Eyeworld

EW FEATURE 96 Current and future IOL choices • March 2018 Good candidates are "people who are distance-oriented, want sharp, high contrast distance vision, like golfing and driving at night," Dr. Weinstock said. "They appreciate the optics of the Crystalens. They tend to do better with the Crystal- ens than a multifocal lens' optics, which can create dysphotopsias at night and other unusual lighting conditions." A key part of patient selection is looking at their lifestyle to help them make decisions about what kind of technology they would do best in, Dr. Weinstock said. Poor candidates for the accom- modating lenses, according to Dr. Lindstrom, include "those with poor Crystalens implantation Source: Jack Singer, MD visual potential, although accom- modation would not hurt them. The cost benefit ratio would be poor." Bad fits for the lenses, Dr. Wein- stock said, include natural myopes who don't have a lot of accommo- dation and who take their glasses off to read and use their natural myopia. "They don't have a lot of accommodation because they've never had to use those muscles," Dr. Weinstock said. "They are also used to good reading vision up close naturally, and the Crystalens doesn't provide that, so they tend to be dis- appointed if their expectations are not set properly." People who have unusually long or short eyes can be challeng- ing for the Crystalens because of the flexible nature and size of the lens. "It's designed more for the average-shaped eye rather than the extremes of shapes and sizes of eyes," Dr. Weinstock said. Poor candidates also include those with any type of capsular instability related to trauma or a condition like pseudoexfoliation syndrome. "Those are not good candidates because the Crystalens is reliant on the capsule to be in good integrity, and it needs to be healthy for it to function and be stable in the eye," Dr. Weinstock said. Targeted vision In the Crystalens, Dr. Weinstock almost always targets the dominant eye for plano and the non-dominant eye for –0.3 to –0.5, which allows a little more freedom from glasses without compromising the distance vision. Dr. Yeu targets the non-domi- nant eye to –0.5 to –1.0. The vari- ation depends on how the patient has performed with a trial monovi- sion lens or prior use of monovision in a soft contact lens. She targets the dominant eye to plano. Dr. Lindstrom prefers a monovi- sion approach, with one eye target- ed to plano and the second targeted to –1.5 to –2.0. He also noted that mini-monovision works with the Crystalens. In those cases, he targets plano in one eye and –0.75 to –1.0 in the second eye. EW Editors' note: Dr. Lindstrom has financial interests with Alcon, Allergan (Dublin, Ireland), Bausch + Lomb, Johnson & Johnson Vision (Santa Ana, California), Carl Zeiss Meditec (Jena, Germany), and Elenza. Dr. Yeu has fi- nancial interests with Bausch + Lomb, Carl Zeiss Meditec, Alcon, and Johnson & Johnson Vision. Dr. Weinstock has financial interests with Bausch + Lomb. Contact information Lindstrom: rllindstrom@mneye.com Weinstock: rjweinstock@yahoo.com Yeu: eyeulin@gmail.com Delivery systems New IOL delivery systems are also on the way. "The advent of pre- loaded IOLs is a wonderful advance for us," Dr. Koch said. "But most of the preloaded lenses still have little quirks with their injectors, so I'm looking forward to seeing some new advances in that area. Alcon has a new injector called AutonoMe that has a CO2 cylinder and is incredibly slick. I don't see advances in injec- tors as critical, but any time you can use a preloaded IOL injector, it's a plus." None of the multifocal IOLs come preloaded, Dr. Miller said. "We still have to load these lenses into injectors manually. If you look at multifocals once they're in the eye, there are often little scratches or ding marks on them because some- one touched the optic surface. It would be nice if they were preload- ed by an expert in the factory. The next step beyond that would be to have an auto-inject type of system. Alcon has one currently, but it's cumbersome to use. It would be nice if the injector itself auto-advanced. The AutonoMe looks promising," he said. Dr. Rubenstein added that it would be helpful for injectors to go through smaller incisions. "The smallest inserter goes through a 1.8- mm incision. I think there is some value to developing inserters that go through even smaller incisions. Advantages would include less induced astigmatism and a smaller wound to worry about with post- operative wound leaks or post-trau- matic wound leaks. I think there will be more movement toward preloaded lenses and auto-insertion techniques. We will need to eval- uate these developments as they come along and determine if they are making a significant impact in clinical outcomes," he said. Future Extended range of focus lenses and trifocals are the next lenses to gain popularity in the U.S. "My Europe- an colleagues tell me that they are predominately using two categories of IOLs: extended depth of focus and trifocals," Dr. Koch said. "Their use of multifocals has dropped dramatically in lieu of these other options. The elegance of the trifocal IOL is that it actually loses light compared to the multifocal IOL. It provides a more continuous range of vision from distance to near with no increase and perhaps fewer glare symptoms than a multifocal IOL. I will also be interested to see how extended depth of focus IOLs might be modified to extend their near range while preserving the excel- lent quality of vision they provide. Also, manufacturers are designing pseudoaccommodative IOLs with new optical properties. Our industry colleagues are making great strides for our patients." EW Editors' note: Dr. Miller has financial interests with Alcon and Johnson & Johnson Vision. Dr. Koch and Dr. Rubenstein have no financial interests related to their comments. Contact information Koch: dkoch@bcm.edu Miller: kmiller@ucla.edu Rubenstein: jonathan_rubenstein@rush.edu Current continued from page 94 Getting continued from page 95

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