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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