EyeWorld India December 2021 Issue

REFRACTIVE EWAP DECEMBER 2021 23 focusing where the problem is,” Dr. Bafna said, explaining that as the lens continues to get worse, cornea-based options lose more of their effect. With lens-based options, you either wait for the patient to develop a cataract or you perform a refractive lens exchange before a cataract develops, he said. There are a lot of different lenses in development, Dr. Bafna said. Surgeons currently have access to multifocal and extended depth of focus lenses. “In the past, most multifocal lenses we employed were bifocal lenses,” he said. “When PanOptix [Alcon] got approved in the U.S., that changed things to where we got to the same level as the rest of the world.” He added that more trifocal lenses are being developed, and these tend to be more effective, covering distance, intermediate, and near vision. The main downside of multifocal lenses is they use a diffractive optic that splits light, so patients will have some dysphotopsia, especially at night. As the technology has improved, the amount of dysphotopsia has been reduced, he added. Extended depth of focus lenses include the Symfony (Johnson & Johnson Vision) and Vivity (Alcon). Symfony has a diffractive optic, which could have some degree of dysphotopsias, and it doesn’t give as much near vision, Dr. Bafna said. “What’s unique about Vivity is it’s the first and only non-diffractive IOL, so it does not split light,” Dr. Bafna said. “It has a dysphotopsia profile that’s similar to other monofocal lenses and gets distance and intermediate and some functional near while avoiding dysphotopsia.” Dr. Waring said he thinks one of the most exciting areas of presbyopia surgery is lens replacement procedures. “We now have femtosecond lasers, which are intuitive to patients looking for laser vision correction,” he said. There is also a selection of presbyopia-correcting refractive implants that can really deliver on both quantity and quality of vision, he added, as well as a rich pipeline of implants in development that have great promise. “We think of presbyopia as one of the emerging subspecialties within the specialty of refractive surgery and refractive cataract surgery,” Dr. Waring said, adding that a large portion of his practice is dedicated to the art and surgical management of presbyopia. He said there are more diagnostics geared toward diagnosing the different stages of the dysfunctional lens, which will help clinicians make a better decision in terms of what type of treatment is appropriate. Pharmacological options Another presbyopia treatment in development is the use of eye drops, though no product is currently approved by the FDA. Dr. Waring served as the principal investigator for the Allergan clinical trial for a novel eye drop for the treatment of presbyopia. If approved, it will be the first eye drop to help reduce dependence on reading glasses and contact lenses for the treatment of presbyopia. He said there are a number of other drops in development as well, though other products are earlier in the development process than the Allergan one. “These drops will likely serve as a gateway to help the public and eyecare providers understand what presbyopia is,” he said. “It is a naturally ubiquitous condition that can be helped, and they will have an alternative to reading glasses, bifocals, and contact lenses. These could be perfect for those that are recently experiencing the earlier stages of lens dysfunction.” Dr. Bafna highlighted the eye drops under investigation, primarily in clinical trials. Some of them are based on the concept of pupil constriction, which increases the overall depth of field. The idea is that patients will only have to apply drops once or twice a day. Dr. Bafna said the drops look promising overall. For patients who want a stop gap measure between glasses or contacts and a surgical procedure, he thinks these drops are a good noninvasive methodology. EWAP References 1. Waring GO, Rocha KM. Characterization of the dysfunctional lens syndrome and a review of the literature. Curr Ophthalmol Rep . 2018;6:249–255. 2. Mercer RN, et al. Future trends in presbyopia correction. J Refract Surg . 2021;37:S28–S34. Editors’ note: Dr. Bafna practices at Cleveland Eye Clinic, Brecksville, Ohio, and has interests with Alcon, CorneaGen, and Carl Zeiss Meditec. Dr. Waring practices at Waring Vision Institute, Mt. Pleasant, South Carolina, and has interests with Ace Vision Group, Allergan, and Johnson & Johnson Vision.