LENSTEC CLEARVIEW 3 MULTIFOCAL

BY J. MORGAN MICHELETTI, MD

Multifocal IOLs have been an option in the US-based refractive surgeon’s toolbox since 1987 when the first multifocal IOLs were implanted (3M Vision Care and IOLAB models). Each commercially available multifocal IOL from that point forward has had a concentric-ring optical design, in which a zone of distance power is flanked between alternating powers: historically near power, but more recently, either near or intermediate power.

The Lenstec ClearView 3 (SBL-3) multifocal IOL received FDA approval in July 2022 and is the first and only non-concentric ring-based multifocal IOL approved for use in the United States. It has a unique design: one side of the optic has distance power, while the other portion has a 3.0 D add sector. The stacked optic configuration creates a single transition area in which one power (distance) changes to another (near). Traditional concentric ring designs have multiple transition zones, which can scatter light and lead to visual disturbances such as halos and glare. As per FDA study data, the visual disturbance profile of the ClearView 3 aligns closely with that of the control monofocal IOL.

Based on my experience, patients typically report minimal visual disturbances and largely maintain spectacle independence. I’ve been implanting the ClearView 3 since August 2022, with consistently favorable outcomes.

When using the ClearView 3, consider the following key insights:

1. The design enables the surgeon to position the visual axis through a part of the optic where there are no transition zone interferences, specifically, the distance zone. As a result, the lens offers a smooth, continuous range of vision while avoiding the typical visual disturbances often encountered with other design approaches.
2. Typically, I start by positioning the IOL with the add segment oriented infero-nasally. However, I will adjust the IOL’s orientation as needed to align the Purkinje reflex within the distance segment.
3. Selecting patients with photopic pupils of 3 mm or larger enhances the likelihood of optimal results, though I do not necessarily exclude patients with smaller pupils.
4. The IOL’s availability in 0.25-D increments allows for a greater likelihood of hitting the planned post-operative target, which for me is typically plano with the ClearView 3.
5. The four-footplate haptic design allows effective centration in the capsular bag. Post implantation, it demonstrates minimal rotation, approximately 2 degrees as noted in the FDA registration study.
6. The IOL is not available in a toric option, so consider an LRI or other kerato-refractive surgery if the patient has greater than 1 D of corneal astigmatism. To boost the likelihood of optimal visual outcomes, it is recommended to minimize postoperative astigmatism as much as possible.

J. Morgan Micheletti, MD, FACS, is a board-certified cataract, refractive and complex anterior segment surgeon. He was named to the Best Cataract Surgeons in America list, recognized as Castle Connolly Top Doctor and was named to Ophthalmology Management’s 40 Under 40 in 2022. Email him at morgan.micheletti@gmail.com. Disclosures: Dr. Micheletti revealed relationships with Alcon, Glaukos, Johnon & Johnson Vision, New World Medical, RxSight and Zeiss.

RAYNER RAYONE EMV

BY ATHANASIOS G. MARNERIS, DO

The Rayner RayOne EMV is a single piece non-diffractive hydrophilic acrylic lens that utilizes positive spherical aberration to increase range of focus. This design allows monofocal-like quality vision with a low level of dysphotopsia and superior intermediate vision when compared to standard monofocals. Further, it provides patients with up to 1.50 D of high-quality vision when targeting emmetropia. RayOne EMV is optimized for monovision with its unique positive spherical aberration design that provides a smooth transition between distance and near vision. The lens is available from 10.00 to 30.00 D in 0.50-D steps in a fully preloaded system that accommodates up to a 2.2-mm incision. The toric version is currently unavailable in the United States.

Below are some useful tips for planning, selection and utilization of this IOL.

1. TARGET

For dominant eyes, target plano with consideration of hedging to “plano first plus.” This is because inducing positive spherical aberration also induces a myopic shift. Due to the extended depth of vision and the “hyperopic tail” present on modulation transfer function performance curves, the dominant eye will be more forgiving of post-operative myopic shift when compared to aberration negative aspheric IOLs. The non-dominant eye offset can be anywhere from -0.50 D to -1.00 D to achieve either a mini-mono vision or blended vision state with good distance acuity and stereoacuity. I consider this one of the greatest strengths of this lens implant.

2. PATIENT SELECTION

The RayOne EMV is an excellent choice for patients looking for good quality vision who may not be candidates for trifocal lens implants, such as those with severe dry eye or ocular surface disease. While this lens is incredibly forgiving, patients with extreme ocular surface disease, excessive regular astigmatism or irregular astigmatism should be avoided. Effective treatment of ocular surface disease, good quality biometry and expectation setting are paramount. Astigmatism management is critical for good results; Patients with regular astigmatism beyond +0.75 to +1.00 D would benefit with the addition of LRIs, on-axis incisions or femtosecond-assisted laser treatment.

3. PLAY TO THE LENS’ STRENGTHS

Higher order aberrations (HOAs) play a significant role in image quality. Consider a few scenarios. First, lens decentration can induce HOAs degrading vision quality. Postoperative capsule contraction is a potential cause. To combat this, the RayONE EMV haptic design allows the outer haptics to eventually compress and lock into the inner haptics. Per Rayner, this mechanism allows for an average offset of only 0.08 mm up to 6 months after surgery.

Second, there is a point of diminishing returns when addressing spherical aberration; too much and we begin to decrease contrast sensitivity. Post-refractive patients experience changes in spherical aberration post-treatment. For example, post-hyperopic refractive patients tend to have increases in negative spherical aberration while positive spherical aberration increases in post-myopic treatments. The RayOne EMV induces a modest amount of positive spherical aberration (approximately +0.15). Evaluating a patient’s HOAs may allow the lens to be used in a complementary way.

4. IMPLANTATION

The pre-loaded format is convenient and easy for both surgeon and technician to use. When using the push plunger, a slow and steady approach is recommended. Because of the hydrophilic nature, the lens inserts smoothly and opens consistently. The large haptics may appear daunting at first; however, they are gentle and easy to manipulate upon insertion. Withdrawing the injector slightly during implantation can help ease implantation into the capsular bag.

To conclude, the Rayner RayOne EMV lens implant is an excellent lens option that bridges the gap for patients who desire more from a traditional monofocal IOL but are not good candidates for a trifocal lens. The ability to customize the patient’s range of vision without sacrificing stereoacuity is a great tool in the ophthalmologist’s armamentarium in addressing presbyopia.

Athanasios G. Marneris, DO, is a comprehensive ophthalmologist at Multack Eye Care group in the Chicagoland area. Dr. Marneris completed ophthalmology residency training at University of Michigan Health Metro Health Hospital followed by an ocular inflammatory and medical cornea fellowship at Proctor Foundation University of California San Francisco. He specializes in refractive and complex cataract surgery and minimally invasive glaucoma surgery, with a special interest in ocular inflammatory disease. Dr. Marneris reports no relevant financial disclosures.

RXSIGHT LIGHT ADJUSTABLE LENS

BY O. BENNETT WALTON IV, MD, MBA

With RxSight’s Light-Adjustable Lens (LAL), surgeons choose the IOL power preoperatively, have patients wear UV protecting spectacles until the process is complete, then adjust one to three times as needed with the light delivery device (LDD) prior to two lock-in treatments to permanently “fix” the IOL power.

Here are some pearls based upon our years of experience so far.

IN THE OR

It’s nice to have a lens that corrects astigmatism without having to think about marking, iris registration, alignment or postoperative IOL movement. Additionally, because the three-piece design centers itself in the capsular bag more automatically than a smaller wingspan acrylic would, centration is easy. The injector requires approximately a 2.8-mm incision. Prior to removing viscoelastic with my standard, smaller coaxial sleeve, I hydrate the roof and sides of the incision to swell the enlarged incision around the smaller sleeve.

TARGETING AND ADJUSTING

Phase 4 data have shown that 98% of LAL patients adjusted for bilateral emmetropia have binocular uncorrected distance vision of 20/25 or better, and 93% have binocular uncorrected near of J3 or better. These uncorrected near results are more impressive than one would expect for a monofocal at distance in each eye, and we usually end up targeting some amount of near in the near-preferred eye to expand the range further.

Whenever I use the LAL, I prefer to pull patients’ focal points in rather than pushing them out. Since the LAL is “swelled” by a light adjustment rather than “whittled down,” starting further out into distance and pulling an eye closer means I can treat a central portion of the IOL, which makes it easier in the event of a difficult dilation. Additionally, when an eye is targeted for a non-distance target with some amount of myopia, the LDD automatically includes some additional range of vision via increased negative spherical aberration. This means that eyes targeted for distance have a small amount of negative spherical aberration to offset a natural cornea’s positive average spherical aberration, and eyes targeted for some amount of near have even more negative spherical aberration to boost reading without splitting light.

In general, whatever the ultimate target is for a non-dominant eye, plan an IOL choice for slightly hyperopic of that and use the treatments to fine tune.

ENJOY THE ACTIVSHIELD

Not available upon the initial FDA approval and commercialization, ActivShield is a layer in the anterior LAL surface that blocks UV sub-spectrum when exposed to broad spectrum light in the event a patient forgets to protect the eye from the sun. It is temporarily deactivated automatically by the beginning portion of a light treatment.

I cannot overstate how important the ActivShield is. Previously, most patients were very happy, but we had the occasional patient whose noncompliance with UV protection required an IOL exchange due to premature photopolymerization. Our LAL recommendation rate temporarily declined after a few of these exchanges. Since ActivShield was introduced, however, we have not had any issues, and my confidence level and comfort with LAL is higher than ever.

IDEAL FOR ISBCS

Immediate sequential bilateral cataract surgery (ISBCS) is a hot topic, and there are certainly more advantages and concerns than can be fully addressed here. When considering lens technologies, however, there is no better technology for ISBCS than the LAL. After all, we fine-tune the targets postoperatively, we do not need to see where the first eye heals to hedge the second eye’s IOL power estimation, and silicone optics have among the lowest dysphotopsias rates among IOLs. In the special cases in which we allow ISBCS for patient convenience, it’s almost always with the LAL.

CONSIDER THE ADJUSTMENT VISITS

Many practices have optometrists or physician assistants perform the postoperative adjustment visits to ease the clinic demands of the surgeon. We still have surgeons perform the light treatments in our practice. Consider your state scope-of-practice requirements, and check with your malpractice provider to ensure compliance. OM

O. Bennett Walton IV, MD, MBA, is a cataract, refractive and cornea surgeon. In addition to clinical practice, Dr. Walton is a surgeon for clinical trials and evaluation of new refractive and cataract technologies. Financial disclosures: Dr. Walton revealed relationships with AbbVie/Allergan, Alcon, Avedro, Bausch + Lomb, Beaver-Visitec International, Bruder Healthcare Company, LensAR, RxSight, Staar Surgical, Tarsus Pharmaceuticals and Carl Zeiss Meditec.