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What is your preferred approach to correcting presbyopia in patients undergoing cataract surgery?
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Symfony may be the new go-to
For my practice, the Symfony IOL has been a long-awaited and welcomed addition to my surgical armamentarium. While my experience is still relatively early, this is my new go-to method of presbyopia correction with cataract surgery. Prior to the Symfony approval, my use of multifocals increased significantly once the low add powers were made available in recent years, but they still only comprised about 10% of my total cataract surgical volume because of the more stringent patient selection criteria and the lack of a toric multifocal option.
Now, the Symfony has opened new opportunities, with astigmatism correction, improved contrast and continuity in the range of vision. If this IOL also proves to mitigate night vision symptoms to an incidence that is not much higher than a monofocal IOL, the distribution of the IOL market may look very different in the U.S. in the next 12 months. For me, I now have more patients who are presbyopia-correcting IOL candidates, and this has been a very positive change to my clinical practice.
Elizabeth Yeu, MD, is an assistant professor at Eastern Virginia Medical School and practices at Virginia Eye Consultants. Disclosure: Yeu reports she is a consultant for Abbott Medical Optics.
Customize surgery, implant selection
My preferred approach to correcting presbyopia is to customize the cataract surgery and the selection of the implant to each patient’s ocular situation.
For patients who have successfully worn monovision contact lenses for decades, I often use monofocal IOLs mimicking their previous monovision with one eye aimed for distance and one eye aimed for near.
For patients who have 1 D or more of symmetric astigmatism, I offer either an accommodating IOL that also corrects astigmatism (Trulign) or, as of a few weeks ago, the Symfony toric. Both of these implants provide excellent distance and intermediate vision with functional near vision.
For patients who have less than 1 D of astigmatism, I offer a multifocal IOL with a limbal relaxing incision to address their pre-existing cylinder. The low add multifocal IOLs provide better intermediate and near vision with less photic phenomena than the older models. In myopic patients, I use the Tecnis ZKB00 IOL with a +2.75 add in the dominant eye and aim for plano. Then, I engage the patient and ask whether they wish to see a little closer at near. If they answer affirmatively, I select the Tecnis ZLB00 with a +3.25 add for their non-dominant eye. In contrast, in hyperopic patients, I implant bilateral ZKB00s.
In patients who have some macular or corneal pathology, I offer blended vision with a mini-mono with the Softec HD hydrophilic acrylic IOL where I aim the non-dominant eye between –0.62 D to –0.75 D. This small interocular difference does not interfere with depth perception yet delivers excellent intermediate and functional near vision.
The new Symfony IOL with extended range of vision and correction for chromatic aberration is more forgiving and may be an option for many patients, especially ones with mild corneal or macular pathology.
Cynthia Matossian, MD, is an OSN Cataract Surgery Board Member. Disclosure: Matossian reports she is a consultant for Abbott Medical Optics and Bausch + Lomb and a speaker for Lenstec.