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BLOG: ‘It’s the astigmatism, stupid!’
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In Bill Clinton’s successful presidential campaign in 1992, adviser James Carville famously said, “It’s the economy, stupid,” shouting out the most important issue of the day. In the cover story for this issue of Ocular Surgery News, we explore advancing lens implant technologies available outside the U.S.
To summarize, there are many exciting options available throughout Europe and the rest of world that we may never see approved in this country. Good or bad, this limits physician and patient choices. Most damaging, though, is the unavailability of toric multifocal implants in the U.S. and our inability to precisely correct higher degrees of astigmatism among patients wanting distance and near vision.
This is a public health problem. Surveys of U.S. surgeons show that, among those using presbyopia-correcting lenses, about half are not prepared to perform limbal relaxing incisions for patients who have more than 0.75 D of astigmatism. Essentially, astigmatism goes uncorrected in their patients with multifocal lenses.
How does this impact patients? In our practice, we follow closely patient perceptions of their surgical outcomes, and last year we published a study showing that “top box satisfaction,” or patients reporting the highest level of satisfaction, is unlikely to happen if a patient has more than 0.5 D of residual cylinder after surgery. Leaving astigmatism uncorrected or undercorrected among premium lens implant patients is a sure recipe for dissatisfaction.
We know that toric multifocal implants work well from multiple studies from our colleagues in Europe, where these lenses perform similarly to their monofocal counterparts. They employ the same skills of calculation, implantation and alignment, and their rotational stability is, not surprisingly, just as dependable as other toric lenses.
A word about Crystalens (Bausch + Lomb): For about 2 years we’ve had availability of the Trulign (Bausch + Lomb), the toric version of the Crystalens, and this implant has gained wide acceptance in my practice, especially for patients who want presbyopia correction and have more than 1 D of astigmatism, where the most accurate astigmatic correction requires a toric implant. As valuable as Crystalens is, though, it’s a shame we can’t offer patients a toric multifocal.
The FDA has been the subject of criticism from all sides, some fair and some unfair. Maintaining public safety clearly precedes the agency’s desire to make new devices available. But if you ask me where the priority should be in upcoming refractive technologies, with playful respect for our governmental colleagues, I’d certainly paraphrase Mr. Carville: “It’s the astigmatism, stupid!”
Disclosure: Hovanesian reports he is a consultant for Bausch + Lomb, Alcon and Abbott Medical Optics.