Which lens do you consider implanting in a patient with AMD?
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Preserving contrast sensitivity
There are a couple of different considerations when putting an advanced technology lens in a patient who has at least signs of macular degeneration vs. more advanced changes in the retina.
For early signs of macular degeneration, meaning a patient who may have just a little pigmentary change or a few drusen and may not have any risk factors for macular degeneration, that presents a very different scenario from somebody with advanced macular degeneration with a family history who you are sure has an increased risk of progressing to more significant disease. Those are different patients, and I consider the options for these patients differently as well.
Some of the decision-making depends on the age of the patient as well. A younger patient with more significant disease will be more concerning to me in contrast to an older patient with earlier disease. The underlying theme is that you do not want to decrease contrast sensitivity in patients who have significant macular disease or are at risk of developing significant macular disease. Diffractive optics, which is every multifocal or trifocal lens, will have a decrease in contrast sensitivity, and in patients who are at risk for significant changes in the macula from macular degeneration, diffractive lenses are not appropriate.
We need to be careful about quality of vision in patients who have compromised maculae. The situation is different for patients who are older but have few changes in the macula. In those cases, because the patient is older and does not have significant disease, you could consider putting in something that might have a small decrease in contrast sensitivity but would provide some magnification up close.
There are alternative choices to multifocal lenses. Today we have extended depth of focus technology that can provide a range of vision with little impact on contrast sensitivity. One of the lenses that falls into that category would be the Vivity lens (Alcon), which is a go-to lens for me in patients with non-vision-impacting macular changes. I feel comfortable putting in a Vivity because the contrast sensitivity is near that of a monofocal lens. Other choices could include the Eyhance (Johnson & Johnson Vision) or even the Light Adjustable Lens (RxSight) with some mini-monovision adjustment to give some range of vision. All of our non-light-splitting choices are good options because they maintain excellent quality of vision without a significant decrease in contrast sensitivity.
Cathleen M. McCabe, MD, is a cataract and refractive specialist at The Eye Associates in Florida.
Setting expectations
In general, I prefer not to use multifocal lenses in patients with macular conditions, including epiretinal membranes and macular degeneration.
There are definitely varying degrees of macular degeneration. You can see mild cases with limited amounts of atrophy, rare drusen with normal foveal contour, and the patients have good visual potential. The concern is that you do not know who is going to progress, as well as if and when that visual quality or function is going to be affected. I tend to be conservative with patients with AMD.
You want to preserve the patient’s best quality vision, but you do not know what is going to happen in the future with their macular condition. The quality of vision might degrade, and if the patient needs surgery, the multifocal IOL can affect the surgeon’s view into the eye.
Extended depth of focus lenses can be good options in these patients and are definitely a level up from monofocal lenses. I never promise a glasses-free situation, but compared with monofocal, EDOF lenses will give a patient more range. They also may not have the same visual effects as a true light-splitting diffractive optic, such as a trifocal or a bifocal lens. I have experience with lenses such as the Vivity (Alcon) and the Eyhance (Johnson & Johnson Vision), and I have become more comfortable using them in conditions in which I otherwise would not have.
Patients need to understand and often appreciate knowing the limitations of these technologies. It has to be our job as ophthalmologists to find the best patients and set expectations. Patients end up dissatisfied when something unexpected happens. If you are setting those expectations and telling them they might need glasses to achieve the best quality vision in some scenarios, they usually understand and appreciate that.
Kathryn M. Hatch, MD, is an OSN Technology Board Member, director of refractive surgery at Mass Eye and Ear and assistant professor of ophthalmology at Harvard Medical School.
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