EyeWorld India June 2015 Issue

15 June 2015 EWAP FEATURE starts with good topography and refractions preoperatively, he said. Measure multiple topographies on different devices to ensure that it’s regular astigmatism and that the measurements are repeatable from device to device. Some residual astigmatism is often tolerated with monofocal IOLs, Dr. Henderson said, but with multifocal IOLs, even small amounts can lead to poor vision and patient dissatisfaction. Her goal is to leave the patient with less than 0.5 D of residual astigmatism by operating on the steep axis or making LRIs or laser corneal incisions. New lens options The first toric multifocal IOLs will likely enter the U.S. market this year, allowing physicians to loosen the astigmatism restrictions and offer the technology to a whole new group of patients. “I’m eagerly awaiting the new multifocal designs that are coming out,” Dr. Koch said. “I think that the toric multifocal would be a wonderful advance, and I’m looking forward to recently approved lower- add multifocal IOLs from AMO [Abbott Medical Optics, Abbott Park, Ill.].” A toric version of the AcrySof IQ ReSTOR multifocal IOL (Alcon, Fort Worth, Texas) will be available to U.S. physicians this year, as well as a lower add version of the lens (the ReSTOR +2.5 D), which will give patients sharper distance vision. In addition to toric and low add versions of existing multifocals, Drs. Koch and Weinstock are looking forward to the approval of the TECNIS Symfony extended range of vision lens (AMO) in the U.S. The Symfony’s diffractive echelette design elongates the focal point, giving the wearer a continuous, full range of vision, with incidences of glare and halos comparable to a monofocal IOL. “I think that’s going to be one of the most optimal options we’re going to have going forward for our patients,” Dr. Koch said. The Symfony’s advanced optical system might be a tipping point in reducing unwanted side effects associated with multifocals, Dr. Weinstock said, which could lead to implantation in a larger percentage of patients. ‘Mix and match’ lenses Bilateral implantation is the most tried and true way of using a multifocal lens, Dr. Weinstock said, allowing the brain to receive similar images and facilitating neuroadaptation, but some surgeons have had success mixing and matching multifocal and monofocal IOLs. Dr. Koch will sometimes operate on the non-dominant eye first and implant a multifocal IOL. “If they are pretty satisfied with the near vision but bothered by the halos, I might do a monofocal in the fellow eye,” he said. For a seasoned refractive cataract surgeon, a similar option would be to put a monofocal or Crystalens accommodating IOL (Bausch + Lomb, B+L, Bridgewater, NJ) in the dominant eye to give the patient crisp, high-resolution vision, and then place a multifocal IOL in the non-dominant eye, Dr. Weinstock said. Although there has been success with this technique, Dr. Weinstock said, he sees it as a niche procedure rather than a mainstream one. “It’s a little bit more work to start mixing and matching—it takes more time and energy,” he said. “There have been some studies that show it’s beneficial, but in my opinion, it’s going to be a niche methodology.” “Patients are often happier with their uncorrected near vision when both eyes are implanted with multifocal IOLs,” Dr. Henderson said. “If patients only have one eye implanted, usually that eye allows them to have some functional near vision for short-term vision such as reading the cell phone or looking at a price tag. However, without bilateral implantation, some patients may not feel that their uncorrected near vision is sufficient for longer-term reading. “The benefit of having one multifocal IOL and one distance corrected monofocal IOL is that the patient truly understands the benefits of the multifocal IOL and is usually happy to have at least one eye that can read without glasses.” Dr. Koch thinks that adoption of the mix and match technique will depend on the lenses available. “I think as our options expand, it will be tempting to do more mixing and matching, but we’ll have to see,” he said. “For example, when a lens like the Symfony comes out, which gives distance and intermediate and some near, one could implant that in the dominant eye, and for the non- dominant eye, one could decide whether or not to go for more near vision with a multifocal or perhaps more safely elect micro-monovision with the Symfony.” Future of multifocals Multifocal IOLs—and presbyopia- correcting lenses in general—make up less than 10% of cataract surgeons’ annual volume, according to the 2014 ASCRS Clinical Survey. But if these new technologies can offer patients better visual outcomes and fewer unwanted effects, surgeons will gain more confidence and use them more often, Dr. Weinstock said. “The FDA focuses on safety and the efficacy, but in the real world it’s about the outcomes and the patient happiness,” he said. “Ultimately the patients and doctors decide whether or not the technology is prime time or whether it’s something that is not good enough to be in patients’ eyes.” “To me, the ultimate goal is to find a solution that will enable us to get rid of multifocals,” Dr. Koch said. “They’re a wonderful interim solution with many happy patients, but they compromise vision a bit with regard to clarity and certainly with regard to halos and driving at night. With lenses like the Symfony on the horizon, I hope that we will at last have implants that adequately increase depth of focus with little or no visual compromise.” EWAP Editors’ note: Dr. Weinstock has financial interests with Alcon, B+L, and STAAR Surgical (Monrovia, Calif.). Dr. Koch has financial interests with Alcon and AMO. Dr. Henderson has financial interests with Alcon, AMO, and B+L. Contact information Henderson: bahenderson@eyeboston.com Koch: dkoch@bcm.edu Weinstock: rjweinstock@yahoo.com