Having been the first doctor in Tallahassee to implant a ReSTOR multifocal IOL (Alcon) many years ago, I’ve accumulated much experience working with this lens platform. All of the ReSTOR IOLs, which share the same proven material, mechanics, and optics, are designed to provide presbyopic patients with a range of vision. Most recently, I was the first surgeon in my area to implant the AcrySof IQ ReSTOR +2.5D multifocal IOL with the ACTIVEFOCUS optical design, and this lens has been one of the two best things to happen for my practice in quite some time.

The ACTIVEFOCUS lens design dedicates the center optic to distance vision. It allocates more light than other diffractive presbyopia-correcting lenses to the distance focal point at most pupil sizes, especially in mesopic conditions. The result is excellent, sharp distance vision, the same quality contrast sensitivity as the AcrySof IQ Monofocal IOL, and near (40 cm) and intermediate (53 cm) vision two lines better than the monofocal.¹ With fewer defractive zones than other ReSTOR models, the ACTIVEFOCUS design offers better nighttime vision and improved computer-distance focusing as well. It truly creates a “wow” factor for my patients. Importantly, I have yet to have a patient complain of any halos or “rings.”

The Importance of Intraoperative Aberrometry

I mentioned that the ACTIVEFOCUS design has been one of the two best things to happen for my refractive cataract surgery practice in quite some time. The other very welcome advance has been my use of intraoperative aberrometry. The ORA System with VerifEye+ Technology (Alcon) allows me to refine IOL power in real time. It has not only reduced my IOL exchange rate to zero but also has enabled me to achieve 20/20 distance visual acuity in every eye where it’s possible without fail. Patients pay more for presbyopia- correcting lenses and outcomes, making it imperative that I deliver this level of results.

I enter the OR for each case with my preoperative lens calculations as I have always done, but when the patient is aphakic, I measure the eye with the ORA SYSTEM. In all but the occasional case, I implant whichever IOL power the system recommends for achieving plano. It’s actually intraoperative aberrometry that gives me the confidence to aim for plano. With traditional mathematical IOL calculations, the standard deviation is an issue. Once a surgeon performs a certain number of procedures, some patients inevitably will be overcorrected and some will be undercorrected. A typical fix for this has been to intentionally shift the IOL power toward slight myopia to avoid a hyperopic surprise. Unfortunately, the effect of the fix is not allowing everybody to achieve perfect plano. The ORA System, on the other hand, allows just that. It makes IOL power choice specific to the individual patient, without using formula math, and the results are outstanding.

The ORA System (Figure 1) also allows fine-tuning of cylinder power and IOL alignment in real time, which means it’s also an important tool when I’m implanting the AcrySof IQ ReSTOR Multifocal Toric IOL. The potential to change the planned IOLs does create a need to have multiple lens options at hand. This can detract from efficiency, in particular if ASC policy dictates, as ours does, that only one lens at a time can be in the OR. Our solution was to move our IOL stock into cabinets as close to the OR as possible.

Nuances in My Approach to Patient Selection and Education

Another advantage of the ACTIVEFOCUS design is a somewhat simplified patient selection and education process. Given my lack of concern about potential postoperative distance vision issues, fewer patients are eliminated as candidates for a presbyopia-correcting lens. I’m still cautious about recommending a lens in this category for patients with a Type-A personality, but I have used the ReSTOR +2.5D IOL with ACTIVEFOCUS design in several because they were highly motivated to obtain a range of vision and they fully accepted the risks. In addition, while I wouldn’t fault another surgeon for using the ReSTOR +2.5D IOL with ACTIVEFOCUS design in a patient who makes his or her living flying a plane or driving a truck — the outcomes have been that good — my personal philosophy is to err on the side of caution. I say to these patients, “Why would you put your livelihood at risk, regardless of how low that risk might be?” I have, however, used the lens in patients for whom driving at night is important but not their source of income.

I also ensure that patients understand that the ACTIVEFOCUS design doesn’t specifically provide the best extremely near vision, such as what’s needed to read a medicine bottle label. While it offers functional near vision, much better than a monofocal, other lenses in the ReSTOR family might be best if extremely close-up vision is the main goal. I tell them they’ll have great vision at intermediate and distance with the ReSTOR +2.5D IOL, with the lowest risk of visual disturbances, but they may need reading glasses for some near tasks. As long as they know this up front, they’re very satisfied postoperatively. I take a one-eye-at-a-time approach. I implant the dominant eye with the ReSTOR +2.5D IOL with ACTIVEFOCUS design and then evaluate the patient’s vision post-operatively. Having this option has resulted in great outcomes in my practice.

When it comes to astigmatism, because the center optic of the AcrySof IQ ReSTOR +2.5D IOL with ACTIVEFOCUS performs like a monofocal, the lens is more forgiving than other presbyopia-correcting IOLs that include multifocality. Still, given the importance I place on achieving minimal residual astigmatism for all of my cataract surgery patients, I limit use of the AcrySof IQ ReSTOR +2.5D IOL to eyes with less than 1.0D of cylinder. I am certainly excited about the FDA approval of the AcrySof IQ ReSTOR +2.5D multifocal toric with ACTIVEFOCUS optical design so I can now offer this technology to those with astigmatism.

Mix and Match or Mini-Monovision?

I estimate that I target both eyes for plano in 90% to 95% of my patients who receive bilateral ReSTOR +2.5D with the ACTIVEFOCUS design. As I’ve said, they’re a very happy group of patients. However, while distance vision is usually their top priority, they often would like to have better near vision than bilateral ReSTOR +2.5D IOLs targeted for plano can provide. I’ve found I can deliver this, but I accomplish it differently than most of my colleagues. Whereas most other surgeons currently prefer to implant the fellow eye with an AcrySof IQ ReSTOR +3.0D IOL in this scenario, I prefer to use the ReSTOR +2.5D with the ACTIVEFOCUS design in both eyes to create “mini-monovision.” Following surgery on the first (dominant) eye, if a patient expresses a desire for more near vision, I use ReSTOR +2.5D in the second eye targeted for -0.50D. This enhances the range of near vision, with a focal point not as far out as would be expected with contact-lens or monofocal-IOL monovision. I prefer this mini-monovision strategy because even though the AcrySof IQ ReSTOR +3.0D is a very good lens, I want to do everything I can to lessen the occurrence of a patient experiencing excessive halos or nighttime glare.

A Winning Combination of Technologies

Overall, I find the ACTIVEFOCUS design to be “just what the patient ordered.” It’s a presbyopia-correcting lens that appeals to the large number of patients who want more usable near vision than a monofocal can provide but also want terrific intermediate and distance vision to support an active lifestyle. Patient reactions to this lens resemble the reactions of my LASIK patients: glowingly happy and hugging my neck post-op day 1. And it’s worth repeating that intraoperative aberrometry plays a role in producing those types of reactions time and time again.

Reference

1. AcrySof^® IQ ReSTOR^® +2.5D Multifocal IOL Directions for Use.
2. Alcon Data on File, (Survey 2017).

Dr. Weaver practices with Eye Associates of Tallahassee in Florida, where he specializes in refractive cataract surgery with premium implants. He’s also a clinical professor for the Florida State University School of Medicine and Tallahassee Memorial Hospital Family Medicine and Internal Medicine program. Dr. Weaver is a paid consultant to Alcon.