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Cataracts are a fact of life; if you live long enough, you receive the gift. For now, we have no way to stop the procession of time or cataracts, so it is an inevitability. Eye care providers have the opportunity to help guide our patients through the process. Understanding all the new and traditional options that are available around cataract surgery is important for patient education by both optometrists and ophthalmologists. At all points of contact during the process, the more we are able to discuss the options available to our patients and what is best suited for them, the better informed our patients’ decisions will be.
The history of the IOL is long, but there have recently been numerous advances, and there are some possible game-changers on the horizon. With cataract surgery, loss of accommodation is expected. However, multiple options have been developed to help patients overcome presbyopia and decrease their reliance on glasses after surgery. Premium options for presbyopia correction with IOLs currently fall into four basic categories: monofocal or toric IOLs used with a monovision or blended vision strategy, multifocal IOLs, extended depth of focus or extended range of vision IOLs, and accommodating IOLs. Some of these categories are beginning to overlap, as we shall see below.
The most common method of presbyopia correction is monovision with a standard posterior chamber IOL. Popular models include the Akreos AO (Bausch + Lomb), Tecnis (Abbott), Softec HD and HDO (Lenstec), and AcrySof IQ (Alcon), to name only a few. The focus of this article, however, is not standard lenses and monovision, but rather premium IOLs and recent IOL innovations.
The first generation of multifocal IOLs were approved by the US Food and Drug Administration (FDA) and entered the market in the early 1990s. Issues associated with early multifocal IOLs included poor contrast sensitivity, halos, and glare. Since that time, technologies have improved both in the lenses themselves and in the evaluation and selection of patients, resulting in higher patient satisfaction and a reduction in negative outcomes.
Modern multifocal IOL are available in high-add and low-add configurations. The advantages of high add models include improved near vision and reduced dependence on readers; the disadvantages include limited intermediate vision and halos. Models with lower add powers tend to move the near focal point out, which helps improve intermediate vision and decreases photopsias traditionally experienced with high add lenses. The AcrySof Restor IQ (Alcon) family of multifocal IOLs now includes both high add power (+3.00 D and +4.00 D) and a new +2.50 D lower add lens. The Tecnis Multifocal (Abbott) is also available in a range of add powers, including +2.75 D, +3.25 D, and +4.00 D adds.
Using a low add in one eye coupled with a high add in the contralateral eye is an effective way of providing patients with a large range of vision and decreased dependence on readers.
Another challenge for postoperative visual optimization is compensating for anterior and posterior corneal astigmatism. Low amounts of astigmatism can be corrected with limbal relaxing incisions at the time of surgery or postoperative enhancement with PRK or LASIK. Larger amounts of astigmatism, traditionally greater than 1.25 D, may require the use of a toric IOL to correct the full amount.
Multiple toric IOL models are available, including the STAAR Toric IOL (STAAR Surgical), the Tecnis Toric (Abbott Medical Optics), and the AcrySof IQ Toric (Alcon). The STAAR Toric is a silicone plate haptic design IOL that is available with either 2.00 D or 3.50 D cylinder powers. The Tecnis Toric, a hydrophobic acrylic IOL, is available in six cylinder powers ranging from 1.50 D to 6.00 D.1 The AcrySof IQ Toric, also a hydrophopic acrylic IOL, is available in seven cylinder powers ranging from 1.50 D to 6.00 D.2,3
TORIC AND MORE
Recently, two lenses that merge the correction of presbyopia and astigmatism have entered the market. These are the Trulign Toric IOL (Bausch + Lomb) and the Tecnis Symfony Toric IOL (Abbott Medical Optics).
The Trulign Toric is described by its manufacturer as providing a broader range of vision. Similar to its predecessor, the Crystalens AO (Bausch + Lomb), the Trulign is a silicone IOL with a 5-mm optic and flexible, rectangular hinged haptics with polyamide loops. Both lenses achieve a 2.50 D or greater accommodative amplitude at the spectacle plane and improve intermediate and near vision without correction.4 Cylinder powers available on the Trulign are 1.25 D, 2.00 D, 2.75 D, and spherical equivalent powers from +4.00 to +33.00 D.4
In the clinical trial data submitted to the US Food and Drug Administration (FDA) for US regulatory approval of the Trulign, 78.4% of the patients were within 0.50 D of intended cylinder, and 95.5% were within 1.0 D of intended cylinder.5 The study also found that 96.1% of implants had rotated 5° or less by 6 months postoperative, and 99.2% of patients reported no significant visual disturbances.5 Uncorrected near and intermediate visual acuities of Snellen 20/40 or better were seen in 70.1% and 97.4% of patients respectively.5
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Concerns surrounding Z-syndrome (folding of a plate-haptic lens in the capsular bag postoperatively) and increased fibrosis seen with early iterations of the Crystalens may have slowed initial movement towards the use of Trulign, but the lens seems to be gaining traction recently. Trulign is reported to be effective in providing astigmatism correction in combination with a broader range of vision for patients. In postoperative care, close early monitoring for signs of increased fibrosis, and possibly earlier Nd:YAG capsulotomy, can be helpful in improving overall outcomes for both Crystalens and Trulign patients. As with all premium lenses, patient selection is the key to success.
The Tecnis Symfony Toric, like the Tecnis Symfony IOL, is described by its manufacturer as providing an “extended range of vision.” The Tecnis Symfony and Symfony Toric are composed of a hydrophobic acrylic material with a 6-mm optic that has an aspheric anterior surface and an achromatic diffractive posterior surface to reduce chromatic aberration.6 The haptics are in an offset design that allows three points of fixation. Powers available range from from +5.00 D to +34.00 in 0.50 D increments in both designs, with cylinder powers of 1.00, 1.50, 2.25, 3.00, and 3.75 D in the toric version.6,7
In the overall FDA Symfony IOL study, the Symfony Toric corrected 64.3% of patients to within 0.50 D of intended cylinder and 90.0% to within 1.00 D of intended cylinder. Regarding rotational stability, 93.9% of patients showed IOL rotation of 5° or less within 6 months of surgery. Among patients with the Symfony Toric, distance binocular UCVA of 20/40 or better was achieved by 97.0% of patients.6
Regarding visual symptoms, at 6 months most patients with the toric lens in the FDA study reported “no trouble at all” for most items, but 60.8% reported “no trouble at all” for glare and approximately 25% reported “a little trouble” for glare. By comparison, with the nontoric version, 42.8% of patients reported “no trouble at all” for visual symptoms of glare and 36.6% reported “a little trouble” for glare.6
With the Symfony, 99.6% of patients had binocular distance UCVA of 20/40 or better, 96.6% of patients had binocular intermediate UCVA of 20/25 or better, and 95.9% of patients had binocular near UCVA of 20/40 or better.7
The concept behind extended depth-of-focus (EDOF) technology is a balance between the three related concepts of visual quality, depth of field, and night vision symptoms. As defined by the American Academy of Ophthalmology during an FDA workshop, EDOF lenses are designed to increase positive depth of field to help enhance near visual performance with minimal distance impact by increasing aberrations through refractive and diffractive changes in the optic surface of the IOL.8 With changes in depth of field often visual quality can be affected, but this is reduced in EDOF IOLs by correcting for chromatic aberrations.
Among the keys to success with any premium IOLs are proper patient selection and proper setting of patients’ expectations. As optometrists, we are often patients’ first point of contact regarding cataracts, starting discussions about the options that will ultimately aid in the patients’ decisions.
The premium presbyopia-correcting IOLs that are available today provide a wider range of opportunities for us to help our patients meet their visual needs than existed 15 or even 5 years ago. Suffice it to say, it is an exciting time in eye care as IOL technology continues to advance. n
1. Tecnis Toric 1-Piece IOL [brochure]. Abbott Medical Optics. 2015. http://www.tecnisiol.com/us/media/pdf/toric/TECNIS%20Toric%20Print%20Brochure.pdf. Accessed September 1, 2016.
2. Lane SS. The Acrysof Toric IOL’s FDA trial results. CRST. May 2006;66-68.
3. Product Information: AcrySof IQ Toric IOLs. Alcon. 2016. https://www.myalcon.com/products/surgical/acrysof-iq-toric-iol/specifications.shtml. Accessed September 1, 2016.
4. Trulign Toric Model Specifications. Bausch + Lomb. 2016. http://trulign.com/professionals/en-us/AboutTrulign/ModelSpecifications.aspx. Accessed September 1, 2016.
5. Trulign Toric Posterior Chamber Intraocular Lens. Summary of Safety and Effectiveness Data. May 20, 2013. US Food and Drug Administration. http://www.accessdata.fda.gov/cdrh_docs/pdf3/P030002S027b.pdf. Accessed September 1, 2016.
6. Tecnis Symfony Extended Range of Vision IOL [package insert]. Abbott Medical Optics. 2016. http://www.accessdata.fda.gov/cdrh_docs/pdf/p980040s065d.pdf. Accessed September 1, 2016.
7. Tecnis Symfony IOL. Abbott Medical Optics. 2016. http://www.tecnisiol.com/eu/tecnis-symfony-iol.htm. Accessed September 1, 2016.
8. Calogero, D. New Catagories of IOLs for Improved Near and Intermediate Performance. FDA/AAO workshop. March 28, 2014.
Cecelia Koetting, OD, FAAO
• Referral optometric care and externship program coordinator, Virginia Eye Consultants, Norfolk
• (757) 622-2200; http://www.virginiaeyeconsultants.com; firstname.lastname@example.org
• Financial interest: none acknowledged