s GLOBAL PRACTICE PATTERNS ALL ABOUT IOLS | Preferred designs, premium IOL adoption rates, and the pipeline. Premium Lens Technology Is an Important Part of JORGE L. ALIÓ, Any Refractive Cataract Practice MD, PHD, FEBOPHTH resbyopia-correcting IOLs this lens in clinical practice once it has are an important part of any the CE Mark—to clarify, I am particularly Alicante, Spain refractive cataract surgery interested in a group of lenses sometimes practice, including mine. In my referred to as monofocal plus. routine practice of lens surgery, I am impressed by the results Pwhich includes cataract surgery and achieved with the Tecnis Eyhance in my refractive lens exchange, I implant a independent clinical study. I am even presbyopia-correcting IOL in about more impressed by the superior near am also impressed with the CapsuLaser 70% of cases. vision outcomes reported with the (Excel-Lens), which I routinely use AcrySof IQ Vivity. I think that, in the in these cases to make a perfect CURRENT AND POTENTIAL future, these lenses will replace most of capsulotomy. This device is much more FUTURE PREFERENCES the monofocal lenses that I currently cost-effective than a femtosecond laser, I participate in many clinical implant. (Editor’s note: For more a technology I abandoned for cataract studies of various models and types on these and other new-technology surgery due to its poor cost-effectiveness. of multifocal and extended depth of monofocal IOLs, see the article on pg focus (EDOF) lenses,1 and I therefore 24). I see no reason not to use IOLs CONCLUSION have my own outcomes for most of that provide my patients with better I forsee a new category of monofocal the available premium IOLs. I do not intermediate vision without reducing IOLs: monofocal plus IOLs, which offer EDOF IOLs, with the exceptions contrast sensitivity, giving an inadequate actually is a new type of EDOF lens. (I of the Tecnis Eyhance (Johnson & quality of vision, or causing unwanted am currently developing a classification Johnson Vision) and AcrySof IQ Vivity dysphotopsias such as occurs with for monofocal+ lenses, as there is (Alcon) in my private practice because current EDOF IOLs.4,5 confusion surrounding this topic.) I have found that many so-called EDOF I also plan on integrating the Lumina IOLs provide poor near vision and PATIENT SELECTION into my armamentarium as soon as it an inadequate quality of vision. My Many patients, when properly becomes commercially available. If real multifocal IOL preferences outside of selected, do well with a multifocal IOL accommodation can be achieved by this clinical investigations are the diffractive that is chosen to meet their conditions IOL, the approach of multifocality will be AT LISA tri (Carl Zeiss Meditec) and needs. When I assess patients for abandoned in clinical practice. and the refractive Acunex Vario cataract surgery, I start by asking myself 1. Alió JL, Pikkel J. Multifocal Intraocular Lenses: The Art and the Practice. (Teleon Surgical) with a near vision add the following question: “Why should Springer; 2014. 2. Alió JL, Simonov A, Plaza-Puche AB, et al. Visual outcomes and accommodative of +1.50 D and a new IOL hydrophobic this patient not have a multifocal or response of the Lumina accommodative intraocular lens. Am J Ophthalmol. 2016;164:37-48. material. I also frequently use the EDOF lens?” My first choice is always 3. Alió JL, Simonov AN, Romero D, et al. Analysis of accommodative performance RayOne Trifocal (Rayner), FineVision to consider a multifocal IOL for of a new accommodative intraocular lens. J Refract Surg. 2018;34(2):78-83. 1 4. Alió JL. Presbyopic lenses: evidence, masquerade news, and fake news. Asia (PhysIOL), and Intensity (Hanita). every patient. Pac J Ophthalmol. 2019;8(4):273-274. In the near future, my preference I do not, however, implant 5. Kanclerz P, Toto F, Grzybowski A, Alió JL. Extended depth-of-field intraocular lenses: an update. Asia Pac J Ophthalmol. 2020;9(3):194-202. will become accommodating IOLs, as presbyopia-correcting lenses in patients the Lumina (Akkolens International), with maculopathy or poor macular implanted in the sulcus,2,3 will be the function, retinal dystrophy, optic JORGE L. ALIÓ, MD, PHD, FEBOPHTH first accommodating IOL to truly work atrophy, and moderate to advanced n Professor and Chairman of Ophthalmology, as designed. I was the investigator in glaucoma because the benefits of using a Vissum-Instituto Oftalmologico de Alicante, Spain the preliminary phase 1 and 2 studies multifocal lens do not outweigh its cost n Miguel Hernandez University, Alicante, Spain and am currently the clinical director for these patients. n Member, CRST Europe Editorial Advisory Board and one of the investigators in the When I implant multifocal and n [email protected] phase 3 multicenter study in Spain and other presbyopia-correcting IOL n Financial disclosure: Consultant (AkkoLens Colombia. Results to date have been designs, I use a capsular tension ring International, Hanita Lenses); Clinical impressive, and I look forward to using to guarantee centration and stability. I investigator (Ophtec) 38 CATARACT & REFRACTIVE SURGERY TODAY | JANUARY 2021 GLOBAL PRACTICE PATTERNS s Patients Want a Lens That Will Decrease Their Spectacle Dependence ver the 20 years I have been independence and a decreased need for practicing ophthalmology, a refractive enhancement. the expectations and needs of ASHRAF ARMIA patients have changed. Today, PREMIUM IOLS BALAMOUN, patients who undergo cataract I use multifocal and EDOF IOLs MD, MSC, FRCS Osurgery expect spectacle independence. (Figure 1) in approximately 20% of my In my experience, some IOLs accomplish patients. I always ask patients about their (GLASG), FACS this goal better than others. Herein, I work and recreational activities to get as share my preferred lens technologies complete a picture as possible of their Cairo, Egypt and discuss the technologies I am most predominant visual needs. For example, excited to try next. if manual labor or computer work is an More than 70% of my patients receive integral part of a patient’s lifestyle, good spectacle independence except for some form of astigmatism correction. I intermediate vision is a priority with a reading small print.1,2 Recently released typically use limbal relaxing incisions for multifocal IOL. If spectacle-free reading diffractive lenses may perform better eyes with less than 1.00 D of astigmatism, ability is strongly desired, a multifocal than refractive lenses in terms of near and I use either the AcrySof IQ Toric IOL with a corresponding near addition vision and quality of vision. Likewise, SN60T3 to SN60T9 IOLs (Alcon) or the may be the best choice. If both distances there seems to be less risk of halos with Tecnis Toric IOL (Johnson & Johnson are used equally, a trifocal IOL would be the latest premium IOL technologies Vision) for eyes with more than 1.00 D suitable. I always consider the defocus compared with older diffractive and of astigmatism. In eyes with regular curves of various IOLs when deciding refractive lenses. corneal astigmatism, a toric IOL provides which one to recommend. I find that the AcrySof IQ PanOptix better distance UCVA, greater spectacle I like to use EDOF IOLs with a (Alcon) and FineVision3 IOLs provide independence, and lower amounts of refractive segmental design such as the the best outcomes when the treatment residual astigmatism compared with a Tecnis Symfony (Johnson & Johnson plan takes into account preoperative nontoric IOL paired to limbal relaxing Vision), and I use a blended vision diagnostics such as corneal topography, incisions. Postoperative astigmatism of strategy by targeting emmetropia in OCT of the macula, dry eye evaluation, 0.50 D or less is associated with improved the dominant eye and -1.50 D in the and biometry measurements (Figure 2).4 visual function and increased patient nondominant eye. Patients with this satisfaction due to greater spectacle form of blended vision generally achieve s WATCH IT NOW Dr. Armia provides tips for intraoperative maneuvers A B C with premium trifocal IOLs and showcases some of the tools he uses. Figure 1. The Tecnis Symfony (A), FineVision (B), and AcrySof IQ PanOptix (C) IOLs in situ. Figures 1 and 2 courtesy of Ashraf Armia Balamoun, MD, MSc, FRCS (Glasg), FACS BIT.LY/01ARMIA0121 Figure 2. Measurements and IOL power calculation for an eye implanted with the AcrySof IQ PanOptix IOL. BIT.LY/02ARMIA0121 JANUARY 2021 | CATARACT & REFRACTIVE SURGERY TODAY 39 s GLOBAL PRACTICE PATTERNS ALL ABOUT IOLS I also use the Tecnis Eyhance. With FineVision), and the Tecnis Synergy ASHRAF ARMIA BALAMOUN, MD, MSC, FRCS this IOL, I target the dominant eye (Johnson & Johnson Vision) to become (GLASG), FACS for distance and intermediate vision available in Egypt, where I practice. n Al Watany Eye Hospital, Cairo, Egypt and the nondominant eye for less n Watany Research and Development Center, 5 1. Nivean M, Nivean PD, Reddy JK, et al. Performance of a new-generation Cairo, Egypt intermediate and more near vision. extended depth of focus intraocular lens—a prospective comparative study. Asia Regardless of the chosen IOL and Pac J Ophthalmol. 2019;8:285-289.. n Ashraf Armia Eye Clinic, Giza, Egypt 2. Kessel L, Andresen J, Tendal B, et al. Toric intraocular lenses in the correction n Armia’s Ophthalmology Training Observer-Ship strategy, I always compare two IOL of astigmatism during cataract surgery: a systematic review and meta-analysis. power calculation formulas to ensure Ophthalmology. 2016;123:275-286. Academy, Giza, Egypt 3. Sigireddi RR, Weikert MP. How much astigmatism to treat in cataract surgery. n Founder, Global Education and Research Society the best outcomes. Curr Opin Ophthalmol. 2020;31:10-14. 4. Cochener B, Boutillier G, Lamard M, Auberger-Zagnoli C. A comparative evalu- of Ophthalmology ation of a new generation of diffractive trifocal and extended depth of focus n [email protected]; FUTURE OUTLOOK intraocular lenses.