Eyeworld

EW FEATURE 98 Current and future IOL choices • March 2018 AT A GLANCE • Extended depth of focus IOLs may provide patients with a more natural range of vision, but the near may not be as strong compared with a multifocal IOL. • The best candidates for EDOF IOLs have no coexisting ocular disease and have realistic expectations for the lenses. Patients should still expect to use glasses occasionally. • Surgeons have mixed opinions about using EDOF IOLs in patients with previous LASIK. • Mixing and matching EDOF IOLs and multifocal IOLs in patients is one approach to meeting their visual requirements. by Vanessa Caceres EyeWorld Contributing Writer Cataract surgeons consider visual needs, patient expectations C ataract surgeons continue to find the right place to fit extended depth of focus IOLs (EDOF IOLs) within their toolbox. Currently, the only EDOF IOL available in the U.S. is the Symfony lens (Johnson & Johnson Vision, Santa Ana, California). The pros and cons of EDOF IOLs are best put into context by compar- ing them to other IOL types. When explaining EDOF IOLs to patients, Kendall Donaldson, MD, associate professor of ophthalmol- ogy, and medical director, Bascom Palmer Eye Institute, Plantation, Florida, lets them know that these lenses provide a more natural range of vision. "As compared to a mono- focal distance IOL, they would gain more intermediate vision and some degree of near vision," Dr. Donald- son said. "In contrast to a multifocal IOL, they would gain the interme- diate/computer distance vision with EDOF IOLs." "I tell patients who are interest- ed in EDOF IOLs that the advantage of these lenses is that they provide excellent quality of vision as com- pared to multifocal IOLs. They also provide excellent mid-range vision," said Eric Donnenfeld, MD, Oph- thalmic Consultants of Long Island, Garden City, New York. "However, the disadvantage of EDOF IOLs is that they do not provide near vision that is as good as higher add multi- focal IOLs." Finding the best candidates The best candidates for an EDOF IOL have no concomitant ocular disease, such as macular issues, moderate to advanced glaucoma, or moderate to advanced ocular surface disease, Dr. Donaldson said. "I also prefer not to use EDOF IOLs in patients with a history of prior corneal laser vision correc- tion to avoid induction of further visual disturbances in a patient with potential higher order aberrations from their prior LASIK procedure," she said. In contrast, Dr. Donnenfeld will use EDOF IOLs in patients with mildly irregular corneas such as fol- lowing LASIK or radial keratotomy. That's because the lenses are more tolerant of residual hyperopia and astigmatism, he said. Uday Devgan, MD, private practice, Devgan Eye Surgery, Los Angeles, and clinical professor of ophthalmology, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, thinks ideal candidates for EDOF IOLs are those willing to tolerate night glare and halo in ex- change for a modest improvement in range. Just as with other premium IOL types, there are certain candidates in whom it is best to avoid EDOF IOLs. "Patients who desire maximum im- age quality and are willing to wear spectacles for near work should not be considered for an EDOF IOL," Dr. Devgan said. "Poor candidates are those who have unrealistic expec- tations, are unable to tolerate the visual imperfections induced by the EDOF IOL, or those with concurrent ocular conditions that will prevent best optical performance." Dr. Devgan has tapered down his use of EDOF IOLs due to dys- photopsias experienced by some patients and what he describes as a relatively limited ability to deliver consistent near vision. Finding a niche for extended depth of focus IOLs As with any IOL, it's also a mat- ter of keeping patient expectations in check regarding use of glasses. "I remind patients that our goal is to decrease dependency on glasses, but no technology will guarantee that every patient will be free of glasses all the time," Dr. Donaldson said. Cataract surgeons must contin- ually compare appropriate use of EDOF IOLs with multifocal IOLs. For patients who want both near and far vision without glasses, Dr. Devgan prefers monovision or multifocal IOL use. Extended depth of focus IOLs also may not have as strong near vision compared with a multi- focal IOL, Dr. Donaldson said. Targeting range of vision One pearl Dr. Donaldson has for achieving an ideal range of vision is to mix and match EDOF IOLs and multifocal IOLs. "I tend to use an EDOF IOL in the dominant eye to maximize the distance and interme- diate and couple that with a Tecnis 3.25 add IOL [Johnson & Johnson Vision] in the non-dominant eye to increase near," she said. "In my ex- perience, monovision does not work well with these lenses, and leaving the patient myopic in one eye has a tendency to induce unwanted dysphotopsias." Dr. Devgan targets 1 D of depth of focus at plano to achieve a near point of about 1 meter away. "Other factors such as ambient lighting, pupil size, and other corneal aber- rations will affect this," he said. "To increase the near vision will require the second eye to be aimed a little myopic, about –0.5 or so, which will then bring the near to about 67 cm in that eye." "I aim for a plano distance visu- al result in the dominant eye with EDOF lenses, and if the patient is happy with the mid-range and near vision, I will aim for the same result in the non-dominant eye," Dr. Don- nenfeld said. "However, if the pa- tient requests additional near vision, I will provide mini-monovision with the second cataract surgery." In the latter eye, Dr. Donnenfeld aims for a refractive result of –0.50 D. Although the Symfony is the only EDOF IOL available in the U.S. right now, there are additional ones under development from Carl Zeiss Meditec (Jena, Germany) and Alcon (Fort Worth, Texas), Dr. Donnenfeld said. EW Editors' note: Dr. Donnenfeld has financial interests with Alcon, Carl Zeiss Meditec, and Johnson & Johnson Vision. Dr. Donaldson has financial interests with Alcon, Bausch + Lomb (Bridgewater, New Jersey), and Johnson & Johnson Vision. Dr. Devgan has no financial interests related to his comments. Contact information Devgan: devgan@gmail.com Donaldson: KDonaldson@med.miami.edu Donnenfeld: ericdonnenfeld@gmail.com Tecnis Symfony IOL Source: Uday Devgan, MD

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