Leading Melbourne ophthalmologists spoke about presbyopia correction during cataract surgery at an educational event organised by Johnson & Johnson Vision in Melbourne recently.
With the ageing population growing, people with cataract and presbyopia will increasingly present to ophthalmologists and optometrists seeking solutions for both.
In 2017-2018, presbyopia affected 697,000 Australians while 411,111 had cataract, according to the Australian Institute of Health and Welfare’s Eye health web report (February 2021.)1
Many have both age-related vision conditions so after surgical removal of the cloudy cataract lens, instead of inserting a clear synthetic lens, inserting a presbyopia-correcting intraocular lens (IOL) makes sense for some people.
The educational dinner event, at The Westin Melbourne late last year, featured presentations, case studies and interactive dialogue and was attended by 40 ophthalmologists and registrars working in public and private sectors.
Host Dr Jacqueline Beltz introduced key speakers Dr Lana del Porto, Dr Narelle Spencer, and Dr Georgia Cleary and led questions and answers.
Dr del Porto spoke about patient-centred care in cataract surgery and how to use patient reported outcome measures (PROMS) to choose the right IOL for each patient.
“The days of ‘doctor knows best’ when it comes to IOL selection are over,” she said. “Patients have wised up about IOL choices and the days of leaving every patient presbyopic after cataract surgery are coming to an end.”
Recent technological advances meant many more options for presbyopia correction at the time of cataract surgery including Symfony, Eyhance and Synergy. Surgeons were constantly told to “choose patients carefully” when it came to presbyopia correcting IOL selection, she said.
Dr del Porto said a recent survey of 207 patients with and without cataract found one-third assumed cataract surgery would make them completely spectacle-free.2 They were shown simulated scenarios (monofocal, extended depth of focus (EDOF) and multifocal lenses) of what their near vision, distance vision and halos would be like after cataract surgery. Ninety per cent said they would choose a presbyopia correcting IOL if available, and EDOF outcome increased likelihood to pay out of pocket for surgery more so than monofocal.
ASK QUESTIONS ABOUT LIFESTYLE
Dr del Porto said she now used presbyopia correcting IOLs in 80% of her cataract patients. In 2017, 9% received IOLs for presbyopia during cataract surgery but by 2019 this had increased to nearly one in five.
PROMS are tools that ask about people’s health including symptoms, conditions and quality of life. She said patient’s self-reported visual difficulty relating to cataract could be reliably measured using questionnaire instruments such as Cat-PROM5, which asks five questions to measure self-reported impact of cataracts on vision and quality of life before and after cataract surgery.
“You can adapt and personalise this for your practice which I’ve done. I adapt it to a casual conversation with the patient before and after surgery,” she said. “I start with open-ended then ask specific questions such as if they drive, intend to drive at night, play golf/tennis, watch much TV and with or without subtitles, use a desk-top computer, have/use a smart phone, read newspapers/books, and knit or sew.
“If they can answer, we know what lens to use. It only takes a minute to ask their visual goals but what’s more important?”
ASKING PATIENT PRIORITIES
“For patients who want it all, ask them to prioritise: what’s more important – driving at night or reading a book without glasses? Get the patient to choose the lens by prioritising what is most important for them to do with or without glasses.”
Post-operatively she asks whether they can drive, watch TV including subtitles, use a desk-top computer, cook/eat a meal, read a restaurant menu, book/newspaper and food labels and thread a needle without glasses because this makes them realise how far they’ve come.
“A patient-centred approach to cataract surgery outcomes is needed and PROMS will become a measure of success, especially in the setting of rapidly progressing IOL technology such as presbyopia-correcting IOLs,” she concluded.
Dr del Porto, a consultant for Alcon, Bayer and Johnson & Johnson, said presbyopia correction was not suitable for every eye or every patient. She said it was important to at least mention presbyopia correction to every patient, even if they were not suitable due to macular pathology or other eye conditions. Patients deserved to be well informed and should understand that presbyopia correction was considered but deemed unsuitable.
ACHIEVING CLARITY OF VISION
Dr Narelle Spencer spoke about micromonovision with Tecnis Symfony IOLs. She has used many different presbyopia correcting lenses including Oculentis Comfort, Fine Vision Micro F, Symfony, IC-8, PanOptix, Synergy, Eyhance, Vivity and Rayner EMV.
“I’ve tried the other IOLs over six years, but I keep coming back to the Tecnis Symfony because of great results and excellent vision,” she said. “It’s an extremely forgiving lens and good quality lens material. Clarity of vision is excellent and in six years I have not needed to perform a lens exchange.
“It has uninterrupted vision, image contrast day and night, tolerance to refractive error and residual astigmatism and Tecnis quality.
“Tecnis Symfony IOLs work by stretching the focal point using 92% of light in the full range of vision. This light is distributed across the entire extended depth of focus rather than distributed at specific focal points… the lenses actively correct the naturally occurring chromatic aberration of the cornea, resulting in enhanced image contrast at far, intermediate, and near.
“Tecnis Symfony delivers high quality distance visual acuities, with binocular distance visual acuity of 20/25 or better at six months.3 “Strong visual acuities and high contrast allow Tecnis Symfony IOLs to deliver reduced spectacle wear overall and at all distances;4,5 85% need glasses none of the time or only a little of the time so patients are satisfied.”6
High quality distance plus strong intermediate and functional near vision meant 97% achieved 20/25 or better binocular uncorrected intermediate visual acuity and 84% achieved 20/32 or better binocular near visual acuity at six months.7,8
Dr Spencer said high quality vision led to high patient satisfaction and studies showed 94 to 98% of patients were satisfied with Tecnis Symfony.9,10
Limitations included five to 10% having side effects of halos, glare and starburst,11–13 mainly at night and glare during the day but there was no waxy vision and clarity of vision was excellent, she said.
Her audit of 38 patients with bilateral insertion (aim plano /-0.50) found 60% were spectacle independent, 36% used glasses infrequently and satisfaction was 95%.
PRE-SURGERY CONSULTATIONS
“For EDOFs, multifocals, and monovision lenses, all cataract patients should have preoperative OCT scans and corneal tomography and the most important question is: ‘Do you mind wearing glasses for reading after cataract surgery?’,” Dr Spencer advised.
“If they say no, they don’t mind, don’t do EDOF, go for monofocal as it’s the safest lens.
“However, with EDOF, 85% won’t need glasses with both eyes done although five to 10% have halos, glare and starburst at night, which is a small price to pay.
“With multifocal intraocular lenses, up to 96% of patients are spectacle independent but 100% get halos and glare at night. A small percentage of patients lose clarity of vision and require a lens exchange.
“With presbyopia you have to be willing to make compromises so let people choose but guide them through it.”
ASTIGMATISM AND HIGHER ORDER ABERRATIONS
Dr Georgia Cleary spoke about astigmatism and higher order aberrations, advising surgeons to ask their patients about occupation, budget and lifestyle, and to consider ocular pathology and refractive error.
Presbyopia correcting IOLs were now available with a range of astigmatism correcting powers available, she said.
“Why would you leave astigmatism?” she asked, indicating this can be treated effectively.
This does, however, require corneal topography, Dr Cleary said.
“It’s important in all IOL surgery to assess corneal shape, and if corneal shape is regular, go for it. A high amount of astigmatism shouldn’t be a barrier to presbyopic IOL implantation although patients may need laser refractive ‘top-up’ afterwards,” she said.
Discussions with a laser refractive surgeon ensured a pathway and costs were established beforehand.
Dr Beltz suggested advising, in pre-surgery discussions, that there was a small chance the patient would need enhancement with laser surgery afterwards. She suggested establishing a relationship with a laser refractive surgeon before considering presbyopia correction as it was very important to have facility to ensure refractive targets were met.
Dr Cleary added: “Check the corneal astigmatism. Look at the corneal shape first. Is it regular, is there something reversible (causing the astigmatism)? If so, treat the cornea first (i.e., pterygium).”
With regards to assessing the Chang-Waring Chord preoperatively, she suggested starting with tight criteria, everyone within 0.5, and when more comfortable, consider slightly relaxing this parameter.
Apart from pre-operative tests, counselling including about halos could help build trust and ensure patients returned, she said.
“Discussions before versus complications after,” Dr Cleary said, indicating anything said pre-operatively was a discussion, whereas postoperatively it might be considered a complication. All speakers emphasised that pre-operative discussions were essential for any form of refractive cataract surgery, including presbyopia correction.
About the Speakers
Dr Lana del Porto is a general ophthalmologist with extensive experience in the treatment of cataract. She is a consultant at The Royal Victorian Eye and Ear Hospital, where she teaches cataract and squint surgery, and has private practices in East Melbourne, Springvale and Cheltenham.
Dr Narelle Spencer is a general ophthalmologist with a special interest in cataract surgery who has performed more than 5,000 cataract procedures. She took over ownership of Heidelberg Eye Clinic in 2007 and practises at Canterbury Eye Specialists and Manningham Private Hospital.
Dr Georgia Cleary is a specialist ophthalmologist and cornea specialist with a research interest in cataract surgery and intraocular lenses. She is the Head of the Surgical Ophthalmology Service at the Royal Victorian Eye and Ear Hospital and practises at Bayside Eye Specialists, Lasersight East Melbourne and Southern Eye Centre Frankston.
Dr Jacqueline Beltz is Co-President of the Australasian Society for Cataract and Refractive Surgeons as well as staff specialist in corneal and cataract units at the Royal Victorian Eye and Ear Hospital and a specialist ophthalmologist and associate at Eye Surgery Associates in Melbourne.
Helen Carter is a journalist with extensive experience writing about healthcare.
References
- Australian Institute of Health and Welfare, Eye Health Report, 11 Feb 2021, available at: https://www.aihw.gov.au/ reports/eye-health/eye-health/contents/about.
- Kantar Health Consumer Cataract Awareness Research, July 2021.
- TECNIS Symfony Extended Range of Vision IOL (package insert]. Santa Ana, Cali.
- DOF2015CT0028 Symfony Harmony Observational Study.
- DOF2016CT0024 Concerto Study Report
- TECNIS Symfony IOL DFU.
- TECNIS Symfony Extended Range of Vision IOL [package insert]. Santa Ana, Cali.
- AcrySof IQ ReSTOR +2 .5 D Multifocal Intraocular Lens (MIOL), Model SV25T0 SUMMARY OF SAFETY AND EFFECTIVENESS (SSED).
- DOF2015CT0028 Symfony Harmony Observational Study.
- DOF2016CT0024 Concerto Study Report.
- TECNIS Symfony IOL European Clinical Study.
- TECNIS Symfony IOL European Post-Market Observational Study.
- TECNIS Symfony IOL US Pivotal Study.
