ZKB00 as my preferred multifocal for patients wanting improved spectacle inde- pendence for near. I try to empha- size to all of the patients that the goal is not to completely eliminate glasses." Gary Wortz, MD, Lexington, Kentucky, joined the conversa- tion after seeing his first Symfony (toric) postop. After noting he's an Abbott Medical Optics speaker, telling readers that he has in the past sworn off the use of multifocal lenses because of their side effect profile, and that this was his first patient, he made it clear he was "evaluating this technology based on an N of 1." Still, he commented, "This morning, less than 18 hours after surgery, my patient was 20/20+ distance, 20/20+ intermediate and J1 near with a +12.5 ZXT 150. He was actually still dilated and was ecstatic, and so was I. My experience along with my understanding of the optics and the opinions of colleagues such as Daniel Chang, MD, and Kevin Waltz, MD, give me tremendous confidence that we are being offered a game-changing technology." He continued, "I think the most unfortunate thing about the Symfony platform is that it gets painted with the wide brush of mul- tifocal lenses due to its appearance, given the diffractive rings. … I think we need to approach the Symfony as a new category of IOL and not just another 'low add' multifocal. The defocus curve on this lens is very interesting. It gives about 2 D of 20/20–20/25 vision. There are not two distinct focal points (think peaks and valleys between); rather, this is a plateau. Given that, I think it will make it quite easy to get good results even if you are off on your calculations a bit. … If the Symfony platform were a stock, I would be buying all I could. It's a game changer." Warren Hill, MD, Mesa, Arizona, also weighed in. "What the Symfony brings to the existing armamentarium is the addition of a non-diffractive method of altering the phase of the incoming waveform on top of a diffractive multifocal," he said. "This aspect may be less sensitive to frequency and does not scatter energy in the same way as a diffractive multifocal. Outside the United States, Symfony is becoming increasingly popular in many parts of Europe and Asia, displacing more familiar platforms. Overall, the non- U.S. surgeons using this IOL I have spoken with are happy with it. "In this area, small steps have been made. Trifocal diffractive optics have displaced bifocal optics, and now extended depth of focus appears to be slightly better. I think we all agree that while each innova- tion is a step closer to what we need, they remain placeholders as we wait for the real answer. There are some innovative, true accommodative IOLs on the horizon. It will be fun to see how well they do. Perhaps one of these will be the next small step toward a solution." EW Editors' note: Drs. Cole, Waltz, and Wortz have financial interests with Abbott Medical Optics. Dr. Hill has financial interests with Alcon. Dr. Khan has financial interests with Abbott Medical Optics and Bausch + Lomb. Drs. Brierley, Corbett, Lee, Lipstock, Myers, Posner, and Wei have no finan- cial interests related to their comments. Contact information Brierley: lawbrier@gmail.com Cole: dreyerecole@aol.com Corbett: corbettvision@gmail.com Hill: hill@doctor-hill.com Khan: baseer.khan@mac.com Lee: munwailee@gmail.com Lipstock: klipstock@gmail.com Myers: wmyers2020@gmail.com Posner: mgposner@msn.com Waltz: kwaltz56@gmail.com Wei: drmarcwei@yahoo.com.au Wortz: 2020md@gmail.com while extending the range of vision significantly." In Canada, the Symfony lens is already in use, and Baseer Khan, MD, Markham, Ontario, summa- rized his experiences. He noted the good points include: (1) With two defocus curves close together, the summative MTF of the lens makes it relatively forgiving in terms of targeting distance, which makes it a great IOL for those who have never used multifocal IOLs before to get into the presbyopia market; (2) there are fewer complaints of halos and glare; (3) this gives great distance and intermediate vision; and (4) he has always liked the acrylic material that Abbott Medical Optics uses because it is clear and has no glistenings. Dr. Khan noted what this lens is not. He emphasized that this is still a multifocal IOL, "plain and simple," so it still results in halos, but not as much as others. He said, "As a glaucoma specialist, I would not use this lens in a patient with visual field loss," and "Patients invariably are still disappointed when they can't read. It doesn't mat- ter how much you tell them they will not be better than J5, they still always hope." Lawrence Brierley, MD, Victoria, British Columbia, posted a summary of his experience with Symfony IOLs: "Most [patients] are pleased, even ecstatic with it, but a small group are really unhappy with the halos. You know you have a real problem with 'multifocal' optics when the patient is happy with everything about the lens and surgery, but cannot carry on with it. Or maybe they are unhappy about disappointing their surgeon, but have to bring this up because it is so distressing for them. I have seen this many times in my more credulous years with multifocals, and regret to say that revisiting this again, albeit rarely, with the Symfony put me off using it. "I recognize the hope and wonder in some of the recent posts that we might finally have this thing wired because I felt this way, too. We have all waited a long time and suffered with our patients to try to expand depth of field without paying some price. The Symfony is probably the closest yet to the holy grail, but it is not the holy grail. I would suggest that you strongly cau- tion patients about this potential for visual disturbance and be prepared to exchange." Marc Wei, MD, Gold Coast, Australia, has used the Symfony lens for the past 18 months in ap- proximately 200 cases. Despite his Discussion continued from page 31

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