We implant more than 7,000 intraocular lenses (IOLs) in our surgery center each year, including every premium lens on the market. Close to 40% of our patients choose a premium lens targeting spectacle independence at distance or across the full visual range.
The patient’s desire to have spectacle independence is a prerequisite for a presbyopia-correcting IOL, but in my practice, it is just the start of the decision-making process.
Considerations and cautions with premium IOLs
When implanting any premium IOL, obtaining accurate pre-operative measurements is imperative. Surgeons must go the extra mile to ensure the accuracy of pre-operative measurements.
We typically look at topography in at least three different ways:
- Using a Pentacam (Oculus) or Galilei (Ziemerc) for overall topography and tomography
- Argos (Alcon) or Lenstar (Haag-Streit) biometers to evaluate astigmatism and axial length
- OPD-Scan (Nidek) to look at the wavefront and corneal vs. lenticular astigmatism
A comprehensive evaluation is also needed to identify conditions that would either rule out a presbyopia-correcting IOL or need to be treated before we can trust our measurements. This extra testing is one of the reasons that we are able to bill extra for advanced technology IOLs.
Pro pearl: I will not proceed with surgery until at least two out of three of these measurements are in agreement.
Optimizing the ocular surface before cataract surgery
In particular, I like to look at the patient’s meibography and examine the base of the lashes for collarettes to determine whether meibomian gland dysfunction and/or Demodex blepharitis are affecting tear film quality.
Dry eye doesn’t mean the patient can’t have a premium IOL, but it does need to be addressed to obtain the best visual outcomes. In many cases, premium lens candidates are sent to the dry eye center at our headquarters office, where we have LipiFlow Thermal Pulsation (Johnson & Johnson Vision), intense pulsed light (IPL, ex., Lumenis), punctal occlusion, and extensive experience with topical immunomodulators, steroids, and antiparasitic medications.
If the patient has epithelial basement membrane dystrophy (EBMD), which can masquerade as astigmatism, we are going to perform epithelial scraping and make sure the epithelium is healed before cataract surgery. There is no rush to perform cataract surgery without first addressing other underlying conditions.
The value of treating OSD before IOL implantation
Patients sometimes ask why they need to undergo dry eye treatment before surgery. My answer to them is that I don’t want to guess how much astigmatism they truly have, and I don’t want them to invest in a premium lens when there are other barriers to good vision.
In my experience, residual refractive error is the most common reason for patient dissatisfaction after premium lens surgery. I prefer to do everything pre-operatively to make sure I can obtain the best results. On our end, we also commit to doing everything we need to do postoperatively to achieve that result.
If the patient needs LASIK, PRK, or a piggyback lens to fine-tune their visual result within the first year, that is included. I think premium lens surgeons have to be able to finish the job when the goal is spectacle independence.
Caution with capsulotomy
I am also very cautious about performing an Nd:YAG capsulotomy in the early post-operative period. If patients have significant dysphotopsia or quality-of-vision complaints, I recommend waiting 2 to 3 months for them to neuroadapt and will only consider a lens exchange after 3 months.
During that time, it is very important to preserve future lens exchange options by keeping the posterior capsule intact.
My preferred premium IOL
We now have three IOLs—the TECNIS Odyssey (Johnson & Johnson Vision), enVista Envy (Bausch + Lomb), and Clareon PanOptix (Alcon)—that offer an excellent range of vision for patients who want to be spectacle-free at all distances.
Of these, my current go-to lens is the TECNIS Odyssey, because in addition to the range of vision, it also has very low rates of bothersome dysphotopsia and a wide “landing zone” or tolerance to residual refractive error.
In clinical trials for the Odyssey lens, 100% of patients said they had no starbursts or only mild starbursts, 94% had no or mild glare, and 93% had no or mild halo.1 Manufacturer data demonstrates that TECNIS Odyssey has good tolerance to residual defocus and cylinder (Figure 1), which is what I have seen in clinical practice, as well.
In a small retrospective analysis I conducted that included 33 eyes of 18 patients implanted with this lens, the mean monocular distance visual acuity at 1 month was 20/24, intermediate was 20/20, and near vision was better than J2. I find that patients get to “20/happy” very quickly, without a long period of adaptation.
Figure 1: Even with 0.5D of residual sphere or 0.75D of residual cylinder error, most eyes implanted with the TECNIS Odyssey IOL could still achieve 20/25 or better simulated visual acuity.2
Final thoughts
We can now give patients so much more than just a standard monofocal. When surgeons learn how to use these lenses in the best way and to prepare the eye by getting it in the best shape for optimal post-operative vision, we can truly partner with our patients to give them the spectacle independence they want.
Dr. Whitman is a consultant for Alcon, Bausch + Lomb, Johnson & Johnson Vision, and Tarsus Pharmaceuticals.
