Phakic, premium IOLs driving a surge in lens-based refractive surgery

Varied lens choices require clinicians to ramp up preoperative assessment, patient counseling and follow-up.

Lens-based refractive surgery is a viable alternative to cornea-based refractive surgery for many patients, according to several experts.

It offers a wider range of corrections without complications such as glare, halos and diminished contrast sensitivity. Lens-based procedures also help patients gain independence from contact lenses and spectacles.

OSN Cataract Surgery Board Member R. Bruce Wallace III, MD, said better outcomes have attracted patients to lens-based refractive surgery instead of cornea-based procedures.

“[Lens-based refractive surgery] is an exciting field,” Dr. Wallace said. “It’s an area that recently evolved into being much more predictable. Therefore, we can offer it to patients who don’t even have cataracts. It’s an off-label use for those patients.”

Lenses include multifocal options such as the AcrySof ReSTOR (Alcon) and ReZoom (Advanced Medical Optics) and the monofocal accommodative Crystalens (Bausch & Lomb).

Phakic IOLs approved by the U.S. Food and Drug Administration include the Verisyse (AMO) and the Visian ICL (STAAR Surgical).

The FDA approved the AcrySof IQ ReSTOR +3 D IOL in December, the diffractive multifocal Tecnis (AMO) in January, and the latest-generation of the Crystalens, the HD, was approved in June.

In addition, the Synchrony dual-optic accommodating IOL (Visiogen) and the Tetraflex accommodating IOL (Lenstec) are undergoing FDA clinical trials.

Growth in the field

Lens-based refractive surgery will increase during the next decade, with accommodating lenses leading the way, OSN Chief Medical Editor Richard L. Lindstrom, MD, said.

“If you survey an ophthalmologist and ask them what they think they’ll be doing in 10 years, they all say accommodating IOLs,” Dr. Lindstrom said. “Lens-based refractive surgery is now competitive with cornea-based refractive surgery.”

Lens-based refractive surgery will fill a void as cornea-based refractive surgery slumps amid an ongoing economic downturn, he said.

A boom in lens-based refractive surgery will require ophthalmologists to step up diagnostic screening, patient counseling and postoperative follow-up, Y. Ralph Chu, MD, said.

“Basically, cataract surgery has become refractive surgery,” Dr. Chu said. “It demands precision in terms of each of the measurements that are required to implant the lens, from the keratometry to axial length measurements.”

Recent approvals

The newly approved Tecnis aspheric multifocal lens gives excellent reading vision independent of pupil size and lighting conditions, Dr. Chu said.

In addition, the Crystalens HD improves reading vision and range of focus.

“To me, that platform represents a significant improvement over the previous generations of Crystalens,” he said. “We were happy with the previous generations of the Crystalens. We liked the accommodating platform because it provided expanded range of focus without quality-of-vision issues. With the Crystalens HD, we actually see patients with better reading vision and better range of focus than previous generations. Right now, that has been our dominant lens for presbyopia correction.”

The Crystalens is an ideal choice because it enhances intermediate and near vision without reducing quality of distance vision, Dr. Lindstrom said.

“It’s my fastball,” he said. “It’s the lens I use as my first choice.”

Mix and match, other options Dr. Wallace said the ReSTOR, ReZoom and Crystalens are solid, reliable performers in his practice.

“We use all three. It really sort of depends on the patient’s situation,” he said. “Most recently, Crystalens has been our most popular premium IOL.”

Mixing and matching IOLs is an option, particularly the ReSTOR and ReZoom.

“We do mix-and-match lenses,” Dr. Wallace said. “In that situation, we’ll typically start with the patient that we thought would be a good candidate for the ReZoom lens. Then if in the first week or two of postop visits their near vision is not what we expected, we would consider putting a ReSTOR in the second eye. We’ve had good results with that.”

Dr. Lindstrom said patients generally adapt to mixing and matching.

“There is a small period of neuro-adaptation, where patients have to adapt to their new vision,” he said. “But if you give the patients time and encouragement, almost all of them neuro-adapt.”

Phakic IOLs are a viable option for high myopes who are poor candidates for LASIK or PRK, Dr. Lindstrom said. LASIK and PRK are less invasive than lens-based procedures, but lens exchange and phakic IOL implantation are attractive to many patients.

Virtually any refractive error may be corrected with a lens implant, he said.

“One needs to analyze this in the face of each individual patient’s needs and risk-benefit ratio, but you can correct every single refractive error safely, in my opinion, and effectively with a lens implant,” Dr. Lindstrom said.

Counseling and follow-up

“Patient demands and expectations have changed tremendously,” Dr. Chu said. “Age is not necessarily even the major factor. We used to think that older patients were less demanding and younger patients were more demanding. That holds true to a certain extent, but since people are aging more gracefully and older people are healthier, the demand exists regardless of the age. I think that’s a trend we’re going to see in the future.”

Increasingly, surgeons will need to conduct rigorous preoperative assessment and counsel patients about treatment options and desired outcomes, Dr. Chu said.

Dr. Wallace said it is important to understand patients’ motivations and expectations.

“It starts with how motivated the patient is to reduce their need for glasses,” he said. “The second important element is reasonable expectations. Everyone in the office should have antennae up and look at those two elements to decide if this is the right patient for this technology.”

Biometry and accurately targeting refraction are also critical.

“We want to be within ±0.5 D of our spherical target over 90% of the time,” he said.

The choice of phacoemulsification system and the use of a topical nonsteroidal to reduce postoperative inflammation also affect outcomes.

“All of these factors are coming together,” Dr. Wallace said. “It’s not just the implants. It’s the whole procedure that’s important here.”

Glaucoma is also an indication for lens-based refractive surgery, Dr. Lindstrom said.

“That is the patient who has glaucoma or is a significant glaucoma suspect and also has a significant refractive error, and perhaps an early cataract,” he said. “We’re also learning that removing the natural lens has a significant impact on lowering the intraocular pressure.” – by Matt Hasson

• Y. Ralph Chu, MD, can be reached at Chu Vision Institute, 9117 Lyndale Ave. S., Bloomington, MN 55420; 952-835-0965; fax: 952-835-1092; e-mail: yrchu@chuvision.com. Dr. Chu is a consultant for Advanced Medical Optics, Bausch & Lomb and Visiogen.
• Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 DuPont Ave. S, Suite 200, Bloomington, MN 55431; 952-888-5800; fax: 952-567-6182; e-mail: rllindstrom@mneye.com. Dr. Lindstrom is a consultant for AMO, Alcon and B&L.
• R. Bruce Wallace III, MD, can be reached at Wallace Eye Surgery, 4110 Parliament Drive, Alexandria, LA 71303; 318-448-4488; fax: 318-448-9731; e-mail: rbw123@aol.com. Dr. Wallace is a consultant for AMO, Allergan and Bausch & Lomb.