Exploring New IOL Options: Selecting the Best IOL for Each Patient

LEARNING OBJECTIVES

On completion of this CPD activity, participants should:

1. Realise the nuances in currently available intraocular lenses,

2. Understand important considerations when deciding on lenses for individual patients, and

3. Be aware of new and emerging IOL technologies.

 

Premium IOL is a term that refers to any IOL that is not a standard monofocal IOL.¹ This is a misnomer as all of the IOLs we use in Australia are ‘premium’ quality.

Giving a patient a standard monofocal IOL is indeed a ‘premium’ IOL if that is the most appropriate IOL for that patient.

Cataract surgery gives us an opportunity to not only reverse cataract, but to improve our patients’ quality of life by offering an IOL that will give them the best visual outcomes from their surgery and ideally, a degree of spectacle independence.

Our patients, whether in the private or public sector, should have the opportunity to have the most appropriate ‘premium’ IOL technology available at the time of their cataract surgery, regardless of their financial status.

Patient Education

An informed patient is a happy patient. We see a wide variety of patients, ranging from those who know the exact make and model IOL they wish to have implanted, to those who don’t have any understanding of basic eye anatomy. Both these scenarios have their challenges and can be equally difficult to manage.

The most frustrating thing for any surgeon is when we see a patient the day after their surgery and they ask, “why was I not given a multifocal lens?”. It is an essential part of the informed consent process that we, as surgeons, make our patients aware of different IOL options and at least mention why they may or may not be suitable to have certain IOL options.

The discussion about IOL choices can be overwhelming for patients. There is a lot of new information for our patients to process before deciding on which IOL technology they would prefer to have at the time of their cataract surgery.

This makes it favourable for patients to be aware of the possible IOL options available to them before they come in for their initial assessment. This at least gives the surgeon a starting point and can make the decision-making process a lot more collaborative and efficient.

Patient education is best done by the referring medical practitioner, where possible. I have prepared an information video that my team shares with patients, and ask that they watch the video before they come in for a cataract surgery assessment.² This helps to a degree, although can be technologically challenging for some patients. You can watch the video at: vimeo.com/1075996135.

Tailoring the IOL to the Patient

The ideal lens for each patient depends on multiple factors:

Visual goals: Does the patient wish to be spectacle-free? Patients often don’t mind wearing glasses and are happy to continue to do so if they have excellent vision with glasses. Occupation, hobbies, and lifestyle factors need to be considered when discussing IOL options.

Astigmatism: Residual astigmatism will compromise the outcome of any cataract surgery. This is even more profound with extended depth of focus (EDOF) and multifocal IOLs (MFIOL), where astigmatism has a detrimental effect on the best corrected visual acuity and patient satisfaction.³ Regular astigmatism should be addressed with a toric version of whichever IOL variety the surgeon chooses. Irregular astigmatism, however, limits the IOL options available and can have poor outcomes if combined with an EDOF or MFIOL. Corneal topography is, therefore, an essential diagnostic tool in the cataract surgery work up and should be done on every patient having cataract surgery with premium IOL technology.

Ocular pathology: Any underlying ocular pathology needs to be considered when making an IOL choice: EDOF and MFIOLs are best avoided in patients with underlying macular pathology or optic nerve dysfunction (including glaucoma). Even though there is no conclusive evidence to support this,⁴ common sense would suggest that any reduction in contrast sensitivity would negatively impact these patients.

Advanced biometric considerations: Newer IOLs with more complex optics require additional consideration. Corneal spherical aberration, pupil size, and angle kappa need to be assessed and considered when determining the most suitable IOL for patients.

Does The Patient Have Cataract?

Patients are presenting earlier for cataract surgery as the visual benefits and presbyopic solutions of advanced IOLs become more desirable. This is also driven by positive patient experiences and word of mouth referrals, which can be misleading. Advanced cataract surgery techniques have also improved the risk profile of IOL surgery.

Clear lens extraction/ refractive lens exchange refers to IOL surgery in the absence of cataract. This surgery is non-rebatable and not covered by health insurance.

Presbyopic patients without cataract, who are suitable to have laser assisted in situ keratomileusis (LASIK) surgery and pass the monocular blur test, should be made aware of alternative surgical options to clear lens extraction surgery such as Presbyond laser blended vision (LBV) correction. This is a less invasive and more accurate surgical intervention for presbyopic patients without cataract.⁵

Diagnosing early cataract can be difficult. Having an objective measurement device, such as an aberrometer, topographer or high definition analyser, helps decide if early cataract surgery will be more appropriate than LBV in patients with early, visually significant lens opacities.

Getting It Right

Pre-operation

Accurate biometry⁶ is the most important step in achieving the desired refractive outcome in cataract surgery. Advanced biometers, such as the ZEISS IOL Master 700, in combination with third generation IOL formulas (Barrett, Kane, Hill)⁷ improve the chances of achieving excellent refractive outcomes. This can, however, all be undone if the ocular surface is poor at the time of assessment.⁸ It is imperative that patients address their dry eye syndrome before having their pre-surgical assessment. A sufficient contact lens holiday (seven days for soft contact lenses, 30 days for rigid gas permeable contact lenses) will allow the corneal surface and epithelium to stabilise before biometry and achieve more accurate results.

Intra-operation

Digital IOL alignment systems, such as Alcon Verion and ZEISS Callisto help reduce the likelihood of residual astigmatism and have become essential tools when offering premium IOL options.⁹

Spherical aberration: All eyes have a degree of natural spherical aberration (SA). The ‘normal’ corneal SA is +/- +0.2 µm. This offsets some of the natural lenticular spherical aberration. Increased SA (between +/- 0.2 µm to +/- 0.6 µm) increases depth of focus without compromising best corrected visual acuity (BCVA).

SA greater than +/- 0.6 μm becomes toxic and leads to a degradation of visual quality and BCVA.

Knowing the individual corneal SA (corneal wavefront measurement) and targeting a post-operative range of spherical aberration by selecting an appropriate IOL (positive, neutral, or negative) will help achieve increased depth of focus if desirable.^10,11

Pupil size: Pupil size plays a significant role in determining the visual outcomes of IOL surgery, particularly when using premium IOLs such as MFIOL and EDOF IOLs.¹² In patients with larger pupils, especially under dim lighting conditions, light rays may enter through the peripheral zones of the IOL where optical aberrations are more likely to occur. This can lead to increased haloes, glare, or reduced contrast sensitivity, especially with diffractive trifocal lenses. Conversely, small pupils may limit the effective use of the IOL’s full optic zone, potentially either reducing or increasing the depth-of-field benefits seen with EDOF lenses, depending on the optic design. Some aspheric IOLs that correct for spherical aberration may also underperform if the pupil is significantly smaller or larger than average. Therefore, preoperative assessment of mesopic and photopic pupil size is crucial for matching the right IOL type to the patient’s anatomy and visual expectations, ultimately leading to more predictable and satisfactory outcomes.

IOL Options

Patients have four options for the potential outcome of their cataract surgery. None of these are perfect, and all have an advantage and disadvantage / compromise, which the patients need to understand and agree to, before proceeding with their surgery.

Bilateral Monofocal IOL

Monofocal IOLs remain the most widely implanted lenses in cataract surgery. Many patients are quite happy to continue wearing glasses for intermediate and near tasks, knowing they have the best quality vision, albeit with the aid of glasses.

Some myopic patients enjoy being able to read without glasses and prefer that we target myopia in order to continue to wear glasses for distance vision after their cataract surgery.

There are some differences in materials and design among the many monofocal IOL options, however it’s important to consider the spherical aberration of the IOL and match this with the patient’s corneal SA to achieve the desired optical quality.¹⁰ Most monofocal IOLs have a negative SA of +/- -0.2 μm which offsets the average corneal SA (+0.2 μm) and achieves high-quality vision, but little depth of focus.

Patients who have had previous refractive laser surgery – photorefractive keratectomy (PRK), LASIK or small incision lenticule extraction (SMILE) – will have a change in their corneal SA. Myopic treatments lead to increased positive SA.¹³ These patients may benefit from an IOL with negative SA (Alcon Clareon) or an IOL which is aberration neutral (Rayner RayOne). Hyperopic ablations induce negative SA, and these patients would benefit from an IOL with positive SA (Rayner RayOne EMV), or an aberration neutral IOL (Bausch and Lomb Envista).¹⁴

Bilateral EDOF

EDOF IOLs claim to create a single elongated focal point to provide improved intermediate and some near vision, while minimising the visual disturbances seen with diffractive full range of vision multifocal lenses. This makes them ideal for patients seeking greater visual function with fewer photic side effects.

The degree of spectacle-free near vision achieved with EDOF lenses can be unpredictable, and as such, patients receiving these IOLs need to be prepared to wear glasses for near vision tasks after their surgery.¹⁵

Common EDOF IOLs available in Australia include:

Alcon Vivity: ideal for patients who want extended vision with no diffractive rings and minimal visual disturbances.¹⁶

Tecnis PureSee: a clean, non-diffractive EDOF design with a focus on natural intermediate vision and reduced dysphotopsia.¹⁷

Bausch and Lomb LuxSmart: one of the few EDOF IOLs with aberration-neutral optics, balancing distance and intermediate vision with a very low risk of glare.¹⁸

ZEISS At Lara: a diffractive EDOF that provides the widest range of vision, including some near, but with a higher chance of haloes.¹⁹

Enhanced Monovision

Monovision is a very useful way to achieve spectacle independence, however they often offer poor intermediate or near vision, depending on the degree of myopia achieved in the non-dominant eye.

The RayOne EMV by Rayner was designed to be used with monovision and has a controlled amount of positive SA, resulting in higher post-operative whole eye spherical aberration. This results in greater depth of focus in each eye, of up to 1.5D. As a consequence, one can achieve a full range of vision by targeting mild myopia (-1.00D to -1.25D) in the non-dominant eye, which is more easily tolerated than the greater degree of anisometropia required in traditional monovision.

Neuroadaptation to mini monovision can take some time, and patients need to be prepared to have some blurred vision in the non-dominant eye after their surgery. Night driving can be difficult initially, but tends to improve with time. Patients may require distance correction spectacles, especially when driving at night in the first few months as neuroadaptation evolves.²⁰ The RayOne EMV can also be used without monovision to deliver excellent distance and good intermediate vision, in a similar way to EDOF lenses.

Bilateral Multifocal IOL

Implanting bilateral MFIOLs gives the best chance of achieving true spectacle independence with cataract surgery.²¹ Diffractive rings in trifocal IOLs split light into distance, intermediate, and near zones, but can result in haloes, glare, and other photic phenomena in mesopic conditions (Figure 1). These photic phenomena can initially be disconcerting for patients, but in most instances, patients neuroadapt to the haloes and achieve excellent functional vision in most lighting conditions.²² That said, MFIOLs are best avoided in patients whose occupation involves night driving and in pilots. MFIOLs reduce contrast sensitivity, and reading can be difficult in low light conditions. The loss of contrast is the main reason for avoiding these IOLs in patients with macular and optic nerve dysfunction.

High angle kappa can result in a decentred MFIOL (Figure 2A and B). Even though studies have shown no decreased visual function in patients with high angle kappa, I avoid placing MFIOLs in patients with an angle greater than 0.5.²³

The two most commonly used MFIOLs are:

The Alcon Panoptix trifocal (hydrophobic): now available in the Clareon material, which has less glistening than its predecessor.²⁴

ZEISS At Lisa Trifocal (hydrophilic): a plate haptic design hydrophilic IOL that gives excellent quality vision but is prone to a high rate of posterior capsular opacity due to its hydrophilic nature.²⁵ This is probably compounded by the plate haptic design.

Rayner Galaxy IOL

This new IOL promises a “full range of vision with less halo”.

The Rayner Galaxy IOL uses artificial intelligence-derived spiral optics in its design (Figure 3). These lenses manipulate the wavefront using spiral-based patterns to offer dynamic depth perception and less photic phenomena than trifocal IOLs. The non-diffractive spiral progressively elongates focus, creating a smooth and continuous variation in optical power along the defocus curve.

Early results demonstrate excellent wide-range vision and reduced incidence of haloes and glare, making it a great choice for patients wishing to be spectacle independent with less chance of photic phenomena.²⁶

My early experience with these IOLs has been promising, with patients achieving excellent vision and little photic phenomena.

Future IOL Trends

Light-adjustable lenses (LAL, RxSight Inc) give the opportunity to fine-tune residual refractive error after surgery. This technology is not available in Australia yet, but is becoming increasingly popular in the United States. LAL is proving to be beneficial in cases where there is a risk of residual refractive error, such as post-refractive surgery patients, as well as offering a premium product that delivers high refractive accuracy and patient satisfaction.²⁷

Currently, these lenses and the laser used to adjust the lenses are costly. However, this will no doubt change as their use becomes more widespread globally. I have no doubt that this technology will make its way to our shores in the near future.

This article was sponsored by Rayner.

Dr Anton van Heerden MBChB FRANZCO WCRS is a cataract and refractive surgeon based in Melbourne. He is a Director of Eye Laser Specialists, Armadale Eye Clinic and Mornington Peninsula Eye Clinic. Dr van Heerden was the Head of Unit, Surgical Ophthalmology Services at the Royal Victorian Eye and Ear Hospital from 2014–2022. He is the current Chair of the Medical Advisory Committee at Windsor Private Hospital.

 

 

 

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