The cataract surgery landscape is changing. First, cataract patients are younger. Baby boomers are now developing cataracts. By 2030, they will all be over 65. These cataract patients are also more demanding. Unlike previous generations, they are educated, tech savvy and many are still in the work force. They want clarity without compromise.

Multifocal IOLs are ideal solutions for presbyopic patients who want freedom from glasses. However, these lenses require significant consultation to effectively match the patient’s needs with the appropriate option.

Cynthia Matossian, MD, FACS, founder of Matossian Eye Associates, describes her cataract patients as, “Living longer, more active, driving, playing sports and engaged in multiple hobbies. Visual clarity is very important to this demographic, and they are well educated … with instant access to information.”

With these factors in mind, Dr. Matossian customizes her IOL plan for each patient. At an initial consultation and following a cataract diagnosis, Dr. Matossian provides them a two-to-four week course of treatment of any accompanying ocular surface disease. During that time, the patients receive an e-mail breaking down their premium IOL choices. This allows the patients sufficient time prior to their scheduled pre-surgical appointment to digest the news, consider their visual options and understand the reason behind the extra cost. Armed with information, they are more apt to select premium IOLs, including multifocals.

Setting patient expectations is key, says Dr. Matossian. She warns all her multifocal IOL patients about starbursts and spider webbing, especially with red LED lights, headlights and taillights, particularly when driving at night.

ACRYSOF IQ RESTOR

Kamran M. Riaz, MD, director of Refractive Surgery and assistant professor, Department of Ophthalmology and Visual Science, the University of Chicago Medicine & Biological Sciences, says that patients who are highly motivated to get 20/20 vision at distance and J1 at near do well with AcrySof IQ ReStor +2.5 D and +3.0 D lenses (Alcon).

The ReStor +2.5 D’s Activefocus optical design is engineered to give cataract patients quality distance vision and balanced near and intermediate performance to reduce dependence on glasses, the company says. Its central portion is 100% dedicated to distance vision.

This multifocal toric IOL demonstrated effectiveness and safety in clinical trials.¹ Across 15 U.S. sites, the ReStor +2.5 D IOL showed superior near (40 cm) and intermediate (53 cm) vision by two lines vs. AcrySof IQ monofocal IOL along with similar distance (4 m) vision. Also, safety profiles and visual phenomena were comparable between groups.

In another clinical study of 279 patients, eight out of 10 patients implanted with the AcrySof IQ ReStor +3.0 D IOL reported complete freedom from glasses six months after surgery.² Also, more than 93% of these patients indicated they would have the ReStor +3.0 D IOL implanted again.

Also, AcrySof Toric IOLs demonstrated rotational stability in a recent study by Bryan S. Lee, MD, JD, and David F. Chang, MD.³ Of 626 eyes that received an AcrySof lens, the mean absolute value of rotation was 2.72 degrees (95% CI, 2.35 to 3.08 degrees). Also, 97.8% of lenses rotated ≤10 degrees from the target of axis, and 98.6% of lenses rotated ≤15 degrees from the target axis.

Dr. Riaz prefers a “mix and match” method of using multifocal IOLs. One approach he uses is an AcrySof IQ Restor +2.5 in the dominant eye and an AcrySof IQ Restor +3.0 D in the non-dominant eye. He says this give “patients some ‘bonus’ focal points at intermediate (dominant eye) and near (non-dominant).”

TECNIS SYMFONY

Dr. Riaz’s patients looking for 20/20 vision at distance and J1 at near also find success with the Tecnis Symfony ZKB00 (+2.75D), ZLB00 (+3.25D) and ZMB00 (+4.00D) (J&J Vision).

Jason Jones, MD, presented a study of the Tecnis Symfony multifocal at the 2016 ASCRS meeting. The results showed that the monocular and binocular distance acuities of the multifocal group were clinically comparable to the control group, while mean binocular intermediate and near vision were 20/20 and between 20/25 and 20/32, respectively.⁴ Another study by Beatrice Cochener, MD, examined 411 Tecnis Symfony patients. With regards to postoperative spectacle independence four to six months after surgery, 91.4% reported never/occasionally requiring spectacles for distance, 91.5% reported never/occasionally needing them for intermediate and 74.5% reported never/occasionally for near.⁵

Dr. Matossian uses a mix-and-match method with the Tecnis Symfony. She operates on the dominant eye first and uses a Tecnis Symfony Extended Depth of Focus (EDOF) IOL. “If they are not thrilled with their reading vision, despite my assurance they will see better at near after both eyes have the EDOF IOL, I opt for a Tecnis ZLB00 (+3.25D) in the non-dominant eye.”

Dr. Riaz uses a similar approach with the Tecnis (+2.75D in the dominant eye, +3.25D in the non-dominant eye. “The Tecnis Symfony offers the added benefit of non-diffractive optics by relying on a defocus curve (essentially a columnization of light) to give a range of vision, providing greater distance and intermediate ranges, correcting for chromatic aberration and offering a subjective improvement in visual quality and satisfaction,” he says.

CRYSTALENS AND TRULIGN

A study by Ahad Mahootchi, MD, presented at the 2016 ASCRS meeting examined 940 Crystalens and Trulign (Bausch + Lomb) cases from 2004 to 2015.⁶ Of the 394 cases for Crystalens models AT-45, 50, 52 and SE (2004-2010), 42% were within +/- .25 D of target, 72% were within +/- .50 D of target and 87% were within +/- .75 D of target. Crystalens cases in this study also demonstrated refractive stability over time and across multiple lens models (AT-45, AT-45SE, AT50, AO and Trulign). Of the 821 Crystalens cases from 2004-2015, 87% had .50 D or less of change.

Crystalens AO and Trulign patients also demonstrated spectacle independence. Patients needed no glasses for distance 99% of the time, no glasses for intermediate 98% of the time and no glasses for near 69% of the time along with an average uncorrected near vision of 20/40.

For former LASIK recipients, Dr. Matossian has had success with the Crystalens AO and Trulign. “These lenses provide excellent distance and intermediate vision, without light disturbances, such as haloes and glare, because they are designed with monofocal optics, without rings or echelettes.”

For post-refractive surgery cataract patients, Dr. Riaz prefers the Crystalens AO. “Many of these patients had LASIK or PRK prior to wavefront-guided or wavefront-optimized ablation algorithms, so many have significant higher-order aberrations, particularly spherical aberration and coma. I would much rather use a Crystalens with mini-monovision of -0.50D in these patients and avoid potentially disabling glare or haloes.”

CONCLUSION

For those looking to provide the best possible vision for their presbyopic patients undergoing cataract surgery, Dr. Riaz offers this valuable clinical pearl: “Listen to your patient’s goals, fears and expectations of cataract surgery. A lot of chair time is frequently needed. The surgery is often the easy part. When you listen to your patients’ goals, you get a good idea of what IOL would be the best option for them.” OM

REFERENCES

1. C-10-016 Clinical Study Report: Clinical Investigation of AcrySof IQ ReSTOR +2.5 D Multifocal IOL. Effective date Aug 7, 2013.
2. AcrySof IQ ReSTOR +3.0 D IOL Directions for Use.
3. Lee BS, Chang DF. Comparison of the rotational stability of two toric intraocular lenses in 1273 consecutive eyes. Ophthalmology 2018 Mar 12. [Epub ahead of print]
4. Jones J. Visual Outcomes of a New Extended Range of Vision IOL. Paper presented at: ASCRS/ASOA Symposium & Congress; May 8, 2016; New Orleans, LA.
5. Cochener B, Concerto Study Group. Clinical outcomes of a new extended range of vision intraocular lens: International Multicenter Concerto Study. J Cataract Refract Surg. 2016 Sep;42(9):1268-1275.
6. Mahootchi A. Durability and Stability of Refractive Results and Spectacle Independence: 10 Year Retrospective of an Accommodating IOL. Poster presented at: ASCRS/ASOA Symposium & Congress. 2016; New Orleans, LA.