For cataract and refractive surgeons, the past year-plus has tested, and even altered, ASC operations. However, a very bright thread has also run through this year: exciting, even groundbreaking, new intraocular lenses (IOLs). There are “firsts” in every major category—monofocal, multifocal, and extended depth of focus (EDOF)—and the first light-adjustable and violet-light-filtering IOLs on the U.S. market.

The Ophthalmic ASC talked to three surgeons who are feeling the excitement in their premium-based practices, and seeing new entry points for those who usually use standard monofocals.

“We have always struck a balance between gaining range of vision and sacrificing something else, like nighttime dysphotopsias. Now we can leverage optical principles in a scientifically sound way and gain something without giving anything up,” says Daniel H. Chang, MD, cataract and refractive surgeon at Empire Eye & Laser Center, Bakersfield, CA, and president and founding member of the nonprofit Advanced Center for Eyecare. “If you learn the science and understand the evidence, you’ll know how to help your patients the most.”

→ Monofocal Tecnis Eyhance

Optical aberrations decrease contrast sensitivity, but they also provide some extended range. If a lens eliminates all aberrations, it can provide excellent image quality and contrast, but the trade-off is a narrower focal range. The new Tecnis Eyhance (Johnson & Johnson Vision) monofocal lens offers the advantages of aberration correction while enhancing intermediate vision, according to Rex Hamilton, MD, cataract and refractive surgeon at Hamilton Eye Institute in Los Angeles.

“The Tecnis one-piece monofocal platform offers the best quality of vision because it corrects the most spherical aberration, but that results in a limited range of vision. The new Tecnis Eyhance makes use of optical aberrations to create a slightly extended range on a monofocal platform,” he says.

Dr. Chang, who appreciates the Tecnis Eyhance as a great monofocal option, welcomes the lens’ ability to balance visual quality, depth of focus, and dysphotopsias. “Fundamentally, when we try to correct presbyopia, we’re exchanging some degree of visual quality and dysphotopsias for the extra depth of field. It’s up to the surgeon to determine what balance is best suited for each patient,” he explains.

Dr. Chang prefers to provide as much depth as possible without sacrificing visual quality and inducing minimal dysphotopsia, typically with an EDOF lens like the Tecnis Symfony (Johnson & Johnson Vision). “Tecnis Eyhance doesn’t provide the same range as a multifocal lens, but my patients get about a 0.5 diopter increase in depth of focus, with minimal night vision symptoms,” he says. “That’s a functional advantage for a lot of patients, including those with concurrent pathology, with fewer side effects, less risk, and less out-of-pocket cost. I’ve talked with a number of my international colleagues who have had this lens for over a year, and they’ve had a very positive experience. I’m excited about adding this lens to my portfolio.”

As someone who does a high volume of premium lenses, Dr. Hamilton suggests that Tecnis Eyhance Toric is a good first premium lens for surgeons primarily using standard monofocal lenses. He notes, “A lot of surgeons don’t feel comfortable using premium IOLs because patients have to pay out of pocket, they have high expectations, there’s a risk of halos, and so on. I see Tecnis Eyhance Toric as a great entry point for those surgeons. They’ll have success because the lens is more forgiving. Because of its slightly wider range, it is easier to hit refractive targets, and there is less risk of halos.”

→ Light Adjustable Lens

Implant power is calculated in part based on the estimated lens position. Because the cataractous lens is much thicker than the implant, the surgeon cannot know the final resting place of the IOL in advance of the surgery. Postoperatively, if the implant sits differently than predicted preoperatively, then that change, combined with posterior corneal astigmatism and incisional healing, can make surgeons wish they’d chosen a different power. Enter the first light-adjustable lens, the monofocal Light Adjustable Lens from RxSight.

“Flexibility is the real beauty of the light-adjustable lens. It’s a game-changer for me. It is the world’s most accurate implant with no close second, because three weeks after surgery, in response to healing variables, we can change the power of the implant inside the eye,” explains Vance Thompson, MD, a cataract and refractive surgeon at Vance Thompson Vision, Sioux Falls, SD, who was a principal investigator in studies of RxSight.

“Because that adjustment makes it easier to hit 20/15 uncorrected distance in one eye, we can then hit -1.00D in the other eye and extend the range of vision. Very precise monovision correction makes it possible for patients to see quite comfortably all three distances.”

To adjust the lens power postoperatively, doctors perform refraction and enter the data into the RxSight system. The patient sits in front of the Light Delivery Device slit lamp with a focusing lens, the surgeon pushes a foot pedal, and the lens is adjusted.

There are other ways to adjust vision postoperatively, such as LASIK and PRK, but by adjusting the IOL power, surgeons often can avoid a second surgery and the potential healing variables associated with corneal refractive procedures. This aspect of the lens may be particularly appealing to doctors who don’t perform corneal refractive surgery.

In addition to reducing LASIK touch-ups, the lens has a long list of candidates, according to Dr. Thompson.

“It’s a good choice for patients who want a premium result without the glare and halos associated with a multi-focal lens, as well as for patients with decreased contrast sensitivity from conditions, such as glaucoma or epiretinal membrane,” he says. “RxSight is particularly advantageous for patients who had previous PRK or LASIK, who enjoyed the results and strongly desire an accurate end result, but whose implant calculations pose a greater challenge. We can achieve their refractive endpoint without touching their cornea.”

Although Dr. Hamilton is not using the RxSight, he views this technology as the future of IOLs. “Currently, I am hitting my refractive targets thanks to newer formulas, such as the Barrett and Hill-RBF, as well as intraoperative aberrometry, so I haven’t used the RxSight. But this lens technology is the future,” he says. “I’m excited for it to become available on multifocal and EDOF lens platforms, particularly for helping fine-tune patients with high expectations to achieve a full range of vision without glasses. It offers another level of precision to optimize outcomes with a simple procedure just sitting at the slit lamp, rather than with LASIK.”

NEW TAKES ON EDOF

EDOF lenses are Dr. Hamilton’s first choice for patients who have had previous refractive surgery, for whom multi-focals would decrease contrast further and adversely affect their quality of vision. Today, he uses Tecnis Symfony and the new AcrySof IQ Vivity (Alcon) in these patients.

“The AcrySof IQ Vivity uses a newer technology of phase shifting, with a small central button on the optic and a refractive lens that elongates the depth of field,” he explains. “Because it does not cause much nighttime dysphotopsia, it’s a good choice for surgeons with limited premium lens experience. If the lens falls short at near, I target nearsightedness, in the -0.75D range on the second eye.”

The Tecnis Synergy (Johnson & Johnson Vision), a lens currently available outside the United States, combines multifocal and EDOF characteristics into a single presbyopia-correcting lens—virtually a new category, according to Dr. Hamilton. “The lens combines the great extended range of the Symfony lens and the multifocality of the higher add power of Tecnis Multifocal to give a full range of unaided vision,” he says. “I look forward to using this promising new technology as soon as it is available in the United States.”

Dr. Chang, who has been a clinical investigator of the technology, observes: “The Tecnis Synergy IOL leverages an even greater correction of chromatic aberration to provide the fullest range of any IOL that I have ever used—all while maintaining excellent visual quality. In my experience, patients had near vision as good as high-add multifocals with no perceivable drop-off anywhere in intermediate vision. I look forward to having this lens option when it becomes available in this country.”

→ AcrySof IQ PanOptix Trifocal IOL

The first trifocal lens to be available to the U.S. market is the AcrySof IQ PanOptix Trifocal (Alcon)—and the excitement is not lost on Drs. Hamilton and Thompson.

“I’m always re-evaluating my go-to lens when new technologies arrive, and the PanOptix is my current choice for patients desiring spectacle independence with otherwise healthy eyes,” says Dr. Hamilton. “In my experience, it provides the best level of uncorrected near vision of any current lens. It does create night dysphotopsia and have some dropout at the 1 meter range, but overall it’s an excellent lens because it gives patients a full range of vision.”

Dr. Thompson has found that success is very high with the PanOptix lens—with the right patients.

“It’s up to us surgeons to match the proper implant to the proper patient, and I’m looking for corneas that are optically clean with a healthy tear film,” he says. “We also need to bring our ‘A’ game in analyzing the eye preoperatively, particularly analyzing the cornea for optical irregularities and quantifying the high-order aberrations, which can rule out a multifocal if they are too numerous. I also check for a healthy macula and optic nerve and look for posterior capsule opacification, which will reduce the image quality of the multifocal implant.”

The result is many happy patients, Dr. Thompson says. “In the FDA-monitored trial, 99.2% of patients said they’d get the same lens again.¹ That’s just amazing patient satisfaction! We see it in practice, too. If we put the PanOptix implant in healthy eyes, the chance of patient satisfaction is very high.”

→ Violet Light Filtering Tecnis Symfony OptiBlue

Blue-light filtering has been available in IOLs for some time, with a goal of protecting the retina and perhaps improving the quality of vision by reducing the dispersion of light. But there are drawbacks. The new Tecnis Symfony OptiBlue (Johnson & Johnson Vision) lens is designed to avoid some of those drawbacks, while offering some specific advantages.

“The issue with filtering blue light is that wavelengths in the blue spectrum are responsible for a larger proportion of vision in dim light than in bright light, so filtering it, particularly in a multifocal platform, can compromise dim light near vision,” Dr. Hamilton explains. “The Tecnis OptiBlue filters out violet light, the shortest wavelengths of visible light, to reduce chromatic aberration without compromising near vision in dim light.”

Adds Dr. Chang: “This technology has existed for years, and now it is finally becoming available in this country. The lens filters very specific, high-energy violet wavelengths that cause phototoxicity, free radical formation, and dysphotopsia while maintaining the blue light required for scotopic vision. It also preserves circadian rhythm entrainment, for which blue light must reach intrinsically photosensitive retinal ganglion cells (ipRGCs).”

TIPS FOR GETTING STARTED WITH NEW LENSES

“I find online forums incredibly useful when learning about new IOL technologies, particularly in the COVID era when in-person meetings are not available,” Dr. Hamilton says. “I check the online forums for the Refractive Surgery Alliance as well as Cedars Aspens Society, and ask overseas colleagues what they’re seeing. It’s very important for me to learn what benefits my patients will get from the new lens.”

Once surgeons are convinced by the data and their peers to try a new lens, they tend to feel comfortable with the procedure. Of the new lenses discussed here, the exception to this rule is the RxSight Light Adjustable Lens, which requires both a hardware investment and schedule adjustment.

While the preoperative workup and surgery for this lens are familiar, postoperative care is not. Patients must wear UV-protective goggles after surgery so that UV light doesn’t change the shape of the implant. Unlike other premium lenses, which require visits at 1 day, 1 week, 1 month, and 3 months, followed by laser touch-up if necessary, a similar number of patient visits for light-adjustable lenses are condensed into 6 to 8 weeks. Visits are longer because patients need refraction, dilation, and light adjustment every time.

“There are things to teach your team, your patients, and your referring doctors about RxSight. It’s a different pattern for scheduling visits, and there’s a different timeline to wrapping up postoperative care and returning patients to their optometrists,” Dr. Thompson says. “Patients need to understand that RxSight carries a higher investment in time and effort after surgery, including wearing goggles and having multiple dilated exams. But my patients have been excited about this lens, and they’re willing to wear the goggles.”

For a patient to get excited about wearing goggles for weeks—particularly when they know others who have not had to do so after cataract surgery—the attraction of RxSight must be strong. Dr. Thompson thinks he knows why.

“The light-adjustable lens takes a lot of pressure off the patient to choose the IOL they want. Unlike LASIK patients, they don’t have the advantage of seeing their options before surgery, so they can only go on our description,” he points out. “It amazes me to see how comforted patients feel when I say, ‘Let’s take out the cataract, put in the implant, and show you your options postoperatively so you can decide where you want your vision to be—both eyes clear at distance or one eye a little clearer up close.’ They can make a commitment after they actually see the difference.”

THE FUTURE

Dr. Thompson thinks the future holds more trifocal options and more light-adjustable lenses, including multifocals. He says, “Light adjustability and trifocality have been such game-changers in our practice. Premium cataract surgery has grown so much more with these two advancements in technology. And it’s an evolution. There is always incremental improvement as well as innovation, and our patients are the beneficiaries.” ■

Reference

1. AcrySof IQ PanOptix Trifocal IOL, Model TFNT00 DF