24 EyeWorld Asia-Pacific | December 2024 About The Physicians Robert Ang, MD | Asian Eye Institute, Makati City, Philippines | rtang@asianeyeinstitute.com Nicole Fram, MD | Advanced Vision Care, Los Angeles, California | drfram@avceye.com Reference 1. Fram NR, et al. Clinical outcomes of the small aperture IOL for complex corneas with irregular astigmatism. Paper presented at the 2024 ASCRS Annual Meeting, April 5–8, 2024, Boston, Massachusetts. This article originally appeared in the September 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Relevant Disclosures Ang: Bausch + Lomb Fram: Bausch + Lomb ASIA-PACIFIC PERSPECTIVES Yeo Tun Kuan, MD Senior Consultant, Eye & Retina Surgeons 1 Orchard Boulevard, #13-03 Camden Medical, Singapore 248649 tunkuan.yeo@gmail.com Off-label Uses for a Small Aperture Intraocular Lens The Apthera IC-8 (Bausch & Lomb) is an intraocular lens (IOL) that utilizes small aperture optics via a central opaque ring. It is approved as an extended depth of focus IOL and for correction of corneal astigmatism up to 1.5D. However, the small aperture optics can also be harnessed in eyes with complex corneas to reduce higher order aberrations as it filters out undesirable peripheral light. At times, we encounter patients with complex corneas with irregular astigmatism and high higher order aberrations (HOAs) that are not suitable for a variety of IOLs. These patient scenarios limit our choices to monofocal IOLs and yet we yearn to provide these patients with a better quality of vision. Examples are eyes with previous radial keratotomy, decentered laser vision correction with coma, penetrating keratoplasty, keratoconus or corneal scars. Eyes with highly irregular astigmatism cannot be corrected adequately by a toric IOL. Similarly for eyes with high HOAs, patients frequently end up requiring gas rigid permeable contact lenses, which may not be suitable for all of them. The IC-8, being an intraocular lens-based solution that is able to negate these issues, definitely is a welcome addition to our surgical options. When using the IC-8, patient selection and counseling remain important. Corneal topography and aberrometry are required to determine the amount of corneal irregularity and HOAs. A variety of aberrometers are able to simulate whether a smaller pupil size would improve visual quality. This is a useful tool to determine whether the patient would benefit from the IC-8. As the IOL filters out some light, it is imperative to inform the patient of the dimming effect of the IOL, especially in low lighting. This can be simulated in patients with less significant cataracts using Pilocarpine eye drops, to gauge their acceptability. I do wish for a manufacturer to provide a pinhole contact lens that can provide simulation without the need to apply eyedrops. In addition, it is also important to examine the mesopic pupil size of the patient, as too large a pupil can potentially lead to halos at night. I also agree that the pupil, when pharmacologically dilated, needs to be adequately large to allow easy laser capsulotomy in the event of posterior capsular opacification in the future. I feel that the Apthera IC-8 is a welcomed IOL that provides us with greater options especially in eyes with complex corneas. It fills a gap in our surgical armamentarium to benefit these patients who otherwise would not have many other choices. Editors’ note: Dr. Yeo Tun Kuan is a consultant for Alcon, Bausch & Lomb, and Zeiss, but has no financial interests related to the comments. CATARACT
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