Adapting to Evolving Vision Needs of Patients

Patient selection key to success with advanced optic IOLs. Dermot McGrath reports

The latest generation of advanced optic IOLs, a category that includes multifocal, extended range of focus (EDOF) and monofocal-plus lenses, should be a standard part of every cataract surgeon’s toolkit even though they are not necessarily adapted for every patient, according to Beatrice Cochener-Lamard MD.

“Advanced optic IOLs are definitely an option for all surgeons because there is an obligation on us to progress with technology and to offer a full choice of options to our patients. But they are not for all patients and we need to make our choices based on biometry, corneal regularity, topography, slit-lamp examination, with a specific focus on ocular surface, and the patient’s age, lifestyle, and expectations,” she said at the online annual meeting of the French Implant and Refractive Surgery Association (SAFIR).

Dr Cochener-Lamard, Professor and Chairman of the ophthalmology department at the University Hospital of Brest, said she prefers to use the term “advanced optic IOLs” rather than “premium IOLs” or “refractive IOls” for these types of implant.

“These lenses are the culmination of technological advances in optical design in recent years, with features such as asphericity, toricity, and multifocality all integrated into the IOL design. Progress in cataract surgery has also played a role thanks to phacoemulsification, microincisions, improved biometry, and more accurate IOL power calculations. This has meant enhanced safety and comfort for the patient, with no induced astigmatism, rapid visual recovery, and the possibility of attaining emmetropia,” she said.

The boundaries between cataract and refractive surgery have dissipated over recent years, noted Dr Cochener-Lamard, with increased emphasis on the quality of vision obtained after cataract surgery.

“It is no longer enough to attain 20/20 vision under optimal conditions, but to deliver a high quality and continuous range of vision at all distances with a maximum of light reaching the retina. Patient expectations, however, should be realistic and the advantages and downsides of each lens type should be discussed. With careful selection, correct biometry, and rigorous surgery, we can obtain consistent outcomes and a high level of patient satisfaction,” she said.

Delivering patient satisfaction increasingly depends on obtaining satisfactory intermediate vision, noted Dr Cochener-Lamard. Which actually represents a range of vision “social vision.”

“Our visual needs have evolved in recent decades. A high percentage of patients now use smartphones, computers, and other digital devices and many of our activities depend on good functional vision in the 40 cm to 1 metre range,” she said.

The frontiers between multifocal, EDOF, and monofocal-plus lenses are not always easy to determine, said Dr CochenerLamard, but important that surgeons understand the concepts behind each category of IOL in order to tailor their choice for each individual patient.

“The days of conventional cataract surgery using the same monofocal implant for all patients are over. Implantation nowadays is performed according to the age, condition of the eye, comorbidities, and lifestyle needs. We need to provide more than the minimum best-corrected visual acuity for our patients, by improving quality of vision at all distances and especially in the intermediate range which is so important today,” she said. We need to offer the best to patients according to state of art.

CONSIDER COMORBIDITIES FIRST Lens choice will be oriented first and foremost by the presence of any ocular comorbidities such as dry eye, corneal anomalies, previous anterior segment surgery, glaucoma, and retinal disease, explained Dr Cochener-Lamard.

“The presence of a comorbidity does not automatically rule out advanced optic IOls for these patients, but it really needs to be assessed on a case-by-case basis in order to make an informed choice,” she said.

Discussing these conditions in greater detail, Dr Cochener-Lamard said dry eye is frequently underestimated.

“Around 50% to 60% of cataract patients have meibomian gland dysfunction which may not be apparent preoperatively but which will be exacerbated by surgery. The consequences postoperatively can be visual symptoms such as halos and glare which may lead to anxiety and depression, and the implant will be unfairly blamed for these problems,” she said. It can produce inappropriate results because of a wrong calculation (especially toric IOL) induced by unstable tear film.

The goal should be, therefore, to diagnose and treat the patient using the full arsenal of dry eye treatments available. If it can be controlled preoperatively, an advanced optic IOL may be considered, otherwise a monofocal-plus lens might be the best option,” she said.

Other contraindications for advanced lenses include corneal anomalies such as opacities, pterygium, leucomas, and anterior dystrophies, as well as eyes with keratoconus and corneal grafts. For glaucoma, an EDOF IOL may be considered if the IOP is controlled and the benefit-risk profile is favourable. For retinal diseases such as AMD or diabetic retinopathy, refractive IOLs should be avoided if disease is progressing and OCT is not normal, she advised.

Dr Cochener-Lamard also said that special attention should be paid to patients presenting for cataract surgery who have previously undergone refractive surgery.

“These patients, which represent a growing population, typically have high expectations as they have already paid to be spectacle independent. Their quality of vision may be impacted by their previous surgery and dry eye may be present. We need to decide on a case-by-case basis and proceed with caution as IOL power calculations in these patients are also more problematic.”

The boundaries between cataract and refractive surgery have dissipated over recent years