Accommodating IOL combination may result in optimum visual results

Surgeon meets patients’ expectations with a mix-and-match approach.

P. Dee G. Stephenson

When a cataract patient opts for an accommodating IOL with the goal of having outstanding near vision as well as good intermediate and distance vision, I now offer what I like to call the “best of both worlds” solution. This involves implanting a Bausch + Lomb Crystalens AO in the dominant eye and a Crystalens HD in the nondominant eye. To date, the approach has produced great visual results and, more importantly, outstanding patient satisfaction.

Playing your strongest cards

The Crystalens HD, with a central area that enhances the depth of focus, provides patients with very good near vision, while the Crystalens AO model, with its aspheric optic, offers patients excellent intermediate and distance vision. This is because the AO combines the accommodative architecture that Crystalens is known for with an anterior and posterior aspheric surface optic that eliminates the induction of spherical aberration. The new optics incorporate uniform center-to-edge power so optical performance is less affected by pupil size, optic decentration or tilt. This enhances quality of vision with the Crystalens AO with minimal loss of range of focus, something that can happen with multifocal IOLs.

Clinical results

Our experience with this combination Crystalens approach is not just based on anecdotal impression. To date, we have taken this approach in 30 eyes of 15 patients, with implantation of an HD in the nondominant eye and an AO in the dominant eye, after undergoing a thorough informed consent process.

For all patients, our target is emmetropia in the dominant eye and slightly under-corrected in the nondominant eye.

At 1 month postop, the monocular results showed that all AO eyes had an uncorrected visual acuity of 20/20, while all HD eyes had an uncorrected near visual acuity of J1 or better. All eyes had uncorrected intermediate visual acuity of 20/20 or better. For the binocular results at 1 month, all 15 patients had an uncorrected binocular distance visual acuity of 20/20 or better, an intermediate uncorrected binocular visual acuity of 20/16 or better and an uncorrected binocular near visual acuity of J1 or better.

Our accuracy in targeting is aided by two factors. First, we now use an intraoperative aberrometer (ORange, Wave-Tec Vision Systems) on all premium IOL cases to confirm the IOL power calculation while the patient is on the table. Second, the Crystalens is available in 0.25 D steps. Using both helps me to hit my intended target with more accuracy and confidence.

What the patient wants

One of the keys to my decision to use this combination approach is to listen very carefully to what patients are saying during the initial consultation about their current vision, as well as their expectations following surgery. Where we are based, in South Florida, public transportation is not really available, so the No. 1 requirement for most patients is to be able to drive at night. We also have many patients who want to be able to maintain good distance vision for golf while also having good near and intermediate vision. These patients are ideal candidates for this approach.

When we counsel patients, we make it clear that our goal is to reduce their need for glasses. I tell patients that they may still need +1 reading glasses to read at night or use a computer, but that their dependence on glasses will be significantly reduced. For the most part, patients are very happy with this concept. In fact, about 95% of the patients that we have implanted with the Crystalens are happy with their vision.

One of these patients was a 60-year-old woman who was a high hyperope her entire life, necessitating that she always wear glasses. Since surgery, she has been surprised by her ability to see well at all distances, telling me: “Never in my life have I ever seen this well, and to think that the first 55 years of my life I had to wear glasses for everything I did.”

Another example is a 75-year-old man who was a myope, but had so much glare and halos from his cataracts that he gave up driving. After surgery, he told me: “I see better than I ever have. I can see the dashboard and the street signs way before I need to, and I love my night vision.”

Conclusion

In our initial experience, the combination of a Crystalens AO in the dominant eye and a Crystalens HD in the nondominant eye provides our patients with excellent distance vision and depth of focus, as well as good intermediate and near vision. What is particularly important is that we can accomplish these great visual results with minimal visual trade-offs, a critical point of differentiation when you are practicing in an area such as South Florida.

• P. Dee G. Stephenson, MD, can be reached at Stephenson Eye Associates, 200 Palermo Place, Venice, FL 34285; 941-485-1121; fax: 941-486-0571; e-mail: eyedrdee@aol.com; website: www.stephensoneye.com.