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Premium IOLs run the gamut from multifocal to neuroadaptive

Despite new lens developments, use of presbyopia-correcting IOLs has been nearly flat since 2005 in the United States.

Issue: June 25, 2012

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The premium IOL market now represents 14% of all IOLs implanted in the United States, but the use of presbyopia-correcting IOLs has been flat since around 2008 and has grown only 1% from 2005 to 2012, according to a surgeon.

“That is an astonishingly flat curve for something that doctors get paid a lot to do,” Douglas D. Koch, MD, said at the Ophthalmology Innovation Summit preceding the American Society of Cataract and Refractive Surgery meeting in Chicago.

Reasons for little growth

Dr. Koch attributed the flat volumes to surgeons’ lack of confidence in the outcomes. For example, with multifocal IOLs, there are concerns about quality of vision.

“Surgeons are not prepared to address patient complaints,” he said. Similarly, accommodating lenses are associated with unpredictability, and surgeons may not know how to handle such fluctuations in their practice.

Surgeons appear to fall short in the surgical precision needed for biometry and astigmatic correction. Some patients also require a second refractive procedure; however, “a lot of surgeons are not doing excimer laser and avoid procedures that might have the risk of requiring an IOL exchange,” Dr. Koch said.

Lack of toric models has contributed to the tepid growth of presbyopia-correcting IOLs. Conversely, the increase in monovision lenses has been “aided by toric lenses,” Dr. Koch said. “In fact, I feel that toric IOLs have actually cannibalized the premium IOL market because with toric you can upcharge the patient with a high likelihood of success, and it is a lot less expensive for the patient.”

The toric IOL market may continue to expand to a degree, due to approvals of new toric multifocal and accommodating lenses and as more surgeons start using them.

Corneal relaxing incisions should also significantly expand, according to Dr. Koch.

“This is the way people can pay for utilizing femtosecond technology,” he said.

Hence, some growth should occur in multifocal IOLs because femtosecond technology allows for better treatment of astigmatism.

“However, the disincentive is that if you are going to charge an upcharge for the femto and you have another upcharge for the multifocal or premium IOL, there is going to be a bit of a tug and pull,” Dr. Koch said.

Newer multifocal lenses

Multifocal IOLs can be divided into two categories: diffractive and refractive.

The Lentis Mplus (Oculentis) is a new refractive model that has raised some interest in Europe, Dr. Koch said. The hydrophobic acrylic lens, with 3 D and 1.5 D add models, has a clear zone; the upper 50% is for distance vision, whereas the lower 45% is for near vision.

“The light in the transition zones is refracted away from the fovea,” Dr. Koch said.

One of Dr. Koch’s colleagues particularly likes the 1.5 D model “because it seems to do very little to impede distance vision, but it is good for the computer and cell phone,” Dr. Koch said.

A single-optic design for accommodating IOLs is currently found with the Crystalens (Bausch + Lomb) and the Tetraflex (Lenstec), which is still in trials in the U.S.

“There may be some flexure in these lenses and some uncertainty about the mechanism, but certainly there are surgeons who are big believers, while other surgeons have tried them and stopped,” Dr. Koch said.

The dual-optic design of the Synchrony (Abbott Medical Optics), which has not yet been approved by the U.S. Food and Drug Administration, has a capsular-fixated lens in which haptics connect two optics — a +32 D anterior optic and a posterior optic with minus power individualized — with a spring action.

“Ultrasound has demonstrated that the Synchrony moves forward a certain amount,” Dr. Koch said.

On the other hand, the dual-optic AkkoLens (AkkoLens) is an investigative sulcus-implanted lens “in which optic elements slide over one another,” Dr. Koch said, who noted that he has seen no clinical data on the lens. “As the optic moves, the optic changes power.”

The NuLens (NuLens) is a neuroadaptive model with two lenses that are placed in the ciliary sulcus.

“As the ciliary muscle relaxes, an accommodative effect is achieved,” Dr. Koch said. “This is rather counterintuitive, but accommodation has been demonstrated.”

The FluidVision lens (PowerVision) is a dynamic optic IOL with small reservoirs of silicone oil that has “the same refractive index as the rest of the IOL,” Dr. Koch said.

“As the ciliary muscle relaxes, the capsule contracts and the lens attains a greater spherical shape in order to accommodate. Animal studies have validated this concept,” he said. – by Bob Kronemyer