KEEPING UP WITH changes and advances in IOL technology is important for both optometrists and surgeons alike. After all, by understanding our patients’ options, we are better able to communicate those options to them and, thus, aid in our patients’ IOL selections.

With these points in mind, here’s a look at the premium IOLs approved in the last two years, their ideal candidates and how, specifically, to discuss them with patients.

EXTENDED DEPTH OF FOCUS (EDOF) IOL

Currently, just one EDOF IOL is available, TECNIS Symfony (Johnson & Johnson Vision). The EDOF IOL is designed with diffractive echelettes to extend range of vision, including far, intermediate and near.¹

Although the TECNIS Symfony is marketed as a distance and intermediate IOL only, patients and surgeons are noting improvements in near vision as well. In fact, in a prospective study by Attia et al., patients who received the Symfony IOL experienced improvements in all ranges of vision. Uncorrected distance vision was 20/21.43, uncorrected intermediate vision was 20/18.67, and uncorrected near vision was 20/31.70.² This finding was also reported by the Journal of Cataract & Refractive Surgery, in which 85% of study participants with the EDOF IOL experienced an increase in spectacle independence.³

Ideal candidate: As with most premium lenses, this lens is not for everyone. Patients with moderate to severe retinal or corneal pathology likely will not benefit from the IOL’s technology. Since this is still a “blended vision” IOL, patients will have good distance and near vision, but may still need a pair of light readers for reading. Therefore, demanding patients may not be the best candidates.

How to discuss: “Patient X, we have been watching your cataracts over time, and we have reached the point at which we need to consider surgery. I know you prefer not to wear your glasses all the time, so there is a possibility you may be a great candidate for an EDOF IOL, which will allow you to see at both distance and intermediate without glasses. You would still need to use a light reading prescription for near vision.”

MULTIFOCAL IOL

Within the multifocal realm, there have been a few additions and improvements to what was already available. The AcrySof IQ ReSTOR +3.0 (Alcon) multifocal was released with a toric version in early 2017, providing our astigmatic patients with another IOL option. This lens has the ReSTOR pupil adaptive optical design with nine diffractive steps closer together, allowing the light to be distributed evenly in brighter conditions.⁴

The AcrySof IQ ReSTOR +2.5D IOL with ACTIVEFOCUS optical design, for cataract patients wanting to address their astigmatism and presbyopia at the same time, received FDA approval in March 2017. This lens offers center distance vision with seven diffractive steps spaced further apart than its +3.0 counterpart, which is designed to help decrease dysphotopsia. The ACTIVEFOCUS distance center also helps to improve a patient’s distance vision compared with the previous model. Together with the ReSTOR +3.0, these two lenses can provide great overall vision. Some surgeons are using both to develop blended vision because the central zone on the ReSTOR +3.0 is intermediate vs. the +2.5 ACTIVEFOCUS, which is distance centered.

Ideal candidate: The patient who has a stable cornea with controlled dry eye and ocular surface disease, with no other retinal or corneal pathologies. Patients with astigmatism greater than 1.25D will likely benefit from a toric version of the IOL.

As discussed with the EDOF lenses, make sure to talk about this with patients who have realistic expectations regarding vision outcomes for both distance and near.

How to discuss: “Patient Y, the reason for your changes in vision is due to cataracts, which is something that develops over time as we age. The best option at this time is to speak with a surgeon about cataract surgery. You may be a great candidate for a multifocal lens, which is similar to the contact lenses you have been wearing, and it can even correct for your astigmatism. It allows you to see at both distance and near free from glasses or contact lenses about 95% of the time.”

LOOKING TO THE FUTURE

There could be a few new additions joining Symfony in the EDOF IOL category:

Mini Well Ready (Sifi Medtech) This EDOF IOL utilizes three different symmetrical zones, each with a different correction of spherical aberrations, creating a progressive light distribution. In German studies, it has good performance at all distances and high patient satisfaction.

AT LARA 829MP (Zeiss) This EDOF IOL provides a wide range of focus. Its optical design and patented Smooth Microphase technology create a surface that minimizes light scattering and visual side effects.⁵

Trifocal IOLs have been used in the European market, but have not quite made their way to the U.S. One such lens in the pipeline:

The AcrySof IQ PanOptix (Alcon) is a trifocal lens undergoing FDA clinical trials. It has been shown to provide patients with a comfortable range of near to intermediate vision and great distance vision by optimizing light transmission to the retina. The IOL transmits 88% of the light to the retina.⁶

Approved outside the U.S. and in clinical trials:

IC-8 IOL (AcuFocus) This small aperture IOL extends depth of focus by combining small aperture technology in a monofocal lens.^{7, 8, 9} It uses a principle similar to its presbyopic product, Kamra, in that it creates a pinhole effect with an opaque annular mini-ring that has a central aperture embedded into a hydrophobic acrylic lens.

KEEP INFORMED

Maintain your education on what is available, for whom and what is coming, so you can best advise your patients. OM

For more information on preparing your patients for surgery and selecting IOLs, see Dr. Koetting’s previous article, “Present Surgical Options to Patients,” available at http://bit.ly/2y0CZnp , and the article “Prepare Patients for Cataract Surgery,” by Douglas K. Devries, O.D., at http://bit.ly/2xZstfV , both of which appeared in October’s Optometric Management.

REFERENCES

1. TECNIS Symfony Extended Range of Vision IOL package insert. Food and Drug Administration website. www.accessdata.fda.gov/cdrh_docs/pdf/p980040s065d.pdf . Accessed Feb. 21, 2018.
2. Attia Mary SA, Auffarth GU, Kretz FTA, et al. Clinical Evaluation of an Extended Depth of Focus Intraocular Lens With the Salzburg Reading Desk. J Cataract Refract Surg. 2017; 33.10:664-669.
3. Cochener B. Clinical outcomes of a new extended range of vision intraocular lens: International Multicenter Concerto Study. J Cataract Refract Surg.. September 2016. 42:9; 1268-1275.
4. AcrySof IQ ReSTOR +2.5D IOL. My Alcon website. www.myalcon.com/products/surgical/acrysof-iq-restor-multifocal-iol/restor-25.shtml . Accessed February 2, 2018.
5. Zeiss AT LARA product guide. Zeiss website. www.zeiss.com/meditec/int/products/ophthalmology-optometry/cataract/iol-implantation/mics-platform/mics-at-lara-iol/at-lara-829mp.html . Accessed February 21, 2018.
6. Shinwook L, Myoung C, Zaiwei X, et al. Optical bench performance of a novel trifocal intraocular lens compared with a multifocal intraocular lens. Clin Ophthalmol, 2016; 10: 1031–1038.
7. AcuFocus Physician Information. www.acufocus.com/int/products/ic8-iol/what-is-a-cataract . Accessed January 20, 2018.
8. Evaluation of Long-Term Clinical Acceptabillity and Satisfaction with the IC-8 Intraocular Lens. U.S. National Library of Medicine website. https://clinicaltrials.gov/ct2/show/NCT03314766 . Posted Oct. 19, 2017. Accessed January, 20, 2018.
9. Grabner G, Ang RE, Vilupuru S. The Small-Aperture IC-8 Intraocular Lens: A New Concept for Added Depth of Focus in Cataract Patients. Am J Ophthalmol. 2015;160(6):1176-1184.
10. Bausch + Lomb introduces Envista 8. Mx60E Intraocular Lens. Bausch + Lomb website. Accessed February 22, 2018. www.bausch.com/our-company/recent-news/id/2383/10162017-Monday .
11. enVista IOL. Bausch + Lomb website. Accessed February 22, 2017. www.bausch.com/ecp/our-products/cataract-surgery/lens-systems/envista-iol .

DR. KOETTING practices at Virginia Eye Consultants in Norfolk, Va. Her primary focus is ocular disease, attending to the anterior segment and corneal disease, neuro-optometry and peri-operative care. She graduated from Southern College of Optometry and completed a residency in Primary Care at the Cincinnati VAMC. She is a fellow in the AAO, a diplomate of the American Board of Optometry and a member of Intrepid Eye Society. She reports no disclosures.