Eyeworld

EW FEATURE 100 Current and future IOL choices • March 2018 AT A GLANCE • The lower add MFIOLs and EDOF IOLs are the best choices for consistent higher quality vision. • Photic phenomena among the current generation of MFIOLs are far less commonly experienced and less bothersome than in previous versions. • Blended vision and mini-monovision successfully combine IOLs to maximize the visual range. • The right IOL combinations can enhance vision and reduce visual side effects. by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer correction to, so more than ever, physicians have excellent choices to offer patients a fuller range of vision. Still, multifocal IOLs are not for everyone. According to Dr. Yeu, a good candidate needs to have some flexibility. "The right candidate for multifocal IOLs has healthy eyes and is motivated to have spectacle independence with realistic goals regarding potentially adjusting their arm span for the best vision. Some- one interested in a MFIOL needs to understand that complete spectacle independence is unrealistic," she said. "Patients can have controlled mild dry eye disease, at worst, and no retinal or macular pathology." Dr. Raviv agreed. "A healthy eye with good visual potential is the most important factor. Furthermore, the patient should understand the benefits and limitations of multifo- cal technology. I explain that 100% spectacle independence may be impossible as well as describe the possible photic phenomenon associ- ated with multifocals. The old warn- ing about avoiding the exacting or type A engineering patients I find inaccurate, as they are usually the most aware of the IOL limitations and the limits of physics and optics when it comes to splitting light en- ergy. Sometimes the most laid back patient with the least understanding can be the most disappointed," he said. Photic phenomena are far less frequent and bothersome than with early MFIOL versions, however, they can still occur and warrant mention. Dr. Raviv takes a lot of time in counseling his patients and educating them about potential side effects before deciding if it is the right choice for them. "I discuss all the surgical options I deem ap- propriate to patients to meet their visual outcome desires, and that includes ways to manage the 'abso- lute presbyopia' that bilateral plano targeted monofocal IOLs induce. I explain that presbyopia correcting IOLs such as MFIOL and EDOF can greatly improve spectacle indepen- dence, but they may have night time artifacts around point sources of light, and I describe those. I also explain that today's fourth and fifth generation multifocals have far less aberrations than the earlier versions that gave the technology a rough start," he said. Although patients need to be fully aware of the potential imper- fections of MFIOL vision, current MFIOL options provide sophisti- cated solutions to individual visual needs, particularly when combined as needed. Blended vision and mini-monovision are IOL combina- tions that have been used success- fully to maximize the visual range through the use of monofocal IOLs of different strengths. Blended vision, or monovision, describes fo- cusing one eye for distance (usually the dominant eye) and the partner eye for near (the non-dominant eye), which allows patients a large degree of spectacle independence. Mini-monovision uses IOLs with a maximal difference of roughly 0.75 D, targeting the patient's domi- nant eye for emmetropia while the non-dominant eye is set for –0.5 D or –0.75 D. The idea is that a greater difference between the two eyes may lead to reductions in contrast sensitivity, stereopsis and binocular visual acuity. Both options have the potential to cover the full range of vision and offer spectacle freedom. IOL combinations According to Dr. Raviv, MFIOL combinations can enhance vision and reduce visual side effects. He explained, "For me, every combina- tion is on the table. Until recently, the most common combination was a pairing of either a ReSTOR [Alcon, Fort Worth, Texas] +2.5 with a ReSTOR +3.0, or toric multifocal [TMF] +3.25 with a TMF +2.75. With EDOF, I frequently start with that IOL and can add a low add TMF in the other eye, if more add is needed. Alternatively, I've mixed low add multifocals and EDOF with a mono- focal IOL as well. I've found that mini-monovision with multifocals doesn't work out well. The multi- focals combined with EDOF IOLs have the least glare and halo when plano is achieved. That being said, the EDOF can tolerate micro-mono- vision of maybe –0.35 D in one eye, which can significantly enhance the binocular near vision. If I think more near is needed on the second eye, I typically will switch to a low add multifocal such as the TMF +3.25." For Dr. Yeu, not all multifocal combinations are suitable in the monovision or mini-monovision context. "Blended vision depends on a few factors, including near vision needs, height, and prior use of multifocal or monovision soft contact lens," she said. "I have not used a 4.0 add multifocal IOL since the mid and low add versions be- came available. In order of frequen- cy of presbyopia correcting IOLs, I use the EDOF IOLs bilaterally most frequently (plano dominant eye, –0.25 to –0.50 non-dominant eye). I always aim to place the lowest add possible in the dominant eye, as night vision symptoms are also lower. In the non-dominant eye, I am a fan of the mid add multifocal for those who have shorter arm spans or prefer to read books/maga- zines over e-readers or computers. I will do a mini-monovision approach when I use EDOF IOLs in both eyes, particularly for those who have been successful monovision patients The latest models of MFIOLs bring patients closer to a full range of vision with fewer photic phenomena T he aim and challenge of multifocal intraocular lenses (MFIOL) is to provide clear vision to patients for a full range of distances, from far to near. Physicians want to pro- vide patients with the best possible vision, suited to their preferences and lifestyle, without compromising all that much on any one end of the spectrum. The evolution of multi- focal lenses is ongoing and always improving, so it is important to keep abreast of what is new and how experienced surgeons are incorpo- rating the latest devices into their practice. EyeWorld spoke with Tal Raviv, MD, associate clinical profes- sor of ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine, New York, and Elizabeth Yeu, MD, Virginia Eye Consultants, Norfolk, Virginia, about which multifocal lenses they choose and why. Who are MFIOLs best suited for? The current generation of multifocal IOLs, particularly the lower add ver- sions, as well as the extended depth of focus (EDOF) IOLs, provides con- sistently higher quality vision than their predecessors. Toric multifocal and EDOF IOLs have expanded the inclusion criteria for whom physi- cians are able to offer presbyopia Where we stand with MFIOLs ReSTOR +2.5 with ACTIVEFOCUS Source: Alcon continued on page 102 Watch Dr. Yeu align a multifocal IOL to the visual axis on EWAR

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