Management strategies for complicated cases eyeworldap.apacrs.org The Asia-Pacific Association of Cataract and Refractive Surgeons ASIA-PACIFIC Vol. 18 No. 1 March 2022 Licensed Publication
EWAP MARCH 2022 3 EDITORIAL Graham Barrett Chief Medical Editor EyeWorld Ƃsia*acific • China • Korea • India EyeWorld Asia-Pacific • March 2022 • Vol. 18 No. 1 T his issue contains an interesting discussion of intraoperative refractive guidance systems and their clinical use. Cataract surgery practice patterns are usually similar in the Asia-Pacific region compared to other regions; occasionally, however, there is a divergence such as the increased use of toric I"Ls in the Asia-Pacific compared to other regions. Intraoperative aberrometry is another technology rarely found in our practices compared to the U.S. Published data comparing the utility of intraoperative abberometry to predict the refractive outcome is inconsistent and recent publications suggest that accurate preoperative measurements with modern formulas is equal if not better than intraoperative aberrometry for spherical power. The accuracy of toric IOL prediction is not superior and using intraoperative aberrometers to determine the alignment axis is relatively infrequent despite the enthusiasm of some U.S. surgeons. The difference could in part be explained by the relative frequency of low toric IOLs. Low toric IOL powers such as T2s are not yet available in the U.S. but are more common in countries like Singapore and Australia. In this context, surgical disturbance of the ocular surface and the speculum may impact the reliability of axis alignment by intraoperative aberrometry. In situations where toric lenses of higher cylinder powers dominate, intraoperative refraction may be more reliable. Predicting the outcome of patients with a previous history of refractive surgery can be challenging and intraocular aberrometry has been recommended. Once again, there is no indication that it is more accurate than careful biometry with modern post refractive surgery formulas. Differences in reimbursement and the opportunity to charge additional fees may also influence the popularity of intraoperative aberrometry. Image-guided alignment, however, is quite popular in the Asia-Pacific region. Different systems are available, including Calisto and Verion, and are an efficient method of determining the correct axis for toric IOL alignment. Unexpected registration issues are relatively rare but surgeons should be cautious to avoid misalignment due to erroneous image acquisition. Simple methods using apps such as toricCAM to accurately determine the reference axis are in my opinion are more reliable. It is my practice to use both methods to avoid technical issues with image-guided systems and surgeon error in setting the alignment axis. Using both techniques provides greater confidence in ensuring the toric lens alignment is accurate and not a major issue in unexpected residual astigmatism after toric IOL implantation. This issue of ye7orld Ƃsia*acific marks 2 years in the ongoing COVID-19 pandemic. There is an element of fatigue as we deal with the Omicron variant, but fortunately it does appear to be less serious than previous variants. Our news journal has been a constant during this pandemic, keeping us informed and in contact as we have resorted to virtual meetings. We are therefore looking forward to our next meeting in Korea in June where we can renew acquaintances and friendships in person.
4 EWAP MARCH 2022 CONTENTS FEATURE Management strategies for complicated cases 07 Negative dysphotopsia: How to explain it and management strategies by Ellen Stodola 16 Premium IOLs in imperfect eyes by Liz Hillman 19 RLE for a patient with a previous corneal inlay by Ellen Stodola 21 Identifying EBMD: Looking for blurry vision and other signs by Ellen Stodola Management strategies for 07 – 23 complicated cases CATARACT 24 Preventing and managing iris prolapse by Liz Hillman 30 Intraoperative refractive guidance systems by Liz Hillman 03 Editorial NEWS & OPINION 62 Review of ‘Effect of residual astigmatism on uncorrected visual acuity and patient satisfaction in pseudophakic patients’ by Thomas Meirick, MD, and Parisa Taravati, MD 64 Review of ‘Repositioning surgery of different intraocular lens designs in eyes with late in-the-bag intraocular lens dislocation’ by Andres Parra, MD 39 Graft detachments in DSAEK and DMEK by Ellen Stodola 46 Looking for corneal disease prior to cataract surgery by Ellen Stodola 50 How to handle ‘pain without stain’ by Liz Hillman 52 The latest in DSO by Liz Hillman 33 The unhappy LASIK patient by Liz Hillman 36 Stemming myopia progression by Liz Hillman REFRACTIVE 60 Get ahead of malignant glaucoma in high-risk eyes by Liz Hillman GLAUCOMA 54 Tube shunt erosion/exposure by Ellen Stodola 58 Handling bleb leaks by Ellen Stodola CORNEA
Jointly organised by MASTERCLASSES & INSTRUCTION COURSE Covering the most relevant topics and conducted by some of the world’s leading surgeons. Expect the hottest topics in ophthalmic surgery today such as Mastering Toric IOLs, Mastering IOL Fixation, Mastering Biometry, Mastering Refractive Surgery Complications, Mastering Corneal Endothelial Transplantation, and Mastering Vitrectomy for Anterior Segment Surgeons. KSCRS will also be conducting an instruction course on basic cataract techniques. APACRS LIM LECTURE The APACRS LIM Lecture is the highest award of the APACRS. Since 1991, outstanding ophthalmologists who have made extraordinary contributions to the development of cataract and refractive surgery have been invited to deliver this prestigious lecture at the APACRS annual meeting. Prof YAO Ke will present the 2022 APACRS LIM Lecture titled Cataract in China: My Cataract Surgery Journey fromCouching to FLACS at the Opening Ceremony of the 34th APACRS annual meeting. APACRS FILM FESTIVAL The APACRS Film Festival is both entertaining and educational, creatively displaying new innovations and breakthroughs in ophthalmic surgery. Not to be missed! COMBINED SYMPOSIUMOF CATARACT & REFRACTIVE SURGERY (CSCRS) A joint symposium of the APACRS, ASCRS, and ESCRS. ZEN – A balance of quality and depth of focus In the current IOL landscape, IOLs that offer more than mere monofocals and fewer image quality issues than multifocals are making headway. These are the EDOF, monofocal plus, and other designs such as pinhole IOLs. Join us to see if this new range of IOLs can effectively bridge the gap between monofocal and multifocal IOLs. SYMPOSIA Exciting symposia covering cutting edge IOL innovations, the latest surgical techniques, and the management of challenging cataract cases and complications. TAEKWONDOMASTERS – Top Cataract Surgery Tips Some of the most renowned cataract surgeons each offer a practical cataract surgery tip that surgeons can use immediately on their next visit to the operating theater. www.apacrs2022.org ProgramHighlights Visit www.apacrs2022.org for meeting information. TAEKWONDO MASTERS Top Cataract Surgery Tips
EYEWORLD ASIA-PACIFIC APACRS Publisher: EyeWorld Asia-Pacific Edition (ISSN 1Ç9Î-18Îx) is published µuarterly by the Asia-Pacific Association of Cataract E ,efractive Surgeons (APAC,S), cÉo Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 1È8Çx1, telephone (Èx) ÈÎ22-Ç4È9, fax (Èx) ÈÎ2Ç-8ÈÎ0, email ewap@apacrs.org. Printed in Singapore. Editorial Offices: EyeWorldAsia-Pacific Edition\ Asia-Pacific Association of Cataract E,efractive Surgeons (APAC,S), cÉo Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 1È8Çx1, telephone (Èx) ÈÎ22-Ç4È9, fax (Èx) ÈÎ2Ç-8ÈÎ0, email ewapJapacrs.org. AdvertisingOffice: EyeWorldAsia-PacificEdition\Asia-PacificAssociationofCataractE,efractiveSurgeons (APAC,S), cÉo Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 1È8Çx1, telephone (1-Ç0Î) 9Çx-ÇÇÈÈ, email donJapacrs.org. Copyright 2021, Asia-Pacific Association of Cataract E ,efractive Surgeons (APAC,S), cÉo Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 1È8Çx1, telephone (Èx) ÈÎ22-Ç4È9, fax (Èx) ÈÎ2Ç-8ÈÎ0, email ewapJapacrs.org. Licensed through the American Society of Cataract E ,efractive Surgery (ASC,S), 4000 Legato ,oad, Suite Ç00, airfax, 6A 220ÎÎ-400Î, 1SA. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. The ideas and opinions expressed in EyeWorld Asia-Pacific do not necessarily reflect those of the editors, publishers or its advertisers. Subscriptions: Requests should be addressed to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 1È8Çx1, telephone (Èx) ÈÎ22-Ç4È9, fax (Èx) ÈÎ2Ç-8ÈÎ0, email ewap@apacrs.org. Back copies: Subject to availability. Contact the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 1È8Çx1, telephone (Èx) ÈÎ22-Ç4È9, fax (Èx) ÈÎ2Ç-8ÈÎ0, email ewap@apacrs.org. Requests to reprint, use or republish: Requests to reprint or use material published herein should be made in writing only to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 1È8Çx1, telephone (Èx) ÈÎ22-Ç4È9, fax (Èx) ÈÎ2Ç-8ÈÎ0, email ewapJ apacrs.org. Change of address: Notice should be sent to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, six weeks in advance of effective date. Include old and new addresses and label from a recent issue. The APACRS publisher cannot accept responsibility for undelivered copies. KDN number\ PPS1ÇÈÈÉ0ÇÉ201Î(0229xx) MCI (P) 0Î9É02É2022 CHINESE EDITION Regional Managing Editor Yao Ke, MD Deputy Regional Editor He Shouzhi, MD Zhao Jialiang, MD Assistant Editors Zhouqi, MD Shentu Xingchao, MD INDIA EDITION Regional Managing Editor S. Natarajan, MD Deputy Regional Editor Abhay Vasavada, MD KOREAN EDITION Regional Managing Editor Hungwon Tchah, MD Deputy Regional Editor Chul Young Choi, MD EDITORIAL BOARD Chief Medical Editor Graham Barrett, MD Chief Publisher Ronald Yeoh, MD Executive Director Kathy Chen athy.chenJapacrs.org Publishing Consultant Donald R Long don@apacrs.org PUBLISHING TEAM Senior Staff Writer Chiles Aedam R. Samaniego chiles.samaniego@apacrs.org Production Team Javian Teh Huang Weitian Sunshine Ng Gretel Tan Christine Shimmon Aileen Bian ewap@apacrs.org Chan Wing Kwong, MD, Singapore Ronald Yeoh, MD, Singapore John Chang, MD, Hong Kong SAR Pannet Pangputhipong, MD, Thailand YC Lee, MD, Malaysia Hiroko Bissen-Miyajima, MD, Japan Kimiya Shimizu, MD, Japan Sri Ganesh, MD, India Chee Soon Phaik, MD, Singapore Johan Hutauruk, MD, Indonesia EDITORIAL MEMBERS Topic Speaker Phacodynamics Ji Won KWON South Korea Phaco-machines and Instruments Kyung Sun NA South Korea Incision Hyun Soo LEE South Korea CCC Sang Beom HAN South Korea Hydrodissection Ronald YEOH Singapore Nucleofractis 1- Divide and Conquer Jin Seok CHOI South Korea Nucleofractis 2- Phaco-chop Eun Chul KIM South Korea I & A Yang Kyung CHO South Korea IOL Implantation Jong Joo LEE South Korea Jointly organised by Basic Cataract Techiques Instruction Course Sunday, 12 June 2022 • 08:00 – 09:30hrs Having a strong foundation in basic phaco technique is essential in acquiring phaco skills. This videobased course introduces the pearls and pitfalls in phacoemulsification for beginning surgeons. Chairs: Joon Young HYON, South Korea • Hyung Keun LEE, South Korea
FEATURE EWAP MARCH 2022 7 by Ellen Stodola Editorial Co-Director Negative dysphotopsia: How to explain it and management strategies Negative dysphotopsia is an issue that patients may face following cataract surgery. While it frequently resolves on its own, several physicians said it’s important to discuss it with patients and explain what’s going on. Jack Holladay, MD, highlighted risk factors that make a patient more likely to develop negative dysphotopsia, though he said you can’t definitively predict who will experience the complication. There are risk factors that can predispose it, but it’s difficult to predict when it will happen and to whom. Dr. Holladay noted primary risk factors from a paper he wrote,1 including a smaller photopic pupil, larger positive angle kappa, the shape of the IOL, smaller axial distance of the IOL behind the iris, nasal anterior capsule overlying anterior nasal IOL, higher dioptric power if equi-biconvex or plano-convex, and if the optic-haptic junction of the IOL is not horizontal. Secondary risk factors include the edge design of the IOL (if it’s truncated vs. rounded), the material of the IOL, and negative aspheric surfaces. Patients who have a small pupil (around 1.5–2 mm) are at higher risk for experiencing negative dysphotopsia when in bright light, Dr. Holladay said. This article originally appeared in the December 2021 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Dr. Holladay said he tries to stress to physicians how important these identifying measures are in helping to recognize high-risk patients preoperatively. Negative dysphotopsia is caused by a gap in rays that pass through the lens that miss the lens. There’s not a gap before surgery with the natural crystalline lens, Dr. Holladay said. “There are no rays that make it into the eye that can get between the crystalline lens and the iris,” Dr. Holladay explained. “That gap appears as a dark crescent or circle where the rays are missing on the retina. “What we showed in our paper is as you adjust the lens and make that gap bigger and various things in the eye different, you can make that crescent move more temporally, and you can make the thickness wider or thinner by how much larger that gap is between the rays that miss the lens and the rays that pass through the lens,” he said.1 Nicole Fram, MD, noted that this is a complication that can happen with any type of lens. The patient often has had perfect cataract surgery and is seeing 20/20. However, they may see a dark shadow off to the side temporally. “The first thing you want to do is reassure the patient that you know what it is,” she said, adding that it’s also important to rule out any retinal or neurological pathology such as a retinal tear or detachment. Contact information Fram: drfram@avceye.com Holladay: holladay@docholladay.com Olson: RandallJ.Olson@hsc.utah.edu Slit lamp photo of secondary reverse optic capture with the optic prolapsed over the nasal and temporal capsule and the haptics in the capsular bag. Source: Nicole Fram, MD
FEATURE 8 EWAP MARCH 2022 Dr. Fram said Robert Osher, MD, reported that the percentage of patients with negative dysphotopsia on postop day 1 is approximately 15%.2 The working theory of negative dysphotopsia based on ray tracing is that some light rays are bent by the lens and some are missed,3 which creates an illumination gap on the nasal retina causing a dark shadow temporally. In talking to patients before surgery, Dr. Fram said that she mentions that this is something that can occur, particularly in patients needing a high power IOL or who have a large angle kappa. However, she doesn’t mention the word “dysphotopsia.” Instead, she explains that the intraocular lenses used have the potential to cause glare or shadowing, and if this is a problem, she can help. Dr. Fram said it’s important to ask if this issue is always there or it comes and goes. “If it’s not always there or only there in certain lighting, I’m optimistic that the patient will adapt and not require an intervention,” she said. Dr. Osher’s research found that 97% of cases resolved within a year.2 That’s very encouraging to the patient, she said. Randall Olson, MD, agreed that this is an issue that’s often seen in the first couple of weeks after surgery, though he also sees a lot of patients who have been referred to him with a persistent problem. For the majority of patients, it’s not a big issue. However, Dr. Olson stressed that it’s important not to tell patients that you don’t know what it is or that it’s a rare complication. “I let them know ahead of time that these IOLs are smaller than our own lens, things can happen, but these things are normal,” he said. “Most of the patients I see, by the time they get to me, have been told they should be happy with their vision, and it’s an uncommon complication,” he said. “The angriest are those who have been led to think they’re crazy.” Dr. Olson said he tells patients that this is something that will go away on its own. The hard part with negative dysphotopsia, Dr. Fram said, is explaining to patients that it’s unknown whether or not it will happen in the other eye. Some patients are cautious about moving on to the other eye, and that’s where you get into a predicament, she said. “If you have a big difference between the eyes or anisometropia, you want to move on to the other eye.” There are a couple of ways to approach this. The physician could say, “We don’t know the true incidence, but there’s about a 50% chance that this could happen in the other eye,” Dr. Fram said. Assure the patient that if this happens, you can help them. You can wait a month to see if it starts to get better or choose a different strategy for the other eye, which is to put the lens in a different position. This involves doing a primary reverse optic capture (ROC) so that the optic is on top of the capsule with the haptics in the capsule bag oriented vertically. This is best performed with a 3-piece IOL. “We prefer the L161AO SofPort IOL B and L [Bausch + Lomb] as silicone has a lower index of refraction than acrylic and is more friendly in the sulcus,” Dr. Fram said. A singlepiece acrylic in the primary ROC position can lead to capsule block and is not ideal for this procedure, she said. Samuel Masket, MD, et al.4 reported on this and found that 100% of patients did not have negative dysphotopsia in the second eye when this strategy was used. That is for the patients who really can’t wait and are bothered by the first eye but need to move on to the other eye because they’re not functional, Dr. Fram said. But for many patients, she’s able to wait and see if the issue resolves over time. In her experience, typically by 3 months, the patient has improved. For patients in whom the negative dysphotopsia has persisted for 6 months or longer, Dr. Fram said you may need to move on to other options. The treatment strategy is to move the optic forward and thus move the illumination gap outside of the nasal retina. The nasal capsule has also been implicated in the multifactorial etiology of negative dysphotopsia, and covering the nasal capsule with the optic has improved symptoms. Strategies for treatment in persistent negative dysphotopsia include ROC, sulcus IOL, piggyback IOL, and nasal capsulectomy. She said secondary ROC works best if the patient’s capsulotomy is 4.5–5 mm and if they have an AcrySof IOL (Alcon) with the haptics oriented vertically.4, 5 It is less predictable with other platforms as they are more rigid and may slip back into the bag, she said. If ROC is not possible, the physician can perform an IOL exchange where a 3-piece lens is placed, and ROC is done. “If the anterior capsulotomy won’t allow for that, we put the lens in the sulcus,” Dr. Fram said. With this option, she will fixate the lens to the iris gently, so it doesn’t move over time. In her research with Dr. Masket,5 ROC worked 96% of the time, and sulcus placement worked 86% of the time. Patients should understand that after ROC procedures early fibrosis of the capsule may occur, requiring a YAG posterior capsulotomy. Piggyback lenses can also be used, as can a secondary IOL on top of the lens to help scatter light, which worked 73% of the time. Bag-to-bag exchange has
FEATURE EWAP MARCH 2022 9 not worked well in Dr. Fram’s experience. Dr. Fram also mentioned a strategy reported by Folden6 and Cooke7 of using nasal capsulectomy, and her earlier research with Dr. Masket also indicated that nasal capsule was implicated in the etiology of negative dysphotopsia. However, many of the strategies such as ROC and sulcus placement move the optic forward and may fit with the ray tracing theory as well. Nasal capsulectomy has reduced rather then cured negative dysphotopsia in Dr. Fram’s experience. This may be a good strategy for a patient with a where you do not want to exchange the IOL and cannot ROC that particular IOL. Dr. Olson said that he tells patients to wait at least 6 months to give the brain time to adapt before pursuing any surgical options. He said that options for eliminating the capsule on the nasal side or moving the optic to the top of the capsule are both effective options. A piggyback can be effective, but you have to make sure you have plenty of room so you don’t get pigment dispersion. The key in these cases, Dr. Olson said, is to not think of negative dysphotopsia as “abnormal.” It’s part of what lenses do. Dr. Olson concluded by stressing several key principles. Let patients know ahead of time that this is common and normal. Physicians should be able to recognize what it is so they can help the patient. Dr. Olson also tells patients, “The more you’re concerned about it, the harder it is for the brain to ignore.” He tries to get patients to not worry too much about it because it will either resolve or can be addressed if it persists. EWAP References 1. Holladay JT, Simpson MJ. Negative dysphotopsia: Causes and rationale for prevention and treatment. J Cataract Refract Surg. 2017;43:263–275. 2. Osher RH. Negative dysphotopsia: long-term study and possible explanation for transient symptoms. J Cataract Refract Surg. 2008;34:1699–1707. 3. Coroneo MT, et al. Off-axis edge glare in pseudophakic dysphotopsia. J Cataract Refract Surg. 2003;29:1969–1973. 4. Masket S, et al. Surgical management of negative dysphotopsia. J Cataract Refract Surg. 2018;44:6–16. 5. Masket S, Fram N. Pseudophakic negative dysphotopsia: Surgical management and new theory of etiology. J Cataract Refract Surg. 2011;37:1199–1207. 6. Folden DV. Neodymium:YAG laser anterior capsulectomy: surgical option in the management of negative dysphotopsia. J Cataract Refract Surg. 2013; 39:1110–1115. 7. Cooke DL, et al. Resolution of negative dysphotopsia after laser anterior capsulotomy. J Cataract Refract Surg. 2013;39:1107–1109. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California, and declared no relevant financial interests. Dr. Holladay is Clinical Professor, Department of Ophthalmology, $aylor College of Medicine, Houston, 6eZas, and declared no relevant financial interests. Dr. Olson is Chair, Department of Ophthalmology and Visual Sciences, ,ohn A. Moran Eye Center, 7niversity of 7tah, Salt Lake City, Utah and has interests with Perfect Lens, Perceive $io, and 6MClear. Negative dysphotopsia is one of those ghosts that can come to haunt you any time even after the most perfect cataract surgery. I read the comments by Dr. Holladay, Dr. Olson, and Dr. Fram, and I feel it is a very concise yet informative feature that explains the causation, risk factors, and possible treatment options for negative dysphotopsia. In my practice, I have seen that with better IOL designs, materials, and a better understanding of the problem, the incidence of negative dysphotopsia has reduced significantly. 9et, the odd patient does come up with the classical dark shadow. It is important to understand what we as surgeons can do to avoid or reduce this complaint. As we know, this is a phenomenon that is more likely to occur in high myopic patients with extremes of I"L power. urther, a significant overlap of the anterior capsule over the nasal IOL optic has also been incriminated. Therefore, particularly in myopic eyes, be mindful of the anterior capsulorhexis siâe. At the end of surgery, if I find that there is a significant area of anterior capsule covering the optic, I will enlarge the capsulorhexis in that half. Often, a patient will come to you having had surgery elsewhere and not happy due to dysphotopsia. In these situations, the most important thing to do is to reassure the patient and let them know that there is nothing wrong with either the surgery or the I"L. I find that once the patient knows that this is a known phenomenon and can happen despite the best surgical and visual outcomes, they are more receptive to the advice that you may give them. The other key thing in management is repeated sessions of talk time for the patient. I try and prioritize such patients when they come for their appointment and give them ample time, listening patiently to their problem. Once we become defensive, the patient also tends to become more offensive! Therefore, the best way is to hear them out, and discuss frankly what the possible options are for managing, first of them being wait and watch. I will typically wait for at least 3 to 6 months before planning any surgical intervention. My preferred approach would be to perform a reverse optic capture of the IOL optic through the anterior capsulorhexis, whenever possible. If not feasible, I would exchange the I"L with a sulcus-fixated I"L. When such a patient comes to you for the second eye surgery, discuss in advance that the same problem can occur in the fellow eye, and what you can do to prevent that from happening. I would choose an IOL design that is amenable to reverse optic capture or a threepiece IOL in the ciliary sulcus if it is a monofocal IOL being planned. In summary, from my experience of managing negative dysphotopsia, I find that honesty is the best policy. Be upfront about the uncommon possibility of this post surgery phenomenon, and after repeated counseling, maybe even asking for a second opinion, perform a reverse optic capture or IOL exchange if the problem continues to nag them. ditors½ note\ Dr. Samaresh Srivastava declared no relevant financial interests. Samaresh Srivastava, DNB Consultant Raghudeep Eye Hospital, Jaipur, India. samaresh@raghudeepeyeclinic.com ASIA-PACIFIC PERSPECTIVES
On 27 November 2021, Johnson & Johnson Surgical Vision convened the Expert Panel in Cataract Surgery (EPICS) TECNIS SynergyTM User Meeting with 12 ophthalmologists from across Asia Paci c, moderated by Dr Fam Han Bor. The experts shared best practices and experiences in patient selection, preoperative evaluation and counselling, as well as postoperative management to optimize patient outcomes with TECNIS SynergyTM. Asian patients’ unique near vision needs A de nition of patients’ vision needs after cataract surgery is important when implanting presbyopia-correcting intraocular lenses (PCIOLs),1 with distances of near vision varying according to the occupation and lifestyle of patients, and may include distances of 25, 30, 33, 35 or 40 cm.1-3 While there is often a need to hunt for the sweet spot with existing trifocal IOLs, near visual acuity (VA) is typically measured at 40 cm.4,5 However, visual performance at 33 cm is becoming increasingly important in meeting the near vision needs of Asian patients.1,6 Various studies have shown that Asians generally view reading materials such as their handheld smartphones and books at a closer distance due to their shorter stature – thus, proportionately shorter arm lengths – compared with Europeans and Africans.6,7 Furthermore, the more elaborate and intricate formation of Asian scripts, particularly Chinese scripts, require 1.5 times more VA than English characters.8 Studies have shown that the functional mobile usage distance is at 33 cm (Figure 1), and smartphones are generally held at an average viewing distance of 33.95 cm among Asians.1,6 “Asians need strong near and good intermediate vision due to challenges in reading Asian scripts such as Chinese, Hangul, Thai, Arabic and Japanese,” Dr Prin Rojanapongpun said. “Another consideration is the reading needs of patients, including tablet / book at distances of 30–35 cm and computer monitor at distances of 45–50 cm.” Speaking from experience in Taiwan, Dr Hsiao Yu-Chuan shared that such near vision needs are prominent among Taiwanese owing to the need for reading traditional Chinese script – which is more complex than simpli ed Chinese script. Clinical pearls on achieving high patient satisfactionwith TECNIS SynergyTM Continuous-Range-of-Vision IOL “For Asians, the functional mobile usage distance is at 33 cm, and smartphones are generally held at an average viewing distance of 33.95 cm.” FAM Han Bor Singapore CHUAH Kay Leong Malaysia HAN Sang-Youp South Korea HSIAO Yu-Chuan Taiwan KIM Myoung Joon South Korea Santaro NOGUCHI Japan Masayuki OUCHI Japan Robert PAUL Australia D RAMAMURTHY India Prin ROJANAPONGPUN Thailand Mahipal SACHDEV India Boonchai WANGSUPADILOK Thailand YAU Kin Hong Kong 33cm Mobile devices Print 40cm Figure 1. Optimal reading distances among Asians
Supported by TECNIS SynergyTM has been shown to offer a wider range of continuous vision with better near, maintaining 20/25 or better VA from -3.0 D to in- nity (Figure 2).10 Furthermore, TECNIS SynergyTM gained an additional line of VA at -3.0D and beyond and achieved higher VA at all distances compared with other trifocal lenses. Most experts agreed that TECNIS SynergyTM IOL is a hybrid PCIOL utilizing various technologies and falls under a new “continuous-range-of-vision” category. Dr Masayuki Ouchi noted that TECNIS SynergyTM is able to provide good vision across distance, intermediate and near to his patients. “TECNIS SynergyTM lls the gaps of troughs created by other trifocal IOLs on the TECNIS SynergyTM represents a new “continous-range-ofvision” category of PCIOL With the evolving needs of modern-day patients, visual tasks including reading, viewing mobile phones, working on computers, walking up the stairs and travelling are becoming increasingly important – and these encompass near, intermediate and distance vision. The ideal IOL should offer good distance through near vision with acceptable glares and halos. However, while most multifocal IOLs deliver good near and distance vision, there remains a gap in intermediate vision.9 Johnson & Johnson Vision has a long history of providing high-quality IOLs. In 2014, Johnson & Johnson Vision pioneered the extended depth of focus (EDOF) technology and introduced the rst EDOF lens, TECNIS SymfonyTM – providing patients with high-quality contrast vision from distance through to functional near vision. Subsequently, Johnson & Johnson Vision succeeded in combining the multifocal and EDOF technologies to deliver continuous high-contrast vision of 0.1 logMAR or better, across distance to even up close at 33 cm.1,6 The TECNIS SynergyTM IOL is patient-centric, allowing patients to experience a range of uninterrupted vision. defocus curves and provides a continuous range of vision. There is no need to hunt for a reading spot,” said Dr Rojanapongpun. What users think of TECNIS SynergyTM Dr D Ramamurthy noted that with TECNIS SynergyTM, mix-and-match implantation of IOLs and micro-monovision are no longer necessary. “Tweaking of the power of the lenses is not required with the use of newer generation formulas for my patients with bilateral implantation of TECNIS SynergyTM, and they are able to function at all distances,” he added. Dr Santaro Noguchi performed a study comparing Alcon’s PanOptix® (n>300) and TECNIS SynergyTM (n=60). Patients receiving TECNIS SynergyTM achieved better distance VA outcomes both with and without correction compared with those receiving PanOptix®. Patients receiving TECNIS SynergyTM also reported higher spectacle independence across all distances compared with patients receiving PanOptix® (97.92% versus 93.43% for far vision; 98.96% versus 95.34% for intermediate vision; and 89.58% versus 75.99% for near vision). There was signi cantly greater visual comfort in viewing mobile phones, viewing under dim light conditions, and for near work in patients receiving TECNIS SynergyTM compared with those receiving PanOptix®. Glare and halos were comparable for TECNIS SynergyTM and PanOptix® when measured three-month postoperatively. Although present, glare and halos did not affect Copyright 2022 APACRS. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or publisher, and in no way imply endorsement by EyeWorld, Asia-Pacific or APACRS. All other trademarks are the intellectual property of their respective owners. © Johnson & Johnson Surgical Vision, Inc. 2022. PP2022CT4024 Figure 2. Binocular distance-corrected defocus curves from head-to-head clinical study10* vs PanOptix® IOL based on 3-month, interim postoperative data.
patients’ daily activities, including driving at night. In a prospective case series study, all patients who underwent bilateral TECNIS SynergyTM implantation achieved complete spectacle freedom for distance vision, with only 3.7% requiring glasses for intermediate or near vision tasks.11 Although 52.4% of patients reported experiencing halos under low-light conditions, 19% of them only experienced halos occasionally whereas 77.3% of the patients had never or occasionally experienced glare.11 The ndings of the study also substantiated the outstanding continuous range of vision covering 33 cm and beyond. “Personally, I nd that other trifocals do not provide near vision enough. TECNIS SynergyTM, on the other hand, delivers very good near vision compared with most other trifocals,” said Dr Fam Han Bor. In his practice, patients are often more concerned about near vision than dysphotopsia. “While my patients who were implanted with TECNIS SynergyTM have had good near vision, they also experienced glare and halos. However, they often think that the ‘trade-off’ is worth it and are satis ed with the near vision outcomes as they can get use to glare and halos over time.” “The visual performance of TECNIS SynergyTM is similar to other trifocals that cover 40 cm and beyond, except that bilateral TECNIS SynergyTM implantation gives good near vision even at 30–35 cm, especially under dim lighting conditions. My patients are quite comfortable with the glare and halos, although I have had one patient with underlying posterior polar cataract who is unable to tolerate glare and halos,” Dr Ramamurthy recounted. He advised surgeons to approach or counsel patients tting TECNIS SynergyTM in a similar way as they would with other trifocals. The right patients for IOLs are often those who seek spectacle independence.3 “Our current cataract patients never wish to wear glasses, considering their capabilities to multitask and their modern lifestyle,” said Dr Rojanapongpun. Generation B and Generation X females who have strong desire for spectacle independence and near vision are Dr Rojanapongpun’s ideal patients for TECNIS SynergyTM. “Indeed, Asian patients need strong near vision as they tend to hold their reading materials at a closer distance due to proportionally shorter arms,” he added. The experts attributed their preference for TECNIS SynergyTM over other trifocals to its continuous range of vision and outstanding near vision. “I do like both PanOptix® and TECNIS SynergyTM, but the reading vision with TECNIS SynergyTM far exceeds that of PanOptix®. I nd that there is a gap between the vision for reading and viewing computer with PanOptix®. However, the continuous range of vision with TECNIS SynergyTM helps my patients cope better with close visual tasks,” said Dr Robert Paul. “Another issue that concerns me with PanOptix® is glistening – many of my patients undergo lensectomy and clear lens extractions for cosmetic reasons and I do not wish to implant a lens that will potentially give glistening. This will affect the quality of vision in 10–15 years and resulting in the need for lens removal. Having said that, TECNIS SynergyTM is my preferred IOL for the better quality of vision and its near vision performance,” Dr Paul continued. Sharing his personal experience in implanting TECNIS SynergyTM, Dr Paul also advised surgeons to address postoperative residual astigmatism to maximize patients’ distance vision as it is less forgiving compared with other trifocals. Some patients may experience reduced quality of distance vision during the early postoperative period, he noted, but they eventually gained 6/6 or 6/5 vision with little to no refractive error. Most experts agreed that TECNIS SynergyTM can offer the best near vision needs for Asian patients amongst other PCIOLs. Achieving spectacle independence outweighs the issues patients may face with glare and halos, given that glare and halos can be easily manage. All experts also agreed that TECNIS SynergyTM allows greater ability to read ne print and at closer reading distances compared with other trifocals. Most importantly, TECNIS SynergyTM can ful l the unique vision needs of Asian patients, whose reading distance is typically at 33 cm.1,6 “Achieving spectacle independence outweighs the issues patients may face with glare and halos, given that glare and halos can be easily managed.” Dr. Clinical pearls on achieving high patient satisfactionwith TECNIS SynergyTM Continuous-Range-of-Vision IOL
Clinical pearls for TECNIS SynergyTM: Patient selection and preoperative counselling The experts noted that most patients adapt well with mild and non-disruptive glare and halos following TECNIS SynergyTM implantation. However, surgeons may encounter a patient who reports less than perfect distance vision and experiences glare and halos. Therefore, Dr Fam believed that good preoperative informed consent and managing patient expectations are crucial. Dr Rojanapongpun advocated patient counselling on their visual goals i.e., perfect clarity versus spectacle independence and prioritization of visual tasks i.e., high contrast versus high comfort. “Patients should be allowed time to discuss with their family and make clear decisions based on their visual task priority,” said Dr Rojanapongpun. Surgeons should understand patients’ expectations and different visual requirements depending on their lifestyle and work.3 According to Dr Rojanapongpun, patient satisfaction equals outcome minus expectations. “To achieve high patient satisfaction and ensure positive postoperative outcomes, assessment of ocular pathology of the cornea, macula and optic nerve head is important,” added Dr Rojanapongpun. He explained that an evaluation of whether the surgery can offer valuable changes to the patient is the key – “if the cataract is too mild, I would recommend my patient to defer the surgery.” A detailed preoperative ocular evaluation can help patients achieve positive outcomes as successful presbyopia-corrections are often based on eye health.3 To achieve best refractive outcomes, surgeons should minimize postoperative residual astigmatic error to ≤0.75 D and consider posterior corneal astigmatism (PCA) as well as surgically induced astigmatism (SIA) in surgical planning.14 Ocular surface conditions such as dry eye disease should also be managed as part of the preoperative assessment. Surgeons should also ensure that patients are aware of the tradeoffs associated with various IOLs. It is important to educate patients on the “give and take” of IOL implantation and that there is always a compromise between multifocality and spectacle independence. Copyright 2022 APACRS. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or publisher, and in no way imply endorsement by EyeWorld, Asia-Pacific or APACRS. All other trademarks are the intellectual property of their respective owners. © Johnson & Johnson Surgical Vision, Inc. 2022 PP2022CT4024 Figure 3. Stepwise approach of preoperative assessment Supported by Step 1 Examine the ocular surface Treat tear film or ocular surface disorders. Step 2 Consider residual refractive error Aim for minimal residual refractive error. Select the lens option closest to plano, and if the first plus and first minus lens are equidistant, then select the first plus lens option (i.e., slight hyperopia). Step 3 Assess capsule and retina Rule out tilted lens position, zonular loss, poor capsular clarity and retina pathology. Step 4 Manage patient expectations Counsel patients on postoperative expectations. Avoid aggressive recommendation of TECNIS SynergyTM to patients who are poor adaptors and those with type A personality.
Dr Mahipal Sachdev explained that he would follow a stepwise approach of preoperative assessment (Figure 2). “Preoperative exclusion criteria such as preoperative dry eye, corneal scarring, pupil size of <2.5 mm and monofocal implant in the rst eye are important in managing postoperative challenges,” he clari ed. Accurate and reliable ocular biometry is essential for IOL power calculation.3,12 Dr Sachdev advised surgeons to analyze the posterior cornea using IOLMaster® 700 (ZEISS) and consider matching the residual cylinder with total keratometry and corneal topography. “Residual cylinder is detrimental to the patient and compromises the outcome any IOL implantations,” added Dr Ramamurthy. “Make sure you have accurate biometry and exclude all contraindications to any multifocals,” advised Dr Paul. Dr Fam shared that the target refraction for TECNIS SynergyTM should be emmetropia- or hyperopia-targeted and not myopia-targeted since TECNIS SynergyTM delivers good near vision. “By targeting myopia, the dysphotopsia will worsen and make the patient more unhappy,” cautioned Dr Fam. Dr Kim Myoung Joon shared that he uses an easy to remember ABC stepwise approach of preoperative assessments for all his PCIOL cases - Astigmatism control, Biometry, and, Corneal status. Large angle kappa plays a role in the decentration of multifocal IOLs and may result in glare and halos, although angle alpha better predicts photic phenomena with multifocal IOLs.3 As such, extremely large angle kappa and angle alpha should be avoided. Patients’ postoperative expectations should be adequately managed and be informed of the need to wear glasses for some activities as well as the possibility of visual disturbances such as glare and halos, especially at night.12 Clear communication such as showing patients various photic phenomena images during preoperative counselling is helpful in managing patient expectations. However, with neuroadaptation, photic phenomena will be tolerated and will not be too bothersome for patients. Furthermore, while glares and halos are common across all trifocals, patients receiving TECNIS SynergyTM who have been counselled can generally accommodate and tolerate them well. Clinical pearls for TECNIS SynergyTM: Postoperative management and neuroadaptation Visual neuroadaptation plays an important role in determining the nal visual outcomes after IOL implantation.13 PCIOLs may require 4–8 weeks for visual adaptation to attain excellent outcomes.12 Early postoperative neuroadaptation has been observed in patients with multifocal IOL implantation. In patients receiving multifocal IOL implantation, adaptation suppression was observed in the early postoperative stage, resulting in visual disturbances. However, these visual disturbances greatly improved following visual neuroadaptation by 3 months postoperation.13 “Neuroadaptation is very important, can be multifactorial, and may be attributable to personality,” said Dr Fam. All other factors such as dry eye and refractive error should be addressed before neuroadaptation. It is also helpful to consider patients’ age and ocular history. “I believe younger patients neuroadapt quicker than older patients,” noted Dr Ramamurthy. To speed up neuroadaptation, Dr Boonchai Wangsupadilok would give his patients some visual tasks to perform at home postoperatively. “I would get my patients to watch television for an hour a day and have them explain how they feel during the rst week follow-up. Generally, my patients can adjust within 2–4 weeks,” said Dr Wangsupadilok. For Dr Rojanapongpun, he would consider intervening if neuroadaptation failed 3–6 months postoperatively in patients with dysphotopsia. “Personally, I have had no issues with lens exchange within 6–12 months, if the surgery was performed well,” he noted. Glare and halos are more common among patients with large pupils.3 Before going to neuroadaptation, Dr Noguchi pointed out that it is important to focus on factors such as patient’s age and pupil size or position. Posterior vitreous detachment (PVD) is common after cataract surgery with IOL implantation.14 Although it is considered a complication of low clinical relevance, its occurrence suggests the impact of cataract surgery on the architecture of the ocular globe. However, PVD does not directly threaten vision. Dr Robert Paul explained that when patients complain of blurring or waxy vision, surgeons should not attribute all complaints to the optics of the lenses, but to rule out other factors. Clinical pearls on achieving high patient satisfactionwith TECNIS SynergyTM Continuous-Range-of-Vision IOL “Neuroadaptation is very important, can be multifactorial, and may be attributable to personality.”
The importance of TECNIS SynergyTM Toric II for presbyopia correction Experts have expressed great interest for TECNIS SynergyTM Toric II and agreed that more patients will bene t from its availability. “TECNIS SynergyTM Toric II is highly necessary, as multifocal IOLs do not tolerate residual astigmatism well – any residual astigmatism of >0.75 D will impair both distance and near vision,” shared Dr Ramamurthy and Dr Chuah. The squared and frosted haptic design of TECNIS SynergyTM Toric II IOL provides resistance to rotation.15 Its engineered design features an outstanding mean rotational stability of 0.87°.15 “We have seen amazing results in our rst few patients with the recent launch of TECNIS SynergyTM Toric II in Hong Kong,” said Dr Yau Kin. “Patients with mild astigmatism have shown accurate and stable outcomes with TECNIS SynergyTM Toric II – with 20/20 distance vision and near vision of J1 post-operation.” While TECNIS SynergyTM Toric II was only available in selected markets – including Australia, Hong Kong, Japan, and South Korea – at the point of the EPICS TECNIS SynergyTM User Meeting, it would be launched in other Asia Pacific markets in the rst half of 2022. Conclusion TECNIS SynergyTM is the lens of choice for a continuous range of vision, especially in ful lling Asian patients’ unique vision needs, necessitated by their shorter stature and thus shorter arm length compared with non-Asian patients; challenges faced in reading complex Asian scripts; as well as near reading needs at a distance of 33 cm and under dim lighting conditions. All experts agreed that full access to TECNIS SynergyTM and TECNIS SynergyTM Toric II IOLs can provide a complete visual range for patients and ful l patients’ vision needs. Surgeons are strongly advised to counsel patients and manage their expectations to optimize patient outcomes. References 1. Soler F, et al. Curr Eye Res 2021;46(8):1240–6. 2. Caltrider D, et al. Evaluation of visual acuity. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing;2022. 3. Xu C. Successful premium multifocal IOL surgery: Key issues and pearls. In: Wang X, ed. Current Cataract Surgical Techniques. IntechOpen;2021. 4. Jonker SMR, et al. J Cataract Refract Surg 2015;41:1631–40. 5. Lapid-Gortzak, et al. J Cataract Refract Surg 2020;46:1534–42. 6. Lan M, Rosen eld M, Liu L. Optom Vis Perf 2018;6(5):204–6. 7. Medscape. How is proportionality determined in the evaluation of pediatric growth hormone de ciency (GHD)? Available at https://www.medscape. com/answers/923688-163415/ how-is-proportionality-determined-in-the-evaluation-of-pediatric-growth-hormone-de ciency-ghd. Accessed January 2022. 8. Zhang J, et al. Optom Vis Sci 2020;97(10):865–70. 9. Shen Z, et al. Sci Rep 2017;7:45337. 10. Data on File, Johnson & Johnson Surgical Vision, Inc. DOF2020CT4014 – Forte 1 Study: A comparative clinical evaluation of a new TECNIS® PCIOL against PanOptix® IOL. 11. Ribeiro FJ, et al. J Cataract Refract Surg 2021;47:1448–53. 12. Data on File, Johnson & Johnson Surgical Vision, Inc. PP2020CT5232. 13. Zhang L, et al. Front Neurosci 2021 Jun 14;15:648863. doi: 10.3389/fnins.2021.648863. eCollection 2021. 14. Mirshahi A, et al. J Cataract Refract Surg 2009;35(6):987–91. 15. Data on File, Johnson & Johnson Surgical Vision, Inc., 2019. DOF20190TH4015. Copyright 2022 APACRS. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or publisher, and in no way imply endorsement by EyeWorld, Asia-Pacific or APACRS. All other trademarks are the intellectual property of their respective owners. © Johnson & Johnson Surgical Vision, Inc. 2022 PP2022CT4024 Supported by “TECNIS Synergy™ is the lens of choice for a continuous range of vision, especially in fulfilling Asian patients’ unique near vision needs.” Dr.
FEATURE 16 EWAP MARCH 2022 by Liz Hillman Editorial Co-Director Premium IOLs in imperfect eyes T here is often discussion about the conditions an eye should meet in order to be successful with a premium, advanced technology IOL, but what about patients who desire independence from spectacles but who have less than perfect eyes? According to Eric Donnenfeld, MD, Stephen Scoper, MD, and Blake Williamson, MD, there are some conditions that are complete no-go’s for any presbyopia-correcting IOL, but with more options available in the presbyopia-correcting IOL market, some can be suitable even if the patient has existing ocular pathology. “At least once a day I have a patient who wants a multifocal implant and has something going on that makes it so they probably wouldn’t be a candidate,” Dr. Williamson said, adding, however, that diabetic eye disease or glaucoma, for example, aren’t discussion stoppers. “It’s a severity scale,” he said. Patients with severe glaucoma, macular edema, uveitic disease, neovascularization, history of retinal detachments, moderate to severe amblyopia, or double vision are not suitable candidates for a This article originally appeared in the December 2021 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Donnenfeld: ericdonnenfeld@gmail.com Scoper: sscoper@cvphealth.com Williamson: blakewilliamson@weceye.com presbyopia-correcting IOL in Dr. Williamson’s practice. Patients who have mild to moderate glaucoma, mild, insignificant epiretinal membrane, stable macular degeneration, or those who’ve had previous refractive surgery are patients who, in the past, wouldn’t have been considered for presbyopiacorrecting IOLs. Newer technology, such as extended depth of focus (EDOF) IOLs and the AcrySof IQ Vivity (Alcon), which is a non-diffractive EDOF IOL, can offer the opportunity for presbyopia correction. “I would lean toward Vivity and Symfony [Johnson & Johnson Vision] in these eyes because we know these are EDOF technologies and do not have multiple focal points. They can be more forgiving in eyes that are less pristine. EDOF as a category is a better solution than bifocal or trifocal in eyes such as this that are borderline,” Dr. Williamson said. “The biggest thing that I do is make sure they understand the different eye diseases they have and how those diseases add up to give them what they perceive to be their vision.” Dr. Scoper said with multifocal lenses, such as PanOptix (Alcon), which became the first trifocal approved in the U.S. in 2019, significant ocular pathology will negatively impact lens performance. He said he won’t offer this lens to patients who have any macular pathology, moderate epiretinal membrane, or significant ocular surface disease. If dry eye is mild, he’s open to treating the patient with artificial tears, plugs, 8iidra (lifitegrast, Novartis), or ,estasis (cyclosporine, Allergan). If after that course of treatment the surface improves, he’s comfortable offering them the trifocal. “But I remind them that dry eye can be a chronic disease and they’re going to have to commit to treating the dry eyes indefinitely for this trifocal lens to work its best for the rest of their life,” Dr. Scoper said. If a patient has more significant ocular surface disease, like epithelial basement membrane dystrophy, Dr. Scoper said he’ll do a superficial lamellar keratectomy to get the surface smooth. If after recovery it looks good, he’ll offer a multifocal. If patients are not candidates for “any lens with a ring in it” due to ocular conditions, Dr. Scoper considers Vivity a viable option to provide some independence from glasses. “The Vivity lens has no rings in it, so it’s not light splitting. Because it’s not light
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