Eyeworld

EW REFRACTIVE 104 September 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer tation of the Symfony IOL up to 1.0 D had a very mild and not clinically relevant impact on visual acuity and patient satisfaction. It showed that the extended range of vision IOL had better tolerance to unexpected postoperative residual errors than diffractive bifocal and trifocal IOLs. Dr. Garg said it is the surgeon's job to figure out which IOL is right for each patient, in light of the wealth of information available from this and other studies. "What I am trying to highlight here is that you want to nail your options. The further you get away from being on target, the less happy the patient is. Some lenses are more sensitive than others depending on whether the patient has with- or against-the-rule astigmatism. Against-the-rule tends to be less tolerant and with-the-rule a little more tolerant. We also need to consider posterior corneal astig- matism. With presbyopic correcting lenses in general, we have to nail the astigmatism, and having a toric platform helps us in that regard," he said. Getting the process right Dr. Garg presented the case of a patient with Symfony toric IOLs bi- laterally. The patient's right eye was dominant, and Dr. Garg planned a Symfony ZXR00 non-toric 15.5 IOL. For the left, non-dominant eye, he planned a Symfony ZXT225 toric 17.0. He aimed for just a touch of myopia, orienting the IOL on the steep corneal axis. The right eye was uncomplicat- ed, but Dr. Garg's aberrometry rec- ommended a ZXT150 15.5, to cor- rect a small amount of astigmatism, which he oriented at 20 degrees. The ORA measured roughly 1.1 D at 20 degrees, and he achieved 20/20 un- corrected distance visual acuity and uncorrected J3 reading. The patient's left eye was also uncomplicated. Dr. Garg oriented the ZXT225 17.5 at 160 degrees. The patient achieved an uncorrected distance visual acuity of 20/40 and uncorrected J2 near, but complained of slightly waxy vision. Dr. Garg noted a disconnect between the patient's uncorrected visual acu- ity and the manifest refraction and thought it was likely that the near rings were refracting. He chalked it up to ocular surface disease and when he examined the patient again at postoperative week 4, UCVA was toric lenses are good, reasonable lenses for people with glaucoma, diabetes, and macular pathology, as long as there is still visual potential there. However, in patients with glaucoma with visual field defects, active diabetic retinopathy, or mac- ular pathology, you want to steer away from the Symfony or AcrySof IQ ReSTOR platforms, but you could consider the Trulign. It used to be that when we talked to patients about these lenses, toric lenses did not equal multifocal or extended depth of focus, but now they do—or they can. I think that's very exciting for our patients because it opens up a lot more options." The effects of astigmatism on lens performance is a topic worthy of further exploration. In a recent prospective, comparative, interven- tional study 2 that investigated the impact of induced astigmatism with four different types of multifocal lenses in 80 eyes, including the AcrySof IQ ReSTOR +2.5 D (20 eyes), AcrySof IQ ReSTOR +3.0 D (20 eyes), AcrySof IQ PanOptix (20 eyes), and the Symfony ZRX00 (20 eyes), inves- tigators found that the differences in IOLs with regard to the impact of the cylinder sign and axis on visual acuity and patient satisfaction were not significant. The PanOptix IOL was most affected by the induced astigmatism with respect to patient dissatisfaction and visual acuity. The highest tolerance to the astigmatic distortion and blurriness induced with a –1.50 D cylinder was ob- tained with the Symfony IOL. The study revealed that the simulated residual cylinders after the implan- Options make choices more complicated "What do more and better options mean for us?" Dr. Garg asked. "It means that things are more compli- cated. There are more considerations and more chair time. Looking at the difference between a standard toric and presbyopia-correcting toric IOL, there are a couple of considerations. For both, you need regular astig- matism and an optimized ocular surface. Standard toric IOLs general- ly cause less glare and dysphotopsia, while you may need to tell patients who are interested in presbyopia- correcting toric IOLs that they can have some glare and dysphotopsia, like with the Symfony and some- what less with the Trulign. Standard Toric presbyopic IOLs combine best of modern IOL technologies to correct astigmatism, presbyopia A ccording to the 2016 ASCRS Clinical Survey, 1 the most common proce- dures used among ASCRS members to manage astigmatism in a patient highly mo- tivated to receive a presbyopia-cor- recting IOL with 0.75 D of cylinder are on-axis incisions, manual limbal relaxing incisions (LRI), astigmatic keratotomy (AK), or femtosecond laser AKs and LRIs. At the tipping point of 1.25 D cylinder, however, physicians prefer toric IOLs. Fortu- nately, surgeons now have several IOL options to meet the needs of presbyopic patients with visually relevant cylinder. According to Sumit "Sam" Garg, MD, Gavin Herbert Eye Institute, University of California, Irvine, California, who spoke at the 2017 ASCRS•ASOA Symposium & Congress in a session called "Pair- ing Astigmatism Patients with the Optimal Technology: What Would You Do?" surgeons have three viable IOLs to choose from that com- bine presbyopic and astigmatism corrections: the Trulign (Bausch + Lomb, Bridgewater, New Jersey), the Symfony Toric (Johnson & Johnson Vision, Santa Ana, California), and the AcrySof IQ ReSTOR Toric (Alcon, Fort Worth, Texas). Spoiled for choice with toric presbyopic IOLs Presentation spotlight " Presbyopia-correcting IOLs raise the bar for delivering a full range of vision. They add complexity to patient selection and expectations, and require a higher level of surgical precision to achieve exceptional outcomes. " —Sumit "Sam" Garg, MD Sumit "Sam" Garg, MD, discusses how to select the appropriate presbyopia procedure by assessing patient needs

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