EyeWorld Asia-Pacific June 2019 Issue

EWAP JUNE 2019 43 CATARACT eye and the other in which emmetropia was the target. “They found that using micro-monovision improved independence and patient satisfaction,” Dr. Juthani said. “About 14% of patients required spectacles postoperatively. While generally 10% or fewer of those with multifocal lenses need spectacles after implantation, the side effect «Àœwi ܈̅̅i -ޓvœ˜Þ i˜Ã was slightly improved with the EDOF lens.” The main disadvantage of these lenses compared to the multifocals is the quality of the uncorrected near vision, especially at the 12 to 14-inch distance, he explained, adding that it’s the nature of these lenses. “The longer you create the focal plane to be, the more blurring you get in that range,” he said. À° Õ̅>˜ˆ w˜`à ̅>Ì Ì…i Symfony lens is best suited for those with little or no astigmatism, who have otherwise healthy eyes and an active lifestyle. “Also, taller individuals who tend to have longer arms— and because of that have a longer working distance—might enjoy these more than people who have shorter arms and are holding a book closer to their face,” he said. Other EDOF lenses rely on different technology. Dr. Juthani pointed to the small aperture lenses, which work by the pinhole effect, blocking unfocused rays of light that can degrade the image quality. /…iÃi ˆ˜VÕ`i ̅i ‡n i˜Ã ƂVÕ œVÕÃ] Àۈ˜i] >ˆvœÀ˜ˆ>® >˜` the XtraFocus pinhole implant (Morcher, Stuttgart, Germany). Such lenses are not available in the United States and the data available on them are limited. “The application seems greatest in patients who have slightly greater amounts of astigmatism and other higher order corneal aberrations,” Dr. Juthani said. Another approach is with a multifocal aspheric lens, such as the Mini Well Ready - i`ÌiV…] >Ì>˜ˆ>] Ì>Þ®] ̅i wÀÃÌ «Àœ}ÀiÃÈÛi >ë…iÀˆV intraocular lens, available in Europe, Dr. Juthani noted. º ˜ÃÌi>` œv…>ۈ˜} `ˆÃVÀiiÌ steps for correcting distance, intermediate, and near, it has more of a blended optic,” he Ã>ˆ`° º ̽à ȓˆ>À ̜…>ۈ˜} > progressive lens in the eye.” 7…ˆi…i w˜`à ̅>Ì Ì…i ˆ˜ˆÌˆ> results for this type of lens look good, there’s a need for longer and more formal prospective studies, he said. ˜ À° Õ̅>˜ˆ½Ã ۈiÜ] " lenses are a valuable addition to the presbyopic armamentarium. º ̅ˆ˜Ž ̅iÀi ˆÃ > }ÀœÕ« œv patients who will be happy with these lenses, and we have to have the right conversations with people to determine what works best for them,” he said. Going forward, he pointed out that there will be some new trials looking at a combination of EDOF lenses in one eye and either a multifocal or a ÌÀˆvœV> i˜Ã ˆ˜ ̅i œÌ…iÀ° º Ì will be interesting to see what these formal studies show,” he concluded. EWAP References 1. Akella SS, Juthani VV. Extended depth of focus intraocular lenses for presbyopia. Curr Opin Ophthalmol. 2018;29:318–322. 2. Cochener B, et al. Clinical outcomes of a new extended range of vision intraocular lens: international multicenter Concerto Study. J Cataract Refract Surg . 2016:42:1268–1275. W e have been fortunate in Asia to have had access to the Symfony EDOF intraocular lens implant since early 2015. Up to that time, Asian cataract surgeons were either using ÌÀ>`ˆÌˆœ˜> LˆvœV>] i>ÀÞ }i˜iÀ>̈œ˜ ÌÀˆvœV> " à œÀ “œ˜œÛˆÃˆœ˜ ̜ `iˆÛiÀ > À>˜}i œv ۈȜ˜ ̜ ̅iˆÀ «>̈i˜Ìð œÜiÛiÀ] Üi > ÀiVœ}˜ˆâi` ̅>Ì `ˆvvÀ>V̈Ûi “Տ̈vœV> " Å>` È}˜ˆwV>˜Ì ÀˆÃŽÃ œv `Þ녜̜«Ãˆ>à and reduced contrast sensitivities while monovision patients often still had to wear supplementary glasses and had to deal with anisometropia and reduced stereopsis. The promise of EDOF lenses at launch was that they offered a reasonably useful range of vision from distance to intermediate while being accompanied by monofocal-like levels of contrast sensitivity and reduced dysphotopsias. Cataract surgeons in Asia implanted these lenses in patients after appropriate counseling and soon discovered that while the lens was reasonably well accepted by patients, near vision at 40 cm was a challenge if the target refraction was plano and ܓi «>̈i˜Ìà ˆ˜`ii` ˜œÌˆVi` È}˜ˆwV>˜Ì ÃÌ>ÀLÕÀÃ̇ˆŽi `Þ녜̜«Ãˆ>ð ˜ ̅i œ˜ViÀ̜ -ÌÕ`Þ }ÀœÕ« ܅ˆV…À° Õ̅>˜ˆ µÕœÌiÃ] ̅iÞ vœÕ˜` that using micro-monovision improved independence and patient Ã>̈Ãv>V̈œ˜° ˜`ii`] Üi > i>À˜i` ̅>Ì ˆv «>˜œ Ü>à Ì>À}iÌi`] «>̈i˜Ìà would complain that near vision was suboptimal and wonder why they ÜiÀi «>ވ˜} vœÀ > «Ài“ˆÕ“ " ̅>Ì Ü>à ˆ“ˆÌi` ˆ˜ ˆÌà >LˆˆÌÞ Ìœ `iˆÛiÀ ˜i>À ۈȜ˜° ˜ “Þ «>̈i˜ÌÃ] vœÕ˜` ̅>Ì Ì>À}ï˜} qä°x ˆ˜ i>V…iÞi yielded good distance vision of approximately 20/30 in 85% of cases, intermediate vision (60 cm) of N6 in 97%, and near vision (40 cm) of N6 in 77% when tested monocularly. However, when tested binocularly, the near and intermediate vision was N6 or better in 100%. This therefore LiV>“i “Þ Ì>À}iÌ ÀivÀ>V̈œ˜ œv V…œˆVi ˆ˜ > V>Ãià >˜` V…œœÃi ˜œÌ ̜ Ì>À}iÌ «>˜œ ˆ˜ }i˜iÀ>° /…ˆÃ…>à ̅i >``i` Li˜iwÌ œv ˜œÌ…>ۈ˜} ̜ console patients disappointed with near vision after a plano outcome. ˆ˜>Þ] vœÕ˜` ̅>Ì Ì…i -ޓvœ˜Þ i˜Ã VœÕ` Li ÕÃi` ˆ˜ «>̈i˜Ìà ܅œ >Ài>`ޅ>` > “œ˜œvœV> " ˆ˜ ̅i wÀÃÌ iÞi >˜` «>̈i˜Ìà Ài>`ˆÞ accepted the lens without noticing any difference in contrast sensitivity. This has obvious applications in patients in whom there is a posterior V>«ÃՏi ÀÕ«ÌÕÀi ˆ˜ ̅i ÃiVœ˜` iÞi >˜` > “œ˜œvœV> " ˆÃ ˆ“«>˜Ìi` ˆ˜ the sulcus and also those patients in whom there is some pathology in ̅i œÌ…iÀ iÞi vœÀ ܅ˆV…> “œ˜œvœV> " ܜՏ` Li “œÀi >««Àœ«Àˆ>Ìi° 'FKVQTUo PQVG &T ;GQJ KU QP VJG URGCMGT RCPGNU QH #NEQP ,QJPUQP ,QJPUQP and Zeiss. Ronald Yeoh, MD Adj Associate Professor Duke-NUS Grad Med School Singapore National Eye Centre Consultant Eye Surgeon & Medical Director Eye & Retina Surgeons #13-03 Camden Medical Centre One Orchard Boulevard, Singapore 248649 ry@ers.clinic ASIA-PACIFIC PERSPECTIVES