EyeWorld Asia-Pacific September 2020 Issue

32 EWAP SEPTEMBER 2020 CATARACT W hen ophthalmologists talk about using small aperture optics to enhance a patient’s depth of focus for increased spectacle independence, most would consider using such technology in the patient’s non-dominant eye. But research involving an IOL that draws on pinhole principles is showing that bilateral implantation might give patients even better visual satisfaction than simply going monolateral. “The notion of monolateral implantation came from the KAMRA inlay [AcuFocus],” said Robert Ang, MD. “There is an impression that bilateral small aperture will be too dim, visual field constricted, and contrast sensitivity decreased.” But that’s not what Dr. Ang found in his prospective, non- randomized, non-comparative study that used the IC-8 IOL (AcuFocus), which is not yet approved in the U.S. 1 In the study, Dr. Ang implanted a monofocal IOL in one eye of 10 patients and IC-8 in the other. A second group had the IC-8 implanted in both of their eyes, self-selecting to receive IC-8 in the second eye after a positive experience with the first. Visual acuity, patient satisfaction, task performance, visual symptoms, defocus curves, and contrast sensitivity were tracked for at least 12 months and compared between the two groups. Overall, Dr. Ang found that “the combination of small-aperture IOL and Study compares small-aperture IOL implantation in one or both eyes by Liz Hillman Editorial Co-Director Contact information Ang: angbobby@hotmail.com This article originally appeared in the June/July 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Robert Edward Ang, MD Senior Consultant, Asian Eye Institute 8th Floor Phinma Plaza, Rockwell Center, Makati City, Philippines 1200 angbobby@hotmail.com ASIA-PACIFIC PERSPECTIVES A s experience with the small aperture IOL grows, more evidence in literature and podium presentations reinforce the IC-8’s safety and effectiveness profile. There is universal acceptance that a pinhole effect extends depth of focus resulting in presbyopia correction. In addition, the small aperture IOL can mask the deleterious effects of residual refractive error, preexisting or induced astigmatism and corneal aberrations. Most would agree that the IC-8 is an ideal candidate for eyes who had previous LASIK, PRK, RK, and even corneal transplant and keratoconic conditions about to undergo cataract surgery. What is controversial will be the ability to use the IC-8 in both eyes because of the perceived drawbacks of small aperture optics. Our experience has shown that contrast sensitivity remains near normal limits, visual field test results are hardly affected, and retina examinations are manageable. Patient selection is probably the most important determinant to a good outcome and a satisfied patient. In our study, our criteria were patient feedback on their experience with the first eye and subsequent request for implantation of the same IC-8 IOL in the fellow eye. 1 I believe these are fair and simple criteria, useful not only in small aperture IOLs but also in other presbyopia-correcting IOLs such as trifocal or other EDOF lenses. Surgeons may be confronted with a situation wherein after implantation of, for example, a trifocal IOL, the patient is not satisfied. Assuming refractive targets are achieved and no pathologies or complications are present in the first eye, do we advise the patient to have the second eye implanted with the same trifocal IOL? Or do we advise another type of IOL so as to avoid exacerbating the dissatisfaction? Post-refractive or aberrated corneas are typically bilateral and will likely benefit from monolateral and probably bilateral implantation. However, in standard eyes with virgin corneas, it is the surgeon who must first be convinced that a small aperture IOL will benefit a patient and subsequently recommend its use even if implanted monolaterally. In terms of bilateral implantation, I believe there is no better criteria than patient feedback and satisfaction in their first-eye experience. My position is we have to be open to newer technology, try it in our practice and apply the same standards whether we use multifocal or EDOF (including small aperture) IOLs, old or new, and decide which ones meet the patient’s and our own satisfaction. Reference 1. Ang RE. Visual Performance of a Small-Aperture Intraocular Lens: First Comparison of Results After Contralateral and Bilateral Implantation. J Refract Surg. 2020 Jan 1;36(1):12-19. Editors’ note: Dr. Ang is a consultant for Acufocus.