EyeWorld Asia-Pacific June 2021 Issue

CATARACT 20 EWAP JUNE 2021 MD, thinks there is still an education gap with this lens option. Dr. Vukich has been working with the LAL for more than a year and said it has become his predominant premium IOL. Other options in the works for adjustability of lenses include refractive index shaping and modular IOLs. Perfect Lens is a company working on the former technique, which uses a femtosecond laser to induce a change in the refractive index of an IOL’s material. Some modular IOLs, which consist of a stationary base and an exchangeable optic, are making advances outside the U.S., such as Harmoni (Alcon), as well as in development, such as the Precisight Lens (InfiniteVision Optics). Dr. Vukich thinks adjustable lenses, like the LAL, can help grow the premium IOL market. Despite upgrades to premium IOLs in terms of performance, the adoption of presbyopia- correcting IOLs is about 15%, he said. “The fundamental reason for that is there has never been a lens with a refractive outcome in mind that has a zero enhancement rate. There is always going to be a small percentage of individuals who will need to have a touch-up or some adjustment to achieve a desired result and to achieve satisfaction, which is critical for someone who has become a consumer, in addition to being a patient,” Dr. Vukich said, explaining that he thinks this is a major disincentive among ophthalmologists for adopting these lenses. From a patient perspective, the adjustments afterward are just part of the procedure and they understand this up front, whereas enhancements, even when discussed preop, can be seen as a complication by patients. “[The LAL], in my opinion, creates the opportunity for every cataract surgeon to be a refractive cataract surgeon. All of those other things that are barriers to entry or disincentives to participate or challenges that are created with other lenses are simply not present with the LAL,” Dr. Vukich said. Some surgeons, though lauding the LAL technology, have not found it essential to their practice. Dr. Cummings, for example, said his enhancement rate is so small, and with access to an excimer laser for these enhancements, it doesn’t make sense to bring in the LAL, which requires more intense follow-up and essential patient compliance. Dr. Donnenfeld offered a similar perspective, citing his low Chul Young Choi, MD Professor, Sungkyunkwan University, Kangbuk Samsung Hospital Seoul, South Korea sashimi0@naver.com ASIA-PACIFIC PERSPECTIVES I think a trend of multifocal IOls can be summarized as “low-add” and “individualizing” with fewer side effects. Because we have faced lots of visual disturbances after multifocal IOLs, that could be the reason to seek a “path to peace of mind” from patient’s complaints. Absolutely, we have never found the perfect optics suitable for every patient, because everyone has a different lifestyle, culture, and physical condition including the complexity of letter design itself (especially Chinese and Korean characters) and relatively shorter reading distance (from arm length) and more light pollution during night time from city life. We published about “Mix and Match” implantation of an EDOF IOL and a multifocal IOL could be an option for patients with high demands for vision with good reading speed. 1 That can explain a new trend of “low-add” premium IOLs including Eyhance (Johnson & Johnson Vision) and Vivity (Alcon) IOLs. The advantage is that it is more forgiving of refractive error and has less dysphotopsia, as we experienced in previous EDOF IOLs. 2 The Synergy (Johnson & Johnson Vision) IOLs from our early experience, it would be a promising new option for Mix and Match with an EDOF or a premium monofocal IOL for better range of vision from far/intermediate to near distance up to 33 cm. Interestingly, we could observe the unique different light transmission profile from our laboratory the Synergy IOL block the specific part of violet wave length (415~450 nm) known as a cause of mitochondria dysfunction in retina, whereas other yellow IOLs block diffuse wave lengths from violet to green (390 to 540 nm). Finally, we have recently experienced the remarkable progress in IOLs, including new optics, adjustable lens and accommodative IOLs. And we know from our past experiences of presbyopia correction for many years, not all the cases were happy, but an absolute majority of cases were happy with the progress. With such progress, we can approach more precisely the demand of patients in clinic today. References 1. Song JE, et al. Comparison Between Bilateral Implantation of a Trifocal IOL and Mix-and-Match Implantation of a Bifocal IOL and an Extended Depth of Focus IOL. J Refract Surg . 2020 Aug 1;36(8):528-535. 2. Son HS, et al. Prospective comparative study of tolerance to refractive errors after implantation of extended depth of focus and monofocal intraocular lenses with identical aspheric platform in Korean population. BMC Ophthalmol . 2019 Aug 19;19(1):187. Editors’ note: Dr. Choi declared no relevant financial interests.