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The case for using a presbyopia-correcting IOL in only one eye
Source: Bret L. Fisher, MD
For ophthalmic surgeons, there are now many options for correcting presbyopia at the time of cataract surgery. All of these new and evolving technologies are indicated and meant to be used bilaterally in order to obtain the greatest benefit for our patients. In my practice, I have had great success with these lenses and routinely find that more than 90% of my patients report never wearing glasses after bilateral implantation of presbyopia-correcting lens implants. But is there a case for unilateral use of these advanced technology lenses?
To illustrate cases in which I have successfully used presbyopia-correcting IOLs unilaterally, let’s look at some typical examples. Jane M. is an active 72-year-old who had cataract surgery in her dominant right eye with a monofocal IOL approximately 10 years ago. She remembers that she was interested in presbyopia correction at the time of that surgery, but it was not offered by the surgeon and she did not feel comfortable asking about it. Her uncorrected distance visual acuity in that eye is good at 20/20 with little residual refractive error. Earlier in my experience with presbyopia-correcting lenses, I would have told her she was not a candidate in her second eye and we should just match her existing monofocal IOL. However, I would now feel comfortable offering her a distance dominant multifocal IOL, such as the ActiveFocus lens by Alcon, which would be a good match in terms of distance vision but also provide some extended range of vision for intermediate and near. An accommodating IOL such as the Crystalens or Trulign toric (both Bausch + Lomb) could also be used, and although I have yet to use an extended depth of focus lens such as the Symfony (Johnson & Johnson Vision) in this setting, I believe it could also be used successfully.
Ralph B. is a 64-year-old in good health who has moderately advanced nuclear sclerotic cataracts in each eye that are symmetrical and visually significant. However, his nondominant left eye also has a significant epiretinal membrane that has been present for at least several years and for which he has been offered but declined surgical removal. OCT reveals macular thickening consistent with the membrane, and potential vision as measured by the Retinal Acuity Meter (AMA Optics) is 20/50 in the left eye and 20/20 in the right. In this case, I would implant a monofocal IOL in the left eye, but I would discuss and offer a distance dominant multifocal or EDOF lens in the right eye. I would again be careful to set expectations appropriately. I would not favor an accommodating lens in the right eye in this setting due to the small risk of Z syndrome in the patient’s best eye.
In addition to these two more common scenarios, I have used a distance dominant multifocal IOL in a monocular patient after careful and lengthy informed consent centered on the need to wear glasses with polycarbonate lenses anytime the possibility of a traumatic eye injury could occur. However, a monocular patient who is otherwise in good health may benefit from the extended range of focus and depth perception from such a lens in a protected environment, such as at home. I have also had success using these lenses in patients with asymmetric changes in their crystalline lens, so that cataract surgery in the second eye could be delayed many years. With older generations of multifocal lens implants, it was sometimes difficult to obtain the quality of distance vision necessary with unilateral implantation in this setting.
In any of these cases, patient education and setting of appropriate expectations would be critical, as patients would need to understand that they would still require reading glasses for some of their near tasks and that some degree of mild night vision disturbance is possible. My experience with these patients has been that they are satisfied with their visual functioning after surgery, as long as they know what to expect. Although I have not had enough patients to collect meaningful data, my impression is that their spectacle independence is midway between those with a monofocal IOL and those with bilateral presbyopia-correcting lenses, as would be expected.
In summary, although the approved indication for presbyopia-correcting lens implants calls for sequential bilateral implantation, there are patients who can benefit from use of these technologies in only one eye. Surgeons should be sure to consider all options and discuss with their patients those technologies that may be appropriate for them. By educating patients and setting realistic expectations, the ophthalmologist can achieve an excellent result and happy patients.
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- Bret L. Fisher, MD, medical director and a founding partner of the Eye Center of North Florida, can be reached at Eye Center of North Florida, 2500 Martin Luther King Blvd., Panama City, FL 32405; email: bfisher@eyecarenow.com.
Disclosure: Fisher reports he is a consultant to Alcon Laboratories.