What IOLs do you most commonly implant during an exchange?
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It depends on the reason for the exchange
The question needs to be qualified a little bit to explain why we are doing the IOL exchange in the first place.
At our practice, we have gone back and reviewed why we are exchanging IOLs, and by far, the No. 1 reason to do a lens exchange is dislocation of an existing implant. That may be somebody who had pseudoexfoliation or had successful cataract surgery, but now there is a worsening zonulopathy and the lens is dropping. Maybe the implant just is not sitting properly. In those cases, we are primarily now exchanging for a three-piece IOL.
We are looking more at the material that the lens is made out of than the actual lens manufacturer. That means a hydrophobic acrylic IOL with a polyvinylidene fluoride haptic. Luckily, the CT Lucia (Zeiss) ticks all of those boxes. We also use lenses such as the AcrySof MA60 (Alcon) and the ZA9003 (Johnson & Johnson Vision) and even in some cases a haptic fixation multifocal IOL. There is still a need for Gore-Tex sutured fixation foldable IOLs such as the MX60 (Bausch + Lomb). To a smaller degree, if we are removing an anterior chamber lens, we may suture the CZ70BD (Alcon), which is a single-piece PMMA IOL.
The next most common indication is dissatisfaction with visual performance of a multifocal IOL. That is a patient who is unhappy with their quality of vision, or they are getting too much positive dysphotopsia, unwanted glare or halo rings around lights. In those cases, if the posterior capsule has not been violated, we are going to exchange for a single-piece acrylic. The exact brand of the IOL is less important than the design, meaning almost any nondiffractive monofocal IOL will do well. Usually, getting rid of the multifocal nature of the diffractive optic of the IOL is going to be enough to make that patient happier with their quality of vision.
Brandon D. Ayres, MD, is a cornea and anterior segment specialist at Wills Eye.
New lens has to fit the patient
If there is a lens with inadequate support and I need to secure a lens to the eye wall with sutures, I most frequently use a PMMA CZ70BD (Alcon). It is a 7-mm optic implant lens that has a tried-and-true track history, and I know that once I have that secured in position, it is never going to cause a problem. Additionally, anytime I suture, I use ePTFE (Gore-Tex) suture.
The CZ70BD, however, is only available from +10 D to +30 D. For patients whose powers are outside of this range, I may choose to fixate with intrascleral haptic fixation, such as the Yamane technique, although it is not my preferred technique because of tilt, intrusion and extrusion risk. In short, one needs to find a lens that fits their needs.
For negative dysphotopsia, the type of implant is not nearly as important as the location of the lens. Exchanging for a different IOL material or type placed in the same position may result in the same dysphotopic problem or a slightly different one, which may be better, worse or the same. Moving the optic forward will reduce negative dysphotopsia in some patients, but it is far from the perfect solution.
For cases in which we do an exchange for power, I will almost invariably use the same model number with a different power because we know how it is going to sit in the capsular bag; the effective lens position has already been established.
For patients who have a monofocal implant and want to switch to a multifocal implant, I would be more inclined to talk to them about what their specific multifocal implant desires are. Some of these lenses perform better at intermediate, some at near and some are equally balanced but have higher halo rates. It becomes a conversation with the patients as to what ranges are important.
In patients with a multifocal lens for which they find the optics undesirable, I almost always switch to a monofocal lens. In someone who has already demonstrated an inadequate ability to neuroadapt to multifocality, it is generally not a good idea to try another multifocal lens. Some people might be able to adapt better to a different one, but the chances of having to go back into the eye a third time would be highly undesirable to me.
Michael E. Snyder, MD, serves on the board of governors at Cincinnati Eye Institute.
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