Eyeworld

EW FEATURE 102 Current and future IOL choices • March 2018 AT A GLANCE • There are a range of "futuristic" IOLs available outside the U.S. or still in development. • Improving presbyopia correction is a major target for many IOLs, including trifocals (currently unavailable in the U.S.) and accommodating IOLs, many of which are still in clinical trials. • Postoperative adjustability is an element on ophthalmologists' wish list to allow them to easily correct missed targets. • Other technologies seek to prevent IOL-induced aberrations, such as negative dysphotopsia. by Liz Hillman EyeWorld Staff Writer U ntil a method to prevent cataracts altogether is de- veloped, cataract surgeons will seek out IOLs that can provide vision that most closely resembles that of a youthful, natural lens. "We ultimately want an adjust- able and accommodating intraocu- lar lens," said Richard Lindstrom, MD, Minnesota Eye Consultants, Minneapolis, and member at large, ASCRS Executive Committee. "I want a lens that's going to give me the accommodation of a 30-year-old, and I want to be able to hit perfect plano so I can have razor-sharp, 20/20 distance vision too," Uday Devgan, MD, Devgan Eye Surgery, Los Angeles, said of his IOL wish list. Companies are working toward this goal on many fronts, as well as addressing some of the unwanted visual aberrations that occur with current lens designs. While some of these IOLs are already on the market in the U.S., others are only available outside the U.S. or are still in other stages of development. Next generation IOLs seek to provide accommodation, adjustability, and more A range of futuristic IOLs coming down the pipeline continued on page 104 The Juvene accommodating IOL is a dual, fluid-optic system that uses the ciliary muscle to achieve accommodation. Source: Michael Landreville/LensGen in the past. I generally prefer a near emmetropia goal, mixing two add powers with multifocal IOLs or an EDOF dominant eye/mid add multifocal IOL in the non-dominant eye. I generally do not implement mini-monovision with multifocal IOLs, but I do mix add powers." When it comes to multifocal toric options, the rules for Dr. Yeu are becoming better understood. For corneal astigmatism that is with-the- rule more than 1.25 D or against- the-rule more than 0.75 D anteri- orly, she uses toric MFIOL versions. "This is the best way to proceed in cases of corneal astigmatism," she said. "I will regularly treat any astigmatism more than 0.2 D, and for lower amounts of corneal astig- matism, by doing femto astigmatic keratotomy at the time of surgery. I correct low levels of postop residual mixed astigmatism with manual limbal relaxing incisions [LRIs] in the office," she said. Dr. Raviv opts for toric multifo- cal IOLs in his patients with corneal astigmatism whenever feasible. "The published literature has proven the Where we continued from page 100 superiority of toric IOLs over LRIs with regard to accuracy, so I use a toric multifocal or toric EDOF when- ever indicated," he said. "Using what we know about posterior cor- neal astigmatism and new thinking about using 0.1 D for our surgically induced astigmatism in the Barrett Toric Calculator, I typically use a toric for against-the-rule astigma- tism of greater than 0.4 D and for with-the-rule astigmatism greater than 1.5 D. I use femtosecond laser arcuate incisions for the rest." Models are physicians using The evolution among MFIOLs has been a 20-year process of learning from mistakes and incorporating the latest technologies. Lower add versions of existent MFIOLs and the development of EDOF lenses now provide excellent options for implantation in cataract surgery. "In the U.S., FDA-approved multifocal IOLs include the ReSTOR multifo- cal IOL [Alcon], Tecnis Multifocal [Johnson & Johnson Vision, Santa Ana, California], and Tecnis Sym- fony EDOFs [Johnson & Johnson Vision]," Dr. Raviv said. "The AcrySof ReSTOR lens was the first diffractive IOL in the U.S. market in 2005 with a +4.0 add, followed by the ReSTOR +4.0 aspheric in 2007. More recently the ReSTOR +3.0 and +2.5 with ACTIVEFOCUS (also toric) were released and are currently the most commonly used ReSTOR IOLs. The Array refractive multifocal IOL [Johnson & Johnson Vision] was introduced back in 1997, followed by the ReZoom in 2005, and the Tecnis multifocal +4. In 2015, the low add Tecnis multifocals +2.75 and +3.25 adds were released, and in 2016 the EDOF Symfony (and toric version) became available. In 2018, most surgeons utilize the low add multifocals or EDOF IOLs, although the older +4.0 add multifocals are still available." Continuous product develop- ment and improvements over the years have built a great deal of confi- dence. Eye surgeons have an array of devices to choose from to personal- ize treatment and are able to come through on their promises. Accord- ing to Dr. Yeu, "Presbyopia correct- ing IOLs, both low add MFIOLs and EDOF IOLs, provide an expanded range of vision, which in turn truly leads to greater spectacle indepen- dence. The technologies available now are the best versions out there. I trust them enough that I placed such technologies in my mother- in-law. You will still need reading glasses for very small print and will need extra light to read in dimly lit rooms. While the advanced optic provides great benefits to range of vision, no technology is without its side effects. At night, you will notice halos, glare, or streaks around point light sources, such as a street lamp, but it is distracting in less than 3% of patients. If a patient encounters this, I will stop after the first eye, and together we will figure out the best plan moving forward." EW Editors' note: Dr. Raviv has financial interests with Johnson & Johnson Vi- sion. Dr. Yeu has no financial interests related to her comments. Contact information Raviv: talraviv@eyecenterofny.com Yeu: eyeulin@gmail.com IOLs zoom in on presbyopia correction In the realm of presbyopia-correct- ing IOLs, though some are available in the U.S., many currently remain out of reach for U.S. physicians. There are no trifocal designs, for example, in the U.S. market, though they are widely available elsewhere. Dr. Lindstrom said despite the availability of some presbyopia-cor- recting IOLs in the U.S. (there are several multifocal designs, one extended depth of focus [EDOF], and one accommodative), he would certainly welcome more options. "A bifocal multifocal gives you far and near, and the weakness is in- termediate [vision]. The EDOF gives

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