1 EyeWorld Asia-Pacific | March 2025 Scan the QR Code or visit www.eyeworldap.apacrs.org for more information. NEW SOLUTIONS TO EXISTING PROBLEMS PLUS Ridley Lecture 2024, presented at the 42nd Congress of the ESCRS in Barcelona: Late Decentration Of IOLs – An Enigma In Trend And In Sight: AI For Surgical Training – A Look Into The Future Vol. 21 No. 1 March 2025 The Asia-Pacific Association of Cataract and Refractive Surgeons
2 EyeWorld Asia-Pacific | March 2025 SPONSOR AD . ™ IOL, ATTAIN PEACE OF MIND with TECNIS PureSee the new purely refractive presbyopia-correcting EDOF IOL.1 TECNIS PureSee™ IOL with continuous-power technology1 provides better predictable patient outcomes2-5, ensuring high patient satisfaction6 and peace of mind for you Find out more with a J&J representative. References: 1. TECNIS PureSee™ IOL, Model ZEN00V DFU INT, Z311973, current revision. 2. DOF2023CT4011 - Simultions of visual symptoms under defocus for TECNIS PureSee™ IOL. 29 March 2023. 3. DOF2023CT4041 - Clinical investigation of the TECNIS™ IOL, C1V000 and C2V000 Tolerance to Refractive Error. 17 July 2023. 4. Black D. et al. Clinical investigation of tolerance to residual refractive errors following implantation with a refractive extended-depth-of-focus (EDF) IOL. Abstract ESCRS 2023. REF2023CT4129. 5. Bala C, et al. Superior intermediate and uncompromised distance quality of vision with a purely refractive extended depth of focus IOL. Abstract ESCRS Vienna 2023. REF2023CT4128. 6. DOF2023CT4043 - Clinical investigation of the TECNIS™ IOL C1V000 and C2V000. Patient Satisfaction Outcomes 18 July 2023. Australia: AMO Australia Pty Ltd, 1–5 Khartoum Road, North Ryde, NSW 2113, Australia. New Zealand: AMO Australia Pty. Ltd 507 Mount Wellington Hwy, Mount Wellington, Auckland 1060, New Zealand. © Johnson & Johnson Surgical Inc. 2024, 2024PP05503.
3 EyeWorld Asia-Pacific | March 2025 CONTENT CATARACT 12 How To Discuss IOL Options With Patients 18 Latest Lessons Learned With The Light Adjustable Lens 22 Allergies Or Intolerance To Materials Used In Cataract Surgery CORNEA 40 Expanded Treatment Options In Dry Eye 44 Corneal Cell Therapy: Current Status And Looking To The Future 50 Preservatives In Ophthalmic Medications And Alternative Strategies NEWS & OPINION 59 AI For Surgical Training – A Look Into The Future GLAUCOMA 53 Is Gonioscopy Dead? 56 Helping Glaucoma Patients Understand Their Disease And Treatment Options EDITORIAL 4New Solutions To Existing Problems FEATURE 8Late Decentration Of IOLs – An Enigma Ridley Lecture 2024, presented at the 42nd Congress of the ESCRS in Barcelona REFRACTIVE SURGERY 29 A Shift Toward RLE 26 Crosslinking: Then, Now, And Next Up 34 AI Expanding In Refractive Surgery
4 EyeWorld Asia-Pacific | March 2025 Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India EDITORIAL BOARD Chief Medical Editor Graham Barrett, MD INDIAN EDITION Regional Managing Editor Abhay Vasavada, MD Deputy Regional Editor S. Natarajan, MD KOREAN EDITION Regional Managing Editor Hungwon Tchah, MD Deputy Regional Editor Chul Young Choi, MD APACRS Publisher: EyeWorld Asia-Pacific Edition (ISSN 1793-1835) is published quarterly by the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Printed in Singapore. Editorial Offices: EyeWorld Asia-Pacific Edition: Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Advertising Office: EyeWorld Asia-Pacific Edition: Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (1-703) 975-7766, email don@apacrs.org. Copyright 2021, Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Licensed through the American Society of Cataract & Refractive Surgery (ASCRS), 4000 Legato Road, Suite 700, Fairfax, VA 22033-4003, USA. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. The ideas and opinions expressed in EyeWorld Asia-Pacific do not necessarily reflect those of the editors, publishers or its advertisers. Subscriptions: Requests should be addressed to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Back copies: Subject to availability. Contact the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Requests to reprint, use or republish: Requests to reprint or use material published herein should be made in writing only to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, telephone (65) 6322-7469, fax (65) 6327-8630, email ewap@apacrs.org. Change of address: Notice should be sent to the APACRS publisher, c/o Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, six weeks in advance of effective date. Include old and new addresses and label from a recent issue. The APACRS publisher cannot accept responsibility for undelivered copies. KDN number: PPS1766/07/2013(022955) MDDI (P) 013/02/2025 CHINESE EDITION Regional Managing Editor Yao Ke, MD Deputy Regional Editor He Shouzhi, MD Zhao Jialiang, MD Assistant Editors Zhouqi, MD Shentu Xingchao, MD EDITORIAL MEMBERS Chan Wing Kwong, MD Singapore Ronald Yeoh, MD Singapore John Chang, MD Hong Kong SAR Pannet Pangputhipong, MD Thailand YC Lee, MD Malaysia Hiroko Bissen-Miyajima, MD Japan Kimiya Shimizu, MD Japan Sri Ganesh, MD India Chee Soon Phaik, MD Singapore Johan Hutauruk, MD Indonesia PUBLISHING TEAM Chief Publisher Ronald Yeoh, MD Executive Director Kathy Chen kathy.chen@apacrs.org Publishing Consultant Donald R Long don@apacrs.org Production Team Gretel Tan Aileen Bian ewap@apacrs.org EDITORIAL “How to discuss IOL Options with Patients” is a topic of interest to all surgeons who perform cataract and implant surgery. Individual surgeons will vary in their approach, which is influenced by their own experiences. Patients do need to be informed of the alternatives, when taking their personal needs and preferences into account. As physicians, we have a responsibility that extends beyond listing numerous options, as the process can be overwhelming. It can become time-consuming and it may be unrealistic to expect patients with little understanding of optics to fully comprehend the impact of their selection. Our role therefore, includes dispensing professional advice to patients on the pros and cons of lens selection, including information on the expected refractive outcomes, so their expectations are realistic. Although some of the interaction can be delegated to technicians and optometrists for efficiency, I do believe that the onus is on us as surgeons, to establish trusting relationships with our patients. The surgeon, therefore, should still bear the primary responsibility when counselling patients on lens selection and refractive outcomes prior to cataract surgery. New Solutions To Existing Problems
5 EyeWorld Asia-Pacific | March 2025 An important component that needs to be considered, is the presbyopic solution that you recommend to your patient, especially when considering the many options that are available today. The total number of different options that are available can be confusing to patients and, indeed, to their surgeon. Not all surgeons will offer the same advice, yet we have an obligation to offer the solution that we truly believe provides the best balance of optical quality and addresses near vision for our patients. Based on these principles, I have personally found discussing lens selection and presbyopia options to be a straightforward matter. It is no longer acceptable to leave a patient with significant astigmatism, and I attempt a target of less than 0.5 D residual astigmatism in all of my patients. Although I have used multifocal lenses in the past, modest monovision with a target of -1.25 D has provided an effective solution for presbyopia. The counselling involved is straightforward and not timeconsuming. Although I do not promise spectacle freedom, many patients are delighted to find that they can manage without spectacles especially if the modest monovision is combined with an EDOF IOL incorporating positive spherical aberration. I have only used two IOLs in the past 10 years: either a monofocal Toric, or an enhanced depth of focus/EDOF IOLs based on these principles. For our current issue of EyeWorld Asia-Pacific, it is clear that there are other approaches to discussing lens selection, and that all have merit. I would simply recommend that you find a pathway that has proven successful in your practice, and advise your patients accordingly. Warmest regards, Graham Barrett LEARNING FROM THE MASTERS IMPORTANT DATES apacrs2025.org Dada Harir Stepwell in Ahmedabad, India 21 MAY 2025 Deadline for 1st Tier Early Bird Registration Rates Deadline for Submission of ePosters and Videos for Film Festival • 21 JUNE 2025 Deadline for 2nd Tier Registration Rates • 22 JUNE 2025 ONWARDS On-site Registration Rates Apply
6 EyeWorld Asia-Pacific | March 2025 EDITORIAL Abhay Vasavada Regional Managing Editor EyeWorld India As always, this issue of Eyeworld Asia-Pacific brings us cutting-edge content and discussion. I note two prominent features within this current issue, both of which give us a good guide to consider the future. There is a discussion on a recently-emerging issue of the late decentered IOL. While it is known that pseudoexfoliation and other diseases associated with zonular weakness can cause a subluxation of the entire capsular bag which holds the IOL, dead bag syndrome is being recognized more among surgeons. Here, there is a spontaneous rupture in the posterior capsule in an in-situ capsular bag. Thus, this condition is truly an “IOL decentration” and not a bag decentration. The fact that there is a spontaneous rupture in the posterior capsule is intriguing. The culprit for this is the death of equatorial lens epithelial cells in the capsular fornices, leading to degeneration of the posterior capsule. At this point, unanswered questions include who will develop the disease, why only certain people develop it, why males predominantly develop the disease. The question remains: is there a relation with the kind of surgical technique or IOL choice? This new disease entity also presents an opportunity for us to better understand it, so as to develop better solutions. This issue of late IOL decentration also comes to mind, since we are now operating on cataracts during a much earlier stage. Refractive lens exchange is gaining ground, one of the other features in this issue. Today, there are so many different options for IOL selection, and I am sure the readers will enjoy the up-front practical tips that experts have shared on how to help patients make an informed choice on the type of IOL. What comes up from the experts’ opinions is that although we have all the counseling tools and counselors, it is usually the ophthalmologist who will be pivotal in making that final decision. So, it is equally important that we ourselves remain abreast of the pros and cons of each option we offer in our practice, and of what is coming in the near future. It is interesting to look at the two contrasting realities that present within the space of cataract surgery:one, where we aim to provide the finest quality and quantity of spectaclefree vision, even in clear lenses, and the other, where we have now started seeing remote but definite instances of late decentration of IOLs and particularly, dead bag syndrome. Would this also mean that we should start talking about this rare possibility to our patients undergoing a “routine” lens extraction and IOL implantation? What happens to patients who undergo surgery in their fifties and then have a long, active lifespan ahead of them? I am very hopeful that we will keep thinking laterally, to find answers to new problems and challenges presented to us!
7 EyeWorld Asia-Pacific | March 2025 LEARNING FROM THE MASTERS PROGRAM HIGHLIGHTS Visit www.apacrs2025.org for regular updates. APACRS LIM LECTURE The APACRS LIM Lecture is the highest award of the society. Outstanding ophthalmologists who have made extraordinary contributions to the development of cataract and refractive surgery have been invited to deliver this prestigious lecture at its annual meetings. Join us as Prof Thomas Kohnen delivers the 2025 APACRS LIM Lecture titled Bridging Laser and Lens Extraction – The evolution of phakic IOLs on Friday, 22 August 2025. MASTERCLASSES Covering the most relevant and focused topics and conducted by some of the world’s leading surgeons on Thursday, 21 August 2025! Expect the hottest topics in ophthalmic surgery today, where you will learn to master Biometry, Corneal Endothelial Transplantation, Intrastromal Refractive Surgery Updates, IOL Fixation, MIGS for the Phaco Surgeon, Paediatric Cataract Surgery, Phaco 2025, Phaco Complications, Phakic IOLs, Toric IOLS, Vitrectomy & OCT for the Cataract Surgeon, and What They Don’t Teach You in Residency. SCIENTIFIC SYMPOSIA Exciting symposia covering General Cataract, IIIC Lectures – The Perfect Save!, Managing Challenging Cases, Navigating Cataract Complications, Presbyopia... Seeing It All, Refractive Surgery Updates, Today’s Innovation Tomorrow’s Impact, What Would You Do? and What’s New In IOLs? COMBINED SYMPOSIUM OF CATARACT & REFRACTIVE SOCIETIES (CSCRS) – Masters Don’t Always Agree! This combined symposium of the three leading cataract and refractive societies (APACRS, ASCRS, and ESCRS) will look at areas of contention in our constant pursuit of precise and perfect outcomes. There are many ways to achieving optimal outcomes and this symposium will address the most topical controversies in our field covering immediate sequential cataract surgery versus delayed cataract surgery, presbyopia correction in the eye versus on the eye, correcting low astigmatism through corneal incision versus using toric IOL. Join us at this thought-provoking session on Friday, 22 August 2025! APACRS FILM FESTIVAL The APACRS Film Festival entertains and educates, creatively displaying new innovations and breakthroughs in anterior segment ophthalmic surgery. Don’t miss this exciting session on the evening of Friday, 22 August 2025. WISDOM FROM THE GURUS – Top Cataract Surgery Tips Some of the most renowned cataract surgeons each offer practical cataract surgery tips that surgeons can use immediately on their next visit to the operating theatre. Join us to learn top practical tips from experts on Saturday, 23 August 2025. The 37th APACRS Annual Meeting will be held in Ahmedabad, a prominent cultural and industrial hub in India that offers colourful landscapes, unique culinary delights and the famous garba dance. Co-hosted with Ahmedabad Ophthalmological Society (AOS) and the All Gujarat Ophthalmological Society (AGOS) and supported by Intraocular Implant & Refractive Society of India (IIRSI), the 37th APACRS annual meeting promises to deliver a great learning experience in 2025. The hunger for more knowledge and quality education in our delegates means that we always strive to present an up-to date yet relevant and practical scientific meeting.
8 EyeWorld Asia-Pacific | March 2025 FEATURE Ridley Lecture 2024, presented at the 42nd Congress of the ESCRS in Barcelona by Abhay Vasavada, MD Late Decentration Of IOLs – An Enigma How often do we face this question from a healthy patient with healthy eyes undergoing cataract surgery: “Doctor, will I need to change the IOL in future? Is it going to last all my life?’’ Late decentration of IOL following an uneventful inthe-bag IOL implantation occurring several years later manifests in two ways. One: where decentration of the entire capsular bag containing the IOL occurs. Although we describe this as an IOL decentration, it is the bag which decenters and it is primarily a zonular disease (Figure 1 & 2). Risk factors for this zonulopathy are well studied, pseudoexfoliation being a number one cause. The other way the late decentration occurs several years following uneventful cataract surgery is as a result of spontaneous rupturing of the posterior capsule (Figure 3), primarily a capsular disease. Globally speaking, quite a few surgeons have been reporting this condition in recent times, and across various platforms. This entity was recently coined by Dr. Samuel Masket as the Dead Bag Syndrome1. In the Dead Bag Syndrome, the capsule remains very clear without fibrotic changes and very thin (Diaphanous). Typically, posterior capsule rupture occurs but the capsule bag remains in-situ with total or partial zonular support1 (Figure 4). Figure 1: (Left) Capsular Phimosis and Fibrosis with a decentered bag, with IOL inside the bag. (Right) Total dislocation of the bag along with IOL and Capsule Tension Ring (CTR) on the retina. Source: Abhay Vasavada, MD Figure 2: Schematic illustration of Zonulopathy; Left panel shows the intact zonules and right panel shows zonular breaks. Source: Abhay Vasavada, MD
9 EyeWorld Asia-Pacific | March 2025 FEATURE Figure 3: Illustration depicts different patterns of lens malposition in Dead Bag Syndrome. Left panel shows the intact lens capsular bag with IOL in situ. The right side top panel shows decentration of IOL inside the bag, the middle panel shows partial dislocation of IOL and the bottom panel shows the complete dislocation of IOL. Source: Abhay Vasavada, MD Figure 4: Posterior capsule rupture with intact anterior capsulorhexis, stable bag in situ and decentered IOL. Source: Abhay Vasavada, MD Figure 5: (Left) Posterior capsule rupture (PCR) with intact capsulorhexis and significant decentration of a single-piece hydrophobic acrylic intraocular lens (IOL). (Right) Fellow eye of the same patient showing a PCR with clear capsular bag and stable, in the bag three-piece hydrophobic acrylic IOL. Source: Abhay Vasavada, MD In contrast, in eyes with zonulopathy, the entire bag containing the IOL gets displaced. Dr. Liliana Werner and the team at Moran Eye Centre showed on histopathological evaluation that there are scanty to no Lens Epithelial (LE) cells at the germinative zone located at the equator of the capsule bag and found a diaphanous frail capsule. There isn’t much information in the literature about the clinical features, risk factors and outcomes following surgical management in cases with the dead bag syndrome. We reported clinical features and risk factors of Dead Bag syndrome (in press, American Journal of Ophthalmology). From June 2021 to July 2024 we had seen 88 eyes with late decentration of IOLs of which 50 Eyes (57%) had confirmed diagnosis of Dead Bag syndrome. In 58% of these eyes, the entire or part of the IOL was inside the bag. In 30% of the eyes, entire IOL was found dislocated into the vitreous. Seven patients in our series had bilateral spontaneous posterior capsule rupture (PCR), yet four of these had an IOL decentration only in one eye with stable IOL in the fellow eye. (Figure 5). Thus, the dead bag syndrome is a disease with a spectrum of clinical manifestations, ranging from spontaneous PCR with a stable IOL, to IOL decentration within the bag, segmental zonulolysis and even total dislocation of the IOL. The mean age at the time of IOL exchange surgery was 67 years. In the majority, the decentration occurred between 11 to 20 years post-primary cataract surgery. A glaring finding from our study is the significant male preponderance. 93% of the eyes belonged to male patients. Another risk factor associated with the dead bag syndrome was axial myopia. 52% of eyes had an axial length (AL) of ≥ 24 mm. It was interesting that no patient had axial length < 22.5 mm. Other studies have reported myopia to be an important predisposing factor for late bag decentration, resulting from zonular weakness. However, the association of myopia with the dead bag syndrome was not well known. The presence of a variety of IOL materials including hydrophobic, hydrophilic and PMMA have been reported in eyes with dead bag syndrome. In our series, 70% were hydrophobic IOLs while the rest were hydrophilic and PMMA. Hydrophobic acrylic IOL has been used more commonly in our hospital as well as in the country during the early 2000s. The association of
10 EyeWorld Asia-Pacific | March 2025 About the Physicians Abhay Vasavada, MS, FRCS (England) | Raghudeep Eye Hospital, Ahmedabad, Jaipur, India | icirc@abhayvasavada.com Reference 1. Culp C, Qu P, Jones J, Fram N, Ogawa G, Masket S, Mamalis N, Werner L. Clinical and histopathological findings in the dead bag syndrome. J Cataract Refract Surg 2022;48(2):177-184. doi: 10.1097/j.jcrs.0000000000000742. 2. Yamane S et al. Flanged Intrascleral Intraocular Lens Fixation with Double – Needle Technique, Ophthalmology, 2017;124:1136–1142. 3. Sumioka T, Werner L, Yasuda S, Okada Y, Mamalis N, Ishikawa N, Saika S. Immunohistochemical findings of lens capsules obtained from dead bag syndrome patients. J Cataract Refract Surg 2024;50(8):862-867. doi: 10.1097/j.jcrs.0000000000001472. 4. FROM THE EDITOR - The dead bag syndrome, Liliana Werner, MD, PhD, Copyright © 2022 Published by Wolters Kluwer on behalf of ASCRS and ESCRS Published by Wolters Kluwer Health, Inc. 0886-3350/$ - see frontmatter https://doi.org/10.1097/j.jcrs.0000000000000930 Relevant Disclosures Vasavada: None IOL material / design remains uncertain with this sample size but warrants further exploration. Only one patient had pseudoexfoliation. Surgery remains the only option. The good news is that there are many options including iris claw lens, refixation / transscleral fixation of the IOL using prolene or Gore-Tex sutures, or exchange of the IOLs using intrascleral fixation with Glued or Yamane technique. Whatever option the surgeon decides, the role of vitrectomy remains indispensable. Working with retinal colleagues is mandatory, in my opinion. Our preference has been the Yamane technique2. The key is to mark the appropriate meridian in the precise way and also mark the distance from the limbus, for penetration of 30 Gauge thin walled needle. It is important to look for Soemmering’s Ring located in the capsular fornices. We detected moderate to extensive degree of Soemmering’s ring in 72% of eyes. This is a result of epithelial mesenchymal transformation (EMT) of the LE Cells located at equator of the capsular bag. Therefore, in the language of Cell biologists, the cells are active and not dead. Histopathological examination reveals split/delaminated capsules and importantly, scanty to no LE cells at the equatorial region of the bag1,3,4. The split capsule is an attempt by remaining LE cells to synthesize and support the frail capsule, also known as pseudo capsule. The million dollar question is: why does it develop only in very few patients, and several years after the primary cataract surgery? For this, we carried out whole exome sequencing in 27 patients. We studied two groups of genes for gene variants: one responsible for survival of the LE cells, and others responsible for the integrity and health of the posterior capsule. We found 6 variants showing remarkably significant higher odds ratios in dead bag cases, in genes responsible for LE cell survival compared to controls with healthy eyes. When we looked into the group of gene variants responsible for posterior capsule integrity, we found 28 variants. So we believe that these genetic variants found in our study could predispose LE cells to undergo programmed cell death, known as apoptosis, and predispose posterior capsules to lose their integrity over a period of time. Whether vitreous plays any role in making the posterior capsule frail remains speculative. But, what does all of this mean to our patients and to us? For our patients, we realize that sudden visual impairment at such a late stage in their life is very impactful as they depend very much on the visual function at that critical phase of their life. For us, the clinicians, we need to emphasize to the patient the importance of remaining under the follow up for his / her lifetime. It is very important that the clinicians and the scientists continue their endeavor together so that spontaneous posterior capsule rupture and the dead bag syndrome no longer remain an enigma. Hopefully, we should be able to predict this event in future and be prepared to change the IOL strategy for implantation. FEATURE
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12 EyeWorld Asia-Pacific | March 2025 CATARACT by Liz Hillman, Editorial Co-Director How To Discuss IOL Options With Patients There are an abundance of choices available for patients and their respective visual scenarios or outcomes—especially with the great opportunity in the world of IOLs. These opportunities, however, also come with a challenge: how to discuss these options efficiently, in a targeted manner without overwhelming or confusing patients. EyeWorld spoke with three members of its Cataract Editorial Board to learn how they manage these discussions (multiple times a day) and gain insights on how their patient conversations have evolved over the years. ‘It sure does add up’ Rosa Braga-Mele, MD Dr. Braga-Mele begins her process of IOL selection and the patient conversation by narrowing down what she needs to focus on based on the patient’s eye anatomy. She noted several factors that could preclude patients from opting for certain advanced-technology IOLs. “Having said that, my patients are all given a sheet that shares what lenses are available, and it’s a broad brushstroke of lenses. Before they even see me to get anything done, they’re reading this list,” Dr. Braga-Mele said. “They have time while in the waiting room, to digest that, and may have some questions they want to ask regarding their eligibility. The first question I ask them is: do they mind wearing glasses, or do they want the opportunity to get rid of glasses for 90–95% of their tasks?” If the patient says they’re OK with wearing glasses, the conversation about their lens option can take just one minute. If the patient has astigmatism and is willing to pay for the lens, Dr. Braga-Mele said a toric IOL is a “nobrainer.” “I think the hardest category is the presbyopia-correcting lens category because it now becomes halo and glare that you have to discuss with your patient,” she said, noting that her conversation with patients interested in presbyopiacorrecting IOLs takes about 5 minutes, and they usually require an additional tele-consultation. If the patient is interested in a full range of vision and says they would tolerate halo and glare, Dr. Braga-Mele discusses trifocal options. If they’re interested in some range of vision but are less tolerant of halo and glare, she’ll discuss EDOF options. She then lets the patient go home and will schedule a phone consultation with them if they want to review the lens options further.
13 EyeWorld Asia-Pacific | March 2025 CATARACT Dr. Braga-Mele said her conversation with patients about these options can be revealing as well. “Depending on the patient’s questions, their astuteness, and their level of anxiety, sometimes their questions make me go, ‘Maybe this patient is not good for a trifocal IOL because nothing is going to make them happy,’” she said. To further understand patient personalities, Dr. BragaMele said she’ll often reveal a bit about her own. “Sometimes I say to patients, ‘I can be very particular about doing things a certain way. I am just meeting you for the first time, so can you tell me what your personality is like because then I’ll know what kind of lens suits you best?’ If you say it that way, where you put yourself in the position of being high anxiety, high OCD … it shortens the conversation a bit, and the patient is not offended,” she said. Even with a detailed discussion based on your observations and assessments of the eye and the patient’s visual desires and personality, Dr. Braga-Mele said about 5% of patients either won’t understand or will later regret their choice. “There is only so much you can do. You have to at least take broad strokes and spend a couple of minutes telling them what’s out there. You have to let your patients know they’re available, and if they want them, they can go see another doctor if you don’t feel comfortable using those IOLs,” she said. IOL options have evolved significantly during Dr. BragaMele’s time in practice. She said toric was not available when she first started out; there were monofocal, nonfoldable PMMA lenses, making the patient discussion of options virtually non-existent. “It was a lot easier in some ways back then,” she said. For those who are just starting to have more of these complex IOL selection conversations, Dr. Braga-Mele said to not be daunted by the initial time it may take. “It does evolve over time. You get more efficient in conveying the message of what the lenses are. I have to say, 80–90% of patients get it,” she said, adding that anything you can do to pre-educate your patients on the different IOL categories helps when they’re in your chair. Dr. Braga-Mele said she thinks there will be future iterations of IOLs that will progress the conversation. Some IOLs will likely have less of a dysphotopsia profile, reducing the need for the emphasis on some of the tradeoffs patients might experience, she said, while others might be a new category, like accommodating IOLs, that would add to the conversation in some ways. “I don’t think there will ever be a lens that is one size fits all. I don’t think that’s going to come, at least within my career, though I could be wrong,” Dr. Braga-Mele said. Something that she thinks is needed, and that is in the pipeline, are better diagnostics. “As Warren Hill says, ‘Garbage in, garbage out.’ What we need are better diagnostics that give us much more confidence in our lens choices,” she said, adding that these along with AI are coming soon. “We’ll see better diagnostics to make better choices and predictions for our patients. That is going to be the key in making better decisions for what to offer patients.” An example of a diagnostic tool she would like to see developed, is a simulator that can demonstrate different lenses and dysphotopsia profiles to patients. ‘This is one of the most time-consuming responsibilities’ Kendall Donaldson, MD, MS Dr. Donaldson’s patient education begins before they even meet. “I find that it is much easier to discuss lens options if the patient has a little background going into the discussion. I prepared a 7-minute video of myself succinctly explaining what cataract surgery is and what lens options are available,” she said, noting that patients often come in with questions about laser cataract surgery vs. ultrasound cataract surgery but are overall unaware of the various lens options. “The video reviews the basics of what cataract surgery is, as well as answers to the common questions I receive during a typical cataract consultation. I find that this video brings everyone to the same level for our discussion.”
14 EyeWorld Asia-Pacific | March 2025 CATARACT From there, Dr. Donaldson said that she tries to acquire imaging (topography, biometry, and macular OCT) before performing the slit lamp exam. This helps her determine which lenses the patient might be a candidate for. “Once I determine their candidacy with the exam and review of imaging, I discuss the patient’s goals for their surgery. I assess their visual needs by learning about their occupation, their pastimes and by assessing their potential desire for spectacle freedom,” she said. While she and the patient might discuss different lens options, Dr. Donaldson said she always ends the consultation with a concrete lens recommendation, clearly stated in the patient’s chart. “This is very important for my staff who will take the conversation to the next level. It delivers a singular message to the patient, despite who they may be interacting with in the office. My surgical coordinator will then discuss scheduling and finances in more detail, following our office visit. If the patient calls with additional questions after our visit, staff can refer back to my notes and specific recommendations to ensure consistency with our message as a practice, and to avoid causing patient confusion,” Dr. Donaldson said. When Dr. Donaldson started practicing 20 years ago, she said there were basic monofocal lenses, one multifocal lens, and one accommodating lens. The discussion involving lens selection at this time was short, and most patients chose a monofocal lens. Soon two new multifocal lenses joined the pack, but Dr. Donaldson said these and the other lenses that tried to offer more spectacle independence had significant dysphotopsias (associated with high near-add powers). “For the most part, we were not very savvy explaining dysphotopsia profiles, and surgeons quickly became frustrated with unpredictable visual side effects,” she said. “We had many happy patients, but just a single unhappy patient could be devastating to clinic flow and to surgeon confidence. This limited the penetration of premium lens technology into the market. “Today, we are very fortunate to have a plethora of lens options with much-improved dysphotopsia profiles,” she continued. “However, lens discussions can consume a great deal of chair time. In larger, high-volume premium practices, specialized staff may whisk the patient away for a full review of the lens options, but it is still the doctor’s responsibility to help the patient decide what best suits their ocular health and their lifestyle. In most practices, this is one of the most time-consuming responsibilities of the typical cataract surgeon.” Looking forward, Dr. Donaldson said she thinks AI and realistic vision simulators will play a role in lens selection. “AI could combine patient lifestyle information, desires for spectacle freedom, and financial concerns with clinical data (including macular health, astigmatism, and degree of myopia or hyperopia) to produce a lens recommendation. The more information input into the system, the more robust the algorithm would become,” she said, adding later that “improved patient educational tools, including realistic simulators, could help provide an opportunity to trial various lens options before surgery. This would increase surgeon and patient confidence with lens choices. It would also help patients better understand potential dysphotopsias.” ‘There is an art to this’ Jonathan Rubenstein, MD When it comes to making an IOL recommendation to the patient, informing the patient to select their best option is, according to Dr. Rubenstein, “a combination of art and science.” “There is an art to this. You have to try to figure out what the patient’s needs are. There are two ways to look at this: one is to ask ‘what does the eye require’ and the second is ‘what does the patient require’,” he said. It starts with what the eye needs. Does the patient have astigmatism? Do they have a current comorbidity (ocular surface disease, a problem with the macula, glaucoma, previous refractive surgery)? “You have to assess the eye because that will narrow down your IOL choices right there,” Dr. Rubenstein said.
15 EyeWorld Asia-Pacific | March 2025 CATARACT Once you’ve narrowed down lens options based on the patient’s ocular situation, you move onto assessing the needs of the patient. “You need to interview the patient to assess their needs based on their vocation and avocation,” Dr. Rubenstein said. “Are they interested in distance vision only, and therefore happy with wearing glasses for computer, intermediate, and near, or do they want to have less of a need for glasses and be able to see distance plus intermediate vision without correction, or lastly, do they want uncorrected vision for distance, intermediate, and near? That’s a discussion you have with the patient based on your perception of their needs and their declared needs.” Dr. Rubenstein said that with more experience in these conversations, you get more of a feel for what the patient may want and need for their best performance. “After a while, you start assessing the patient almost the moment you walk into the room. You can see what type of person they are and what they might want. Then comes the discussion, trying to figure out what the patient’s needs are. You use your experience to target your discussion to what you think is the best fit for the patient. Obviously, that’s going to vary based on the experience of the surgeon.” At this point, the discussion gets into the lens options that are available and that match the patient’s ocular needs as well as their personal refractive desires. Even if a patient is not eligible for a certain type of lens (or if a certain type of lens is inadvisable due to personality or perceived intolerance of dysphotopsias), Dr. Rubenstein still mentions these lens options briefly because patients have often heard about them from their own research or from friends/ family who have experience with them. Dr. Rubenstein said that in his practice, he is the one who talks about lens specifics with the patient, but he does have a surgical coordinator who goes into detailed questions about the surgery, scheduling, and payment based on the IOL recommendation that Dr. Rubenstein has made. As more lens options have come to the market over the last two decades, Dr. Rubenstein said it has been important for the doctor to drive the conversation to the best choice for the patient, based on the ocular assessment and the patient’s visual desires. “You don’t have time to talk about every possible option, and too many options can get confusing to the patient. So I think you have to make an editorial decision yourself. … You have to think about what information you are going to present in an honest and fair way to give the patient the best informed consent possible and hopefully get them to have their best visual result and be as happy as possible.” Going forward, Dr. Rubenstein said there is likely a place for visual simulators to demonstrate the visual experience from the different IOLs as well as increasing pre-education for patients. He said industry is getting more involved in what they can provide surgeons to serve as their partners in providing pre-educational materials for patients about their lenses. John Berdahl, MD, Refractive Editorial Board member, shared what evolving treatments and techniques in ophthalmology he is excited about: “In cataract surgery, presbyopia and adjustable IOLs make every waking moment more convenient, and sublingual sedation can remove IV pokes but more importantly unnecessary fentanyl use while still ensuring patient comfort during cataract surgery.”
16 EyeWorld Asia-Pacific | March 2025 ASIA-PACIFIC PERSPECTIVES The article describes the experiences of four US-based ophthalmologists who have adopted LAL in their surgical practice. I do not have personal experience with this IOL technology, but am looking forward to its availability. This unique technology enables the ophthalmologist to adjust the refractive outcome postoperatively to achieve almost 100% refractive precision. While this may not be required by all patients, it will fulfill the unmet need when managing refractive outliers and demanding patients. When practicing monovision, it allows the patient to experience and adjust the extent of monovision, enabling a personalized refractive outcome. However, there are also concerns regarding LAL. This is a 3-piece IOL which may change its effective position over time as the capsular bag contracts, altering the refractive outcome. In addition, the silicone material may opacify if silicone oil is used in retina surgery. Furthermore, LAL is monofocal and non-toric. The increase in DOF with adjustment is small, matching that of a monofocal plus IOL. The newer LAL+ has a small central area of increased lens power, providing it a slightly greater DOF than the LAL. The DOF achieved after light treatment is purportedly similar to current EDOF IOLs, but more data is needed. The small advantage that LAL+ provides in achieving excellent distance and intermediate, but not near vision, would likely place it on par with EDOF IOLs, which have a flat landing zone on the defocus curve. Furthermore, astigmatism correction is delayed until the first treatment, which is typically done 2 or more weeks later, missing out on the wow factor. Yet another concern is that, in eyes with heavily pigmented iris, postoperative pupil dilation may not reach 6mm and it may be difficult to predict who the poor dilators are. Today, our refractive outcomes have significantly improved, with newer biometry tools and formulae. Thus, the demand for this IOL technology, which started its development more than 10 years ago, is less impactful than was anticipated. Nonetheless, the LAL technology does add to our armamentarium for the treatment of a subgroup of patients who demand refractive precision and the option of adjusting their refractive outcome postoperatively. However, the cost and time spent in patient counseling to treat this select group of patients may put this technology out of reach for many surgical practices in Asia, considering the incremental benefit. Editors’ note: Prof. Soon-Phaik Chee is a consultant for Alcon Laboratories, Inc. and Ziemer Ophthalmics AG, but has no financial interests related to the comments. CATARACT Soon-Phaik CHEE, MD Senior Consultant, Eye & Retina Surgeons 1 Orchard Boulevard, #13-03 Camden Medical, Singapore 248649 cheesp313@gmail.com
17 EyeWorld Asia-Pacific | March 2025 ASIA-PACIFIC PERSPECTIVES The Light-Adjustable Lens (LAL) is an innovative intraocular lens (IOL) option. It features photosensitive macromers embedded in a silicone matrix, allowing the lens curvature to be precisely customized when exposed to the appropriate UV light. The upgraded ActiveShield technology further minimizes the risk of unintended UV light exposure, reducing the dependence on UV-blocking glasses during the initial postoperative period. The LAL is a monofocal lens, which does not correct presbyopia unless monovision is planned. Therefore, it is not intended to replace advanced-technology presbyopiccorrecting IOLs such as extended depth of focus (EDF) lenses or trifocals. The primary advantage of the LAL lies in its post-implantation adjustability, which allows for more accurate vision correction than just relying on preoperative IOL calculations. Presently, IOL power calculations achieve 90% accuracy within 0.5D for normal eyes. The LAL is particularly beneficial when IOL power calculations are challenging or still evolving, such as in eyes that have undergone corneal refractive surgery, or where the IOL cannot be implanted in its physiological position because of compromised capsular bag such as polar cataracts or subluxated cataracts. It is also a suitable option in cases of secondary IOL or IOL exchange for postoperative subluxated IOLs where the capsular bag is absent or compromised when IOL power cannot be calculated with certainty. Editors’ note: Dr. Fam Han Bor is a consultant for Alcon, Johnson & Johnson Vision, Rayner, and Zeiss, but has no financial interests related to the comments. CATARACT The use of LAL requires more patient visits, typically involving 3-4 additional appointments. This change in postoperative clinic flow includes frequent refractions, discussions on target planning, pupil dilations, and laser adjustments, The laser adjustment procedure takes approximately two minutes each time. Adjustments are typically made around one month postoperatively. During that time patients may experience blurred vision, particularly those with astigmatism. Patients who have undergone corneal refractive surgery may need to wait longer for their corneas to stabilize before adjustments can be made. It is important to note that LAL is not recommended for patients with irregular corneas, high higher-order aberrations, or expected postoperative inconsistent refractions. Patients with poor pupillary dilation of less than 6 mm may not be suitable candidates for this technology. As with all medical procedures, the LAL has a learning curve. The precise nature of the adjustments and the need for thorough preoperative planning and postoperative follow-up make it a specialized procedure that requires careful consideration and planning. Nevertheless, the LAL represents an advancement in customizable vision correction, offering patients an opportunity for more accurate and tailored mono-focal outcomes. FAM Han Bor, MD Senior Consultant, Tan Tock Seng Hospital 11 Jalan Tan Tock Seng, Singapore 308433 famhb@singnet.com.sg About the Physicians Rosa Braga-Mele, MD | Professor of Ophthalmology, University of Toronto, Toronto, Canada | rbragamele@rogers.com Kendall Donaldson, MD, MS | Medical Director, Bascom Palmer Eye Institute, Plantation, Professor of Clinical Ophthalmology, Rodgers Clark Endowed Chair in Ophthalmology, Plantation and Miami, Florida | kdonaldson@med.miami.edu Jonathan Rubenstein | Chairman and Deutsch Family Endowed Professor, Department of Ophthalmology, Rush University Medical Center, Chicago, Illinois | jonathan_rubenstein@rush.edu Relevant Disclosures Braga-Mele: Alcon Donaldson: AbbVie, Alcon, Bausch + Lomb, BioTissue, BVI, Carl Zeiss Meditec, Dompe, Eyevance, Glaukos, iOR, Johnson & Johnson Vision, Kala, LENSAR, Lumenis, Novartis, Omeros, Oyster Point, Quidel, PRN, Rayner, Science Based Health, Sun, Tarsus, Versea Rubenstein: Alcon This article originally appeared in the December 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
18 EyeWorld Asia-Pacific | March 2025 by Liz Hillman, Editorial Co-Director ‘It’s a learning curve to load it’ There were a few reasons that the ophthalmologists at Baylor were interested in the LAL. “At Baylor, we do a lot of research in IOL calculations and various formulas, but the results are still not perfect. Formulas are around 75% at best, and we have outliers. I really want [LASIK-like outcomes] for our patients. We see a lot of post-refractive patients now, and their expectations are very different,” Dr. Khandelwal said. The academic practice didn’t join the LAL bandwagon right away, however. It was the second iteration of the lens that included ActiveShield, which reduces issues with accidental UV light exposure before lock-in, that made them more comfortable with offering the technology. But it still came with a learning curve. CATARACT Latest Lessons Learned With The Light Adjustable Lens Since its approval in late 2017, many physicians now have several years of lessons learned under their belt, from working with the Light Adjustable Lens (LAL, RxSight). And with the more recent commercial launch of the LAL+, which has a modified aspheric surface to extend depth of focus slightly, ophthalmologists have even more to talk about with this lens platform. EyeWorld spoke with Sumitra Khandelwal, MD, to learn how an academic center brought on the LAL, and also spoke with Bryan Lee, MD, JD, Neda Shamie, MD, and Taylor Strange, DO, private practice ophthalmologists, to understand their diverse perspectives and experiences to do with this lens. “The real questions when we started to analyze this technology were 1) how were we going to incorporate it in our practice, which is different from a private practice, and 2) is this technology going to cannibalize some of the premium technologies we already use?” she said. “Those are two questions I think everyone has to ask themselves about the Light Adjustable Lens. Personally, I’ve found myself pleasantly surprised by both.” Dr. Khandelwal said the LAL hasn’t taken away from other advanced-technology lenses, rather it’s augmented their offerings. “It’s opened up the space for patients who we may not previously have considered as great candidates for a presbyopia-correcting lens.” From a clinic flow standpoint, Dr. Khandelwal said it’s been helpful to have their research optometrist trained in
19 EyeWorld Asia-Pacific | March 2025 CATARACT refractions and the Light Delivery Device adjustments, but the ophthalmologist is still the one who makes the active decision. From a surgical standpoint, Dr. Khandelwal said the rhexis is very important with this lens. “The rhexis needs to be an appropriate size, covering the optic all the way around,” she said, adding later that it’s also a silicone lens, which has a bit of a learning curve. “First of all, it’s a learning curve to load it. Any scratch on the IOL has to come out, and it comes out fast from the injector.” Dr. Khandelwal advised of being careful with patients who have a lot of fluctuations with refractions, such as with OSD, which she said needs to be optimized before surgery. Finally, she offered that surgeons should guide the patients to their realistic postop goal rather than allowing patients to take the lead. “This is not a trifocal lens. Patients need to understand that they may not get the near vision they intended to, and they may not achieve their desired trifocality in both eyes. I think telling them that upfront and getting them locked in in a timely manner is helpful,” she said. “Patients with decisionmaking challenges should be guided away from this lens.” ‘Lock in … at the end of OR days’ Dr. Lee began offering the LAL in 2019 and has found it to be his preferred lens for patients with a history of refractive surgery and those who want monovision. Clinic flow was one of the main adjustments his practice identified when onboarding this lens. “Patients need to understand they may not get the near vision they were thinking they were going to get, and they may not get the trifocality in both eyes. I think telling them that upfront and getting them locked in in a timely manner is helpful.” Sumitra Khandelwal, MD “Patients may require multiple rounds of dilation, and they need refraction and discussion of the plan for each treatment as well,” he said. “I think the combination of doing so many over the years and the wonderful staff in our office has made it work. We try to spread patients out evenly between clinic days, and it is helpful to have lock-in treatments at the end of OR days. By that point, we know how long those patients take to dilate, and they do not need refraction or the same type of counseling.” When it comes to patient selection, Dr. Lee said he’ll discuss the LAL with all patients who are candidates, even if they are not classic post-refractive or monovision patients. Many patients, he said, have specific refractive goals and are attracted to the increased accuracy offered by the LAL. Some have also decided to try monovision with the LAL and found out that they really enjoy it. “I do mention to those patients that if they don’t like monovision, they will not have a full range of vision to try to make sure they aren’t surprised or disappointed,” Dr. Lee noted. For the surgeon who is already experienced with the LAL, Dr. Lee said a more advanced use of the lens presents in cases where the capsule is not intact, such as post-YAG IOL exchange cases. “I also mention it as a back-up option for patients who prefer a different IOL as plan A, but have a higher risk for intraoperative issues, such as a posterior polar cataract,” he said. When it comes to the latest iteration, the LAL+, Dr. Lee said it has increased the number of patients considering this lens in his practice. He noted that the additional range is not the same for every patient, though this is the case with any IOL. “Just as important is the fact that the LAL and the LAL+ are available down to +4.0 D, which allows offering the IOL to very high myopes who appreciate that their IOL calculations are more challenging but are used to the accuracy of a contact lens,” Dr. Lee said. Kristin Barnes, OD, of Maloney-Shamie Vision Institute, performs a non-invasive light adjustment on a patient 3 weeks following his Light Adjustable Lens procedure. Source: Maloney-Shamie Vision Institute
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