REFRACTIVE EWAP DECEMBER 2023 37 that’s a wonderful opportunity for someone who has a cornea that’s severely aberrated because of keratoconus or RK,” he said, noting that surgeons using the IC-8 Apthera internationally are generally only using it bilaterally in extreme cases. There is the possibility of dimming, but Dr. Williamson said that this may be a small sacrifice for good functioning vision in both eyes. “If you have someone not doing a lot of nighttime driving, usually they’re willing to give that up. It’s not dissimilar to having the halo / glare / starburst talk with multifocal/EDOF patients,” he said. “The vast majority are more than happy to deal with that to have the gain that they do have. I think that bilateral IC-8 Apthera is going to be more common for those eyes.” “If you do an LAL in the first eye, you know what their reading is going to be like, and if you think they’re not a monovision candidate, I might not put an LAL in second eye. I would do IC-8 Apthera on label,” Dr. Stonecipher said. He added that if you have a patient in whom you’re uncertain if monovision will work, and they haven’t had it before, an LAL would be a benefit, and it helps the patient know what they’re getting when choosing for the second eye. Dr. Williamson said that one thing that has surprised in terms of the final visual outcome; there’s a lot more variability in our calculations,” Dr. Bafna said, adding that these patients may also have diurnal fluctuations. There are some patients who may not be ideal candidates for this lens. Dr. Bafna noted that due to the filter in the lens, most patients will get 30–40% less light coming into their eye. If you use it unilaterally, it’s important to let patients know that they will notice that there’s less light and things will appear dimmer in that eye. “A lot of our patients have monovision prior to cataract surgery,” he said, “but before cataract surgery, the natural lens gives them a bit of additional range of vision. One technique often used to simulate monovision is to put a monofocal lens in both eyes.” The whole concept is range of vision, Dr. Bafna said. “A monofocal at near will be good at a particular point, but if you move your hand in and out, it gets out of focus. What’s nice about this lens is I can target –1 or –1.25, so I can give patients that entire range of vision.” Karl Stonecipher, MD, said he has been familiar with this lens for some time. “On label, we’re looking at those patients who are a good monovision fit,” he said. “For me, they have less than 2 D of cylinder because the lens neutralizes 1.5 D. … I think for that classic depth perception monovision patient who wants great distance, it’s a fantastic lens.” In patients who have a highly aberrated cornea — whether RK, hexagonal RK, LASIK with decentration, PRK with higher order aberrations and small optical zones, or keratoconus— Blake Williamson, MD, said these patients do exceptionally well with the lens. He will usually start with the most aberrated eye first to see how the patient does. Dr. Williamson noted that he’s generally using the IC-8 Apthera for off-label indications. If you ask most refractive surgeons, if the patient has a healthy cornea and desires presbyopia correction, the surgeon is most likely going to use an EDOF / multifocal / trifocal IOL, he said. The area where there’s been a need is in the post-RK, keratoconic, and post-LASIK space. While the Light Adjustable Lens (LAL, RxSight) is available, Dr. Williamson said this can be a heavy lift for some surgeons and patients in terms of the capital expense, the number of visits required to lock in refraction, and the need to wear glasses in between treatments. “The thought is that we have another device we can use without having to spend any money on a machine, and it fits better into the workflow for those difficult to treat eyes,” he said. Dr. Williamson has been combining the IC-8 Apthera in the non-dominant and the LAL in the dominant eye. “To me Figure 2. Macular OCT through the left eye IC-8 Apthera of the same patient.
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