EyeWorld Asia-Pacific June 2018 issue

September 2017 3 EWAP EDITORIAL June 8 “ We are indeed fortunate to have available a variety of in- traocular lenses from which we can select the lens we feel offers the best balance of features that we as individual surgeons find important for our patients. ” –Graham Barrett, MD ENLIGHTENMENT W hen I began my career in ophthalmology the choice of a posterior chamber intraocular lens (IOL) was limited to a polymethylmethacrylate (PMMA) optic with different styles of either PMMA or polypropylene open loop haptics. Recognizing these limitations, I developed a hydrophilic acrylic intraocular lens which offered improved biocompatibilty and being foldable for small incision cataract surgery. Today there are several foldable materials available for IOLs and these can be broadly classified into hydrophilic acrylic, hydrophobic acrylic, and silicone materials. Each material has its own advantages—hydrophilic acrylics are extremely biocompatible but there is potential for calcification, particularly when combined with air fluid gas exchange, silicone has a similar caution when used with VR procedures, particularly with silicone oil, and currently hydrophobic acrylic material are the most popular. Concerns with long-term glistening formation that has been noted with hydrophobic acrylic materials have been addressed and the major manufacturers such as Johnson and Johnson, Bausch and Lomb, and more recently Alcon offer hydrophobic acrylic materials with minimal potential for this phenomenon. There is always a trade-off of an optic with a higher refractive index which allows a smaller incision with a full-sized optic compared to lower refractive index materials which require either a larger incision or a reduced optic size depending on the lens power. There are subtle differences in haptic design and stability. Rotational stability is particularly important with toric IOLs and has been shown to differ among the different platforms that are available. In addition, the ability to predict an accurate outcome varies with different optic and haptic designs which also influences one’s choice of a preferred intraocular lens. Finally, in addition to the lens model itself, the delivery platforms have also evolved. Preloaded systems are now available from most companies. This avoids handling the lens and facilitates insertion without exposure to the exterior of the incision. Some of the more sophisticated delivery devices are automated, which allows more control and consistent insertion. Monofocal IOLs do provide the highest quality vision but additional functionality is available to address presbyopia with multifocal as well as extended depth of focus IOLs. We are indeed fortunate to have available a variety of intraocular lenses from which we can select the lens we feel offers the best balance of features that we as individual surgeons find important for our patients. I hope the discussions of the various IOL materials and designs contained in this issue helps clarify some of the properties and features that need to be considered. I’m sure that this area will continue to evolve and we can look forward to a future with intraocular lenses that provide perfect clarity, excellent biocompatibility, and predictable spherical and astigmatic refractive outcomes. EWAP I t gives me immense pleasure to present to you the new issue of the scientifically enriched EyeWorld Asia-Pacific. Our cover features focus on the current and future intraocular lenses in the market. Those with power more than 40 D, smaller increments, extended range of focus lenses and trifocals, among many others are described. Currently, the only accommodative lenses that are approved by the U.S. FDA are Crystalens and Trulign. Hereby we enlighten you with new ones in the pipeline, patient criteria, and vision expectations. We have also added different sections on extended depth of focus IOLs, futuristic IOLs, and toric IOLs. Multifocal IOLs have become extremely popular, but where do we currently stand in terms of the associated photic phenomena? Read our article to find the combinations that work best, and how to select patients accordingly. Our next feature focuses on the intersection of refractive surgery with MIGS. Glaucoma does not necessarily exclude patients from toric or presbyopia-correcting IOLs. Our doctors share their experience of using premium lenses in such patients. MIGS has its own learning curve, but it is a good option for cataract and refractive surgeons because of its microinvasive nature. This section ends with a feature on what the future holds for refractive surgery and MIGS, such as using IOLs for IOP telemetry or as drug delivery devices. We have also added a review of practical surgical pearls while operating on cataract in eyes with long axial length. The next section highlights the interweaving of cataract and refractive surgery. The Light Adjustable Lens is making its mark as it provides patients with the visual outcomes they are looking for without having to perform corneal refractive surgery. One often faces the dilemma of a presbyopic patient without cataract. Replacing the crystalline lens with a presbyopia-correcting IOL or performing monovision LASIK are the two options one has to choose from. Read on to see what our experts have to say. In our pharmaceutical focus, we look at different surgeons’ intra- and post-cataract surgery regime. We conclude this issue with a review article on Xiidra (lifitegrast) which is the latest drug for inflammatory dry eye. As always, I would like to conclude with a quote from Tirukkural: அ�ட்செல்வம் செல்வத்�ள் செல்வம் பொ�ட்செல்வம் �ா ியார் கண்�ம் உள. The gains of compassion are most precious, material wealth is possessed even by the despicable . ( Tirukkural , Chapter 25; Quote 241) EWAP S. Natarajan, MD Regional Managing Editor EyeWorld Asia-Paci c Graham Barrett Chief Medical Editorial EyeWorld Asia-Paci c