EyeWorld Asia-Pacific June 2018 issue

EWAP FEATURE 15 Getting the most out of available accommodating options by Rich Daly EyeWorld Contributing Writer AT A GLANCE • The only accommodating IOLs with U.S. regulatory approval remain the Crystalens and the Trulign. • Some surgeons use the alternative of mini-monovision to target one eye to plano and the other eye slightly myopic. • Good accommodating lens candidates include those who are distance-oriented and who need sharp night vision. Possibilities and limita- tions of accommodating lens technology M ore accom- modating lens options may be coming in several years, but for the immedi- ate future, U.S. surgeons are trying to get the most out of available technology. The only accommodating plat- form approved for sale by the U.S. Food and Drug Administration (FDA) remains the single pseudoac- commodating plate haptic IOL, which comes in spherical (Crystal- ens, Bausch + Lomb, Bridgewater, New Jersey) and toric (Trulign, Bausch + Lomb) versions. A few new accommodating lenses are in the pipeline, but it is uncertain when they will be commercially available, said Elizabeth Yeu, MD , assistant professor, Eastern Virginia Medi- cal School, Norfolk, Virginia. “The various platforms are quite unique, some employing electricity to initiate accommo- dation, and different methods to create an accommodation with fluid or optic shifts to provide greater near vision,” Dr. Yeu said. Future options that are fur- thest along in clinical trials are lenses from PowerVision (Bel- mont, California) and AkkoLens (Breda, the Netherlands), said Richard Lindstrom, MD , founder and attending surgeon, Minnesota Eye Consultants. Additional lens options are at earlier stages of clinical trials. “Of special interest is Al- con [Fort Worth, Texas]/Google [Mountain View, California] and Elenza [Roanoke, Virginia] work- ing on an electronic IOL,” Dr. Lindstrom said. One new accommodating lens that completed its first phase of FDA enrollment was devel- oped by the Crystalens inventor, J. Stuart Cumming, MD , said Robert Weinstock, MD , director of cataract and refractive surgery, The Eye Institute of West Florida. Until such alternatives are approved, some surgeons have supplemented the two approved accommodating lenses with mono- focal IOLs that give broader depth of field because of the way they are designed and their spherical aber- ration, Dr. Weinstock said. He noted that the Akreos AO platform (Bausch + Lomb) has zero induced spherical aberrations. “Technically, they have more depth of field than a lens that has negative spherical aberration induced,” Dr. Weinstock said. Some surgeons use the alterna- tive of mini-monovision, or blend- ed vision, Dr. Weinstock said. That approach targets one eye to plano and the other eye slightly myopic in order to improve the depth of field and decrease dependency on reading glasses. The Crystalens provides most surgeons about 1–1.5 D of accom- modation, Dr. Weinstock said. “That means the patient still needs a pair of light reading glasses for very small print like in a newspaper or paperback book,” Dr. Weinstock said. “But for smart- phones, the dashboard of your car, midrange eating, and a lot of the more functional vision, it does well.” Good and bad candidates Since the central optic of the avail- able accommodating lenses are monofocal, many more eyes are candidates than would match with available multifocal or extended depth of focus IOLs, Dr. Yeu said. Good candidates for the accommodating lenses are pa- tients with realistic expectations, expressed understanding that reading glasses for near vision will likely be necessary, tolerance of mini-monovision, and vision needs that are more within the intermediate realm, such as com- puter use, Dr. Yeu said. “Dry eye disease should be controlled, at best, and only mild to moderate at worst,” Dr. Yeu said. “Patients can have mild macular or retinal pathology, but expectations must be clearly delineated as to prognosis of visual potential.” continued on page 16 June 2018