Match Makers: Part II
Top-level surgeons share how they use today's IOL options for the best outcome in each patient.

LOUIS NICHAMIN, M.D. BROOKVILLE, PA.

"Workhorse" lens: For the majority of his cases, Dr. Nichamin prefers the 3-piece, silicone Bausch & Lomb LI61U. "I prefer today's advanced silicone materials to acrylic. In my experience, silicone is as biocompatible as any material available. I believe a misconception exists that all silicone lenses are the same. Actually, the newer lenses made of the latest generation silicone perform very well. They're more compressible than acrylic lenses, and they've lent themselves nicely to advanced injector designs. That being said, many acrylic lenses are now catching up with regard to injector delivery systems. I happen to think that all lenses will eventually be implanted with injectors.

"I also like the way silicone manipulates in the intraocular environment; it's facile for me, and there's little tissue drag. We also get beautiful optical performance, with no reflections.

"Matching lenses to patients is all about sorting through the particular design and material aspects, and making sure not to confuse whether it's a lens's design or material that's responsible for certain performance attributes. For example, the decreased rate of posterior capsular opacification we've seen with truncated-edge lenses is due to that truncated edge, not, for the most part, to the acrylic material as was once thought. I think that eventually all implants will have a truncated edge."

Dr. Nichamin also uses the LI61U in patients who have a history of uveitis or cystoid macular edema. "There's certainly an argument to be made for using a heparin surface-modified PMMA lens, but in my experience, second- and third-generation silicone has worked well. Independent of the material issue, these patients have a higher proclivity for posterior capsular opacification, and a lens with a square edge might help to inhibit that. So, I've begun to implant and will be looking at results with Pharmacia's new squared-edge silicone lens, the 911.

He also uses the LI61U in most patients with pupil problems, although may switch to a lens with a larger optic diameter in a very unusual condition, such as corectopia.

In diabetic patients whose disease is well-controlled or whose retinopathy isn't significant, he stays with silicone. In cases of advanced disease, he switches to an acrylic lens to allow better fundus visualization for the retina surgeon.

Refractive considerations: In high myopes and hyperopes, Dr. Nichamin uses his workhorse lens in all cases where the available power is sufficient. Above +30D, he uses a variety of piggyback techniques, including placing two silicone lenses in the capsular bag or placing one acrylic lens in the bag and one acrylic lens in the sulcus.

"New technology" IOLs: For astigmatic patients, he uses limbal relaxing incisions. "I'm comfortable with my ability to correct astigmatism with incisions. The concept of a toric IOL is wonderful, but at this time, we only have two sizes, and I don't think the first-generation plate lens is our best design."

With patients younger than 40 who can still accommodate, Dr. Nichamin does discuss the multifocal IOL option, and 35 to 50% of those patients have chosen that route. Overall, multifocal implants account for about 10% of his cases, but he expects that percentage to increase as he examines his data on bioptics -- lens surgery with multifocal implant combined with LASIK. He's been using the technique for more than a year with his clear lens exchange patients and for close to a year on his cataract patients.

"So far it's working great. Multifocal patients need to be emmetropic to enjoy the full benefits of the IOL, and adding LASIK gets them there. We do have some concerns about denervation and epithelial problems from creating flaps in older patients. We'll be reporting on the technique this month."

CALVIN ROBERTS, M.D. NEW YORK, N.Y.

"Workhorse" lens: "My workhorse is the CIBA Vision 232 Memory Lens. I like this lens because:

• It's a hydrophilic acrylic with PMMA attributes. So it has the rigidity and the refractive optical surface of PMMA. I haven't seen any other silicone or acrylic lens match that optical surface. However, unlike PMMA lenses, there's no adhesion of inflammatory cells and products.
• It's pre-folded, so I'm not dependent on an experienced assistant to fold and prepare the lens for me.
• I can insert the lens through a 3.1-mm incision, so I never have to place a suture post-op. I have no concerns about wound stability, and the incision is astigmatically neutral.
• The lens unfolds slowly. I like to do a complete viscoelastic removal, and all other lenses require me to maneuver under the optic to remove trapped viscoelastic. This isn't necessary with the CIBA 232.
• The square-edge design acts as a barrier to epithelial migration, resulting in a low PCO rate."

Co-existing conditions: "The CIBA 232 is my lens of choice for all patients with concurrent medical disease because the material is so inert."

"New technology" IOLs: Dr. Roberts uses the Allergan Array multifocal in patients who:

• are highly motivated not to rely on reading glasses post-op
• are hyperopic or who have low levels of myopia
• have less than 1 diopter of corneal astigmatism, or are willing to undergo post-op LASIK for astigmatism correction
• have binocular vision and are likely to have both eyes operated on within 3 months
• do limited night driving
• aren't obsessively critical of their vision.

LAURENCE KAYE, M.D. TUCSON, ARIZ.

"Workhorse" lens: "My workhorse lens is the CIBA Vision Memory lens. I see its ease of handling as a major advantage. (My staff members appreciate this as well.) It's pre-folded, and I don't have to work with an injector or a shooter. I simply remove the lens from its container and insert it into the eye with the same instrument. Postoperatively, eyes are quiet, and patient satisfaction is extremely high. The only time I don't use this lens is when I'm placing a lens in the sulcus. In those cases, I prefer a lens that opens more rapidly, so that I can be certain about centration."

Co-existing conditions: "I've used the Memory Lens without problems in diabetics, glaucoma patients, patients with small pupils, and patients with inactive uveitis. Some concerns have been expressed about the biocompatibility of hydrophilic materials, specifically with regard to PCO. At 3 years, my YAG rate with the Memory Lens is 11% vs. 8% for hydrophobic acrylics. I don't feel this is a significant difference, and in my opinion it's far outweighed by the Memory Lens's ease of handling."

Refractive considerations/"new technology" IOLs: Dr. Kaye uses limbal relaxing incisions to treat astigmatism, and occasionally uses a STAAR Toric lens for patients with higher amounts of astigmatism.

He's also implanted a limited number of Array multifocals, with mixed results. "Clearly the limiting factor is the halo effect around bright lights at night, which makes proper patient selection critical. In my opinion, the lens has a place for a select few patients, particularly hyperopic presbyopes who don't drive at night and who have realistic expectations."

ALAN AKER, M.D. BOCA RATON, FLA.

"Workhorse" lens: Dr. Aker most often uses the STAAR AQ2010, a three-piece silicone lens. "I can insert this lens through a small, 2.8-mm incision. Also, I like using a cartridge insertion system because it keeps the lens from coming into contact with any tissue, thereby reducing the possibility of infection. The lens inserts quickly and easily with the "plunger" inserter. I've found the 13.5-mm length of this lens to be ideal for placement in the capsular bag or in the sulcus. This means that in the rare case of a ruptured posterior capsule, there's no need to change to a different lens.

"Even in the rare case of an inverted insertion, I can atraumatically flip the lens with either the trailing haptic or the entire lens using the irrigation/aspiration handpiece.

"The AQ2010 centers beautifully, and edge glare has never been a problem for my patients. YAG procedures are easily performed, with no need to 'machine gun' the optic."

Refractive considerations/"new technology" IOLs: Dr. Aker uses the Array in a large percentage of his patients, in particular, high hyperopes without significant cylinder. "Hyperopes are the most miserable victims from a refractive error standpoint, which makes them exquisitely easy to please. After cataract surgery with an Array implant, they're usually thrilled with the rejuvenating effect of the procedure. We always plan to operate on the fellow eye within a week or so of the first because of the imbalance not doing so would present.

"I also choose the Array for clear lensectomy patients who are hyperopic, and for those who are beyond the reach of my Alcon Summit Autonomous LADARVision laser. For a +6.00 -5.00 x 180 hyperope, we use the LADARVision system for LASIK. But for the +8.00 with low cylinder, we use the Array.

"For patients who present with large astigmatic errors that I can't correct with limbal relaxing incisions, my lens of choice is the STAAR Toric IOL. It has hatch marks on the surface, which are aligned with the steep axis at the time of insertion. To ensure proper axis alignment, it's important to mark these patients at the 90/180 meridians while they're sitting upright and prior to any block."

HOWARD GIMBEL, M.D., M.P.H. CALGARY, ALBERTA, CANADA

"Workhorse" lens: Dr. Gimbel prefers the Alcon SA60AT Acrysof for several reasons, including its overall diameter and one-piece design. "I also like the ergonomic injection; the haptics fold right into the optic. It's easy to get into the capsulorhexis with the injector. The lens's edge treatment tends to reduce glare and results in a low incidence of posterior capsular opacification. The lens centers well and stays where it's placed."

Co-existing conditions: For patients with glaucoma, Dr. Gimbel either stays with the SA60AT or uses the 5.5-mm SA30AT. He uses the Pharmacia 812C for high-diopter patients (above 34D). "Both lenses are biocompatible."

The SA60 meets his needs for most other co-existing conditions, including uveitis, cystoid macular edema, and diabetes. For patients with pupil problems, he also utilizes the Morcher capsular tension ring, with Coloboma or Aniridia designs.

Refractive considerations: For hyperopes 34D and higher, Dr. Gimbel's choice is the 812C because of its C-loop design and its Heparin surface modification.

For high myopes outside the LASIK range, he uses implantable contact lenses. The same goes for patients younger than 40 who can still accommodate. But if refractive lens exchange is indicated, he again uses an Acrysof, usually the MA60 because of its availability in the proper powers.

In cases of astigmatism up to 1.5D, he utilizes limbal relaxing incisions. After that, he uses the Canrobert procedure, also known as the C-procedure, which is a type of astigmatic keratotomy. Also, he says, "I'm eagerly awaiting the Toric IOL made from the collamer material."

R. BRUCE WALLACE, III, M.D. ALEXANDRIA, LA.

"Workhorse" lens: "I like the Allergan SI40, which is a foldable silicone lens in powers of 6D to 30D. It provides me with quality optics, a long track record of success, great centration, ease of insertion with the Unfolder, and relatively low YAG rates. For patients, it provides a cosmetically appealing pupil after surgery with little unnatural glinting."

Co-existing conditions: Dr. Wallace says that many surgeons consider using an acrylic lens for glaucoma patients, but "I've implanted many SI40s successfully, with very few adverse effects post-op. We've found that cataract surgery alone, without a filtering procedure, will result in a lowering of the intraocular pressure for many glaucoma patients."

For patients who have unusually miotic pupils, Dr. Wallace uses pupil stretching. "Patients with elliptical pupils or unusually large sector iridotomies might benefit from lenses with larger optics, such as the 7-mm lenses that generally come in PMMA varieties."

The Allergan Sensar AR40 comes into play for Dr. Wallace in cases where there is a potential for uveitis or cystoid macular edema. "For CME suspects, I use nonsteroidal anti-inflammatories, pre- and post-op for an extended period of time, along with topical steroids and oral steroid therapy when necessary." He usually uses the SI40 in diabetic patients, unless there's a history of significant diabetic retinopathy or if there's a risk of developing proliferative disease or a condition that might require a vitrectomy. In those cases, he again prefers the acrylic AR40.

When patients require a secondary implant but don't have sufficient capsular bag support, he uses Alcon's MTA4UO.

Refractive considerations: In hyperopes, Dr. Wallace commonly uses the Allergan Array multifocal (SA40). "Hyperopes tend to be the happiest patients after Array implantation. We consider these patients presbyopic lens exchange (Prelex) patients. Fortunately, hyperopes are less likely than myopes to experience retinal detachment with refractive lensectomy.

"However, with our high myopes, after careful peripheral retinal examination with the assistance of a vitreoretinal specialist, we generally recommend either the Array or Allergan's monofocal SI40, depending on the patient's understanding of the need for visual cortical adaptation after Array implantation. Some of our happiest patients are high myopes who've elected to undergo a Prelex procedure."

Dr. Wallace performs limbal relaxing incisions for astigmatism in approximately 20% of his lens surgeries. "We assess each eye preoperatively to determine if, after standard phaco incisions, the patient would likely still have more than 1D of astigmatism. If so, a limbal relaxing procedure is performed."

And, finally, on the challenge of patients younger than 40 who can still accommodate, Dr. Wallace says: "I discuss with the patient the fact that monofocal IOLs don't provide near acuity in patients who are prepresbyopic. Therefore, lens surgery might produce unwanted presbyopia. For these patients, I've found the Array to be a good choice."

New technology IOLs: "We've been increasing our implantations of the Array. A year ago, we were implanting it in 10% of our cataract patients. Today, we're at 20%. The percentage is likely to increase as we continue to examine our long-term results, which at this point are very favorable."

RICHARD J. MACKOOL, M.D. NEW YORK, N.Y.

"Workhorse" lens: Dr. Mackool most often chooses a single-piece Acrysof lens. "I turned to this lens as my main lens shortly after it was introduced because it has some distinct intraoperative and postoperative advantages, which in combination make it unlike any other lens I've used.

"Intraoperatively, it allows for an atraumatic insertion. The soft, jellylike haptics fold up onto the optic, and release slowly and gently. The more fragile the eye, the zonule, whatever the situation, it's better. The second big intraoperative advantage is the small incision. (Silicone lenses can be injected into small incisions, too.) I can inject either the SA30 or the SA60 through an incision as small as 2.6 mm. When I'm done, the incision measures between 2.8 and 2.9, but I don't have to enlarge my phaco incision to insert it. And while the benefits in the area of astigmatism are probably all equal below 3 mm, the smaller the incision, the quicker it seals. So I don't have to wait 2 to 3 minutes for an incision to seal.

"I should note that I don't use forceps to inject these lenses. I use the Monarch II injector. I don't insert the cartridge tip all the way into the eye. The tip of the leading edge of the bevel gets into the anterior chamber. That's easy to do with this kind of implant because it comes out in one plane. That plane may not be the same plane that the cartridge is in. It can be a little anterior or a little posterior, but it's one plane. So it's easy to direct the single-piece lens into the posterior chamber and deliver it into the capsular bag all at once. With a multipiece, the haptic comes out in one direction, and the optic in another, so you really have to get the cartridge tip into the eye so you can manipulate the direction of the IOL.

"Postoperatively, with the acrylic material, I never see significant deposits. It's also extremely rare that I see posterior synechia, which tend to develop between the iris and the edges of the capsulorhexis. For that to happen, the capsulorhexis has to be pretty close to the iris, and a fairly thick optic has to be pushing the capsule into the iris. So, it may be that the thinness of the acrylic optic prevents that. Or it may be a product of the material, but I suspect it's both.

"Another post-op advantage that I see is that acrylic is easier to YAG than silicone. When you YAG an acrylic lens, you get little or no pitting. If a YAG pulse strikes a silicone IOL, a large pit will be created. I rarely use a contact lens when using a YAG laser if the patient has an acrylic lens, but I commonly have to use a lens when a silicone IOL is in the eye."

Co-existing conditions: The single-piece Acrysof is Dr. Mackool's lens of choice for patients with glaucoma. "Glaucoma patients are more likely to experience anterior synechia, so a thin IOL is an advantage. Furthermore, the lens has to be well-tolerated. Otherwise, cellular deposits recur on the surface of the IOL, requiring repeated YAG laser treatments. When that happens, glaucoma patients need topical steroids, which can raise their intraocular pressure."

Dr. Mackool sticks with a single-piece Acrysof for patients with diabetes, pupil problems or a history of uveitis or cystoid macular edema. "I suspect that the single-piece acrylic lens is the least likely to induce CME. Some autopsy eye studies suggest that the haptics in a multipiece lens, even in the capsular bag, can press against the ciliary body, and this may cause inflammatory changes in the ciliary body over time."

He will switch from the single-piece Acrysof if he's dealing with an open posterior capsule, or any time he needs to put a lens in the sulcus. "A single-piece lens, in my opinion, isn't designed to go there. The haptics have sharp edges and shouldn't be touching vascularized tissue. So, I implant an MA60 in the sulcus, and assuming the opening of the capsulorhexis is still intact and at least .75 mm smaller than the optic, I push the optic through the capsulorhexis, capturing the optic. This provides additional insurance that the lens will remain centered."

Refractive considerations: Dr. Mackool's treatment choice for high hyperopes depends on whether any accommodation remains. If not, he prefers to perform a clear lensectomy, implanting a single-piece Acrysof. If the patient has some accommodation, he likes to preserve it by using a phakic IOL. He's an investigator in the trials of two phakic IOLs.

"You have to consider the wishes of the hyperope. Some patients don't want to use reading glasses. In those cases, you're getting into multifocal implants, where you must consider a whole new set of advantages and disadvantages."

For many high myopes, Dr. Mackool chooses a single-piece acrylic lens, or a multipiece because they're available in low powers now. But "For refractive procedures outside the LASIK range, I'm going to a phakic IOL, especially if the patient is male. Clear lensectomy is OK if the patient is female and doesn't have accommodation. Myopic females have a low rate of retinal detachment after cataract extraction. Males have a much higher rate, so I've got to believe that's true after clear lens extraction as well."

For astigmatic patients, "I'm not one to do limbal relaxing incisions at the time of surgery. At most, you get about a half diopter of change with a small clear-corneal incision. I'm comfortable performing the surgical procedure on-axis. I wait and see how the patients tolerate any astigmatism they have left. If they're having trouble, then, in most cases, I perform a limbal relaxing incision, assuming that the spherical equivalent of doing the limbal relaxing is what the patient wants. Sometimes it isn't. Sometimes I want to change the spherical equivalent also. Then, I do LASIK, PRK or LASEK, or combine the relaxing incisions with some form of RK.

I'm careful with limbal relaxing incisions for another reason, too. Some patients have astigmatism on their K readings that isn't present in their manifest refraction. I think these patients, especially the high myopes, have a slanted, for lack of a better word, posterior pole. So they actually can have astigmatism based on that. I've seen this a lot in eyes with an axial length of 25 mm or more. So, in that patient population, I'd rather avoid limbal relaxing incisions because I'm not quite sure what I'm going to wind up with."

RICHARD L. LINDSTROM, M.D. MINNEAPOLIS, MINN.

"Workhorse" lens: Dr. Lindstrom most often uses the Bausch & Lomb silicone LI63. The features he finds appealing:

• The 6.3-mm optic reduces edge glare.
• He can implant the lens through 2.8-mm to 3.0-mm incisions, which match the size of the keratome he uses for his phacoemulsification incision.
• The associated inserters perform to his satisfaction.
• He finds the second-generation silicone to be highly biocompatible.
• He sees a low posterior capsular opacification rate.
• He finds the price to be fair.

Co-existing conditions: Dr. Lindstrom makes use of a variety of lenses, depending on the situation. For example:

• glaucoma: the LI63 or an Allergan SI40NB or AR40NB
• pupil problems: "I can stick with the LI63 in these cases because I stretch most problem pupils with two Kuglen hooks. Occasionally, I will use the Milvella perfect pupil or Iris retractors."
• uveitis: the AR40 or the STAAR Collamer lens
• CME: a different lens than the one that caused the CME. "With an intact capsule, I implant in the capsular bag and use higher doses of steroids and use NSAIDS longer."
• diabetes: the Allergan AR40 or the STAAR Collamer
• triple procedures, PK, ECCE, PCL: the Bausch & Lomb P366UV, which is a PMMA lens with a 6.5-mm optic.
• scleral fixation: the P366UV

Refractive considerations: For patients with high levels of hyperopia, Dr. Lindstrom uses the Allergan SI40NB, or for patients who desire reduced spectacle dependence, he performs a Prelex procedure with the Array multifocal.

In myopes outside the range of the LI63, he turns to the STAAR AQ5010 or AQ2010.

For astigmats, he implants the STAAR Toric or performs astigmatic keratotomy and on-axis incisions .

"New technology" IOLs: Dr Lindstrom implants both the Array and the STAAR Toric regularly, in 5% to 10% of his patients. He uses the Array in select patients who are looking for decreased spectacle dependence and have 20/20 or better visual potential.

He uses the Toric in patients with 1.5 to 3.5 diopters of astigmatism. "I find that the STAAR Toric rotates less when placed upside down in the bag. If it does rotate, it can be rotated back into position."

TOBIAS NEUHANN, M.D. MUNICH, GERMANY

"Workhorse" lens: "I prefer a hydrophobic, acrylic lens, either the three-piece Allergan Sensar AR40E with the new edge design, or the SA30 or SA60 Acrysof one-piece from Alcon. First, both lenses' injector systems are perfect for me. Second, the lenses' behavior in the eye is superb; they're well tolerated in the capsular bag. Secondary cataract formation is very late. While I don't see these lenses as 'super-biocompatible,' they're very biocompatible.

"I think at the moment there is no gold standard lens, so all of them have advantages and disadvantages. For capsular bag implantation for routine cases, as I said, I think the hydrophobic acrylic lenses are the best at the moment. We have a lot of hydrophilic lenses in Europe, but few long-term results with them. With some hydrophilics, we've recently had problems with haziness and pseudophakic cataracts. We also learned that explantation of these lenses is difficult."

Co-existing conditions: Dr. Neuhann also likes a hydrophobic acrylic lens for patients with glaucoma. "The only problem is that sometimes the capsular bag on these patients is very weak." If he takes the capsular bag out during phaco, he either implants the Artisan aphakic anterior chamber lens or sutures a lens into the ciliary sulcus. "When I suture, I use the STAAR Collamer lens or the Bausch & Lomb Hydroview because of their superb biocompatibility."

For patients with a history of uveitis, when he's able to implant the lens in the capsular bag, Dr. Nuehann likes the Oslo foldable lenses. "The Collamer lens from STAAR is also brilliant for these patients. But I'm eagerly awaiting the heparin-coated silicone lens from Pharmacia. It's not currently available in Europe. The giant cells are less apt to stick to that lens surface in uveitis patients, who have a breakage in the blood barrier that lengthens the duration of inflammation."

His lens choice for patients with a history of cystoid macular edema depends why they have it. "If it's diabetes, I have the same trouble as everybody. My approach is to do the surgery as gently as I can. For a gentle phaco, I fill the entire anterior chamber with Healon5. I use a small, 50-megaHz phaco tip. Everything is done underneath Healon5 viscoelastic. If everything goes quietly, I implant a hydrophobic acrylic. If the capsule is open, I use the Collamer."

In the case of a posterior capsule break, he uses the Sensar lens, placing the optic underneath the capsulorhexis and the haptic in the ciliary sulcus. "This rhexis fixation works very well with three-piece lenses." Dr. Neuhann presented this technique for the first time in his award-winning video presentation at the 1991 ASCRS meeting in Boston.

Refractive considerations: When operating on high hyperopes, Dr. Neuhann uses the Sensar or the Acrysof as long as he can fold the lens. "I use both lenses for hyperopes up to +30D. If I have to go over +30D, I use a foldable hydrophilic acrylic from STAAR. I can implant this with an injector for up to +36D. If I need something higher than +36D, I have to use PMMA lenses. In Europe, we have all kinds of lenses, so we mustn't use piggyback lenses. The highest lens I've implanted was a +75D. We have several patients with +50D and +55D corrections. We use custom lenses from German companies."

His treatment for high myopes depends on their level of myopia. "My indication for LASIK is -1D to -7D. After -7D, for patients who are -15D in glasses and have an anterior chamber larger than 2.8 mm, I use the STAAR Implantable Contact Lens. For those higher than -15D in glasses, I switch from the STAAR to the Artisan phakic IOL, which is available up to -25D, if the anterior chamber is deep enough. Above that level, I use a bioptics technique or clear lens extraction."

For astigmatic patients, Dr. Neuhann prefers the STAAR Toric lens, and he rarely uses corneal incisions. "We were seeing, in 15% to 20% of these patients, the Toric lens turning off-axis. But, with a ring I designed this year (the Acriclip, manufactured by Acritec), I can 100% control the axis of the Toric lens. Also, plate lenses sometimes caused problems after capsulotomy, and we sometimes had shrinkage with the silicone lenses. However, we now have a specially designed capsular ring that acts like a clip in the axis. At the same time, it acts like a capsular tension ring and prevents the lens from falling into the vitreous after a capsulotomy."

Dr. Neuhann is part of a group evaluating the accommodating IOL from C&C Vision, so in patients younger than 40 who can still accommodate, he has used that lens. "We started with older patients, and it took quite a while before they started to accommodate. But, I have two patients who are in their 50s, and they have beautiful accommodation. If these patients are myopic prior to surgery and have a wide pupil, I implant a monofocal IOL. If they're high hyperopes, and we've discussed potential problems with the Array multifocal, I use that."