Surgeons weigh lens options for IOL exchange

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

This month, Beeran B. Meghpara, MD, and John A. Vukich, MD, discuss their lens preferences for IOL exchange in the setting of unhappy multifocal or extended depth of focus IOL recipients.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

Monofocal IOL

Let’s assume you have done everything you possibly could to make your patient happy. You optimized the ocular surface, treated dry eye and addressed any residual refractive error. In that situation, if the patient is unhappy, there is probably a good chance that they were never a good multifocal candidate to begin with.

Maybe there was a mild anatomical issue that was overlooked, and in the end, they were unhappy. The best thing to do with these patients is to take out the multifocal and put in a monofocal to try to give them the best quality of vision at distance that you possibly can.

In other cases, the patient might be anatomically perfect, but they are still unhappy. Then maybe it is more of a patient selection or patient personality issue. Maybe they are particular about their vision or had expectations that were not quite 100% realistic. Often, these patients notice glare or halos around lights at night, and if they make a switch to a different multifocal lens, you are running the risk of the exact same issues coming up. You do not want to exchange the multifocal lens, have the patient still be unhappy, and then have to go into the eye a third time.

In my experience, when this happens, I tell the patient that we did everything we could, but their visual system and their visual requirements do not fit with a multifocal lens. With that conversation, patients usually get it. As surgeons, we never like to admit failure. We always try to do something to make it better, but sometimes you just have to cut your losses.

There is also the financial aspect of it. We do not make our decisions based on money, but these multifocal lenses are not cheap, and someone has to pay for them. Often, the IOL companies are willing to credit back the cost of the lens if a patient is unhappy. However, if you are considering exchanging for a Light Adjustable Lens (RxSight), that becomes an even more expensive proposition. It is great technology, but you are taking a patient who is already unhappy with one technology and asking them to pay for another one. The psychology of that is not great.

For me, the best option is to bring the case to conclusion with the patient as happy as possible. To do that, a monofocal lens is usually the most straightforward choice.

• For more information:
• Beeran B. Meghpara, MD, of Wills Eye Hospital, can be reached at bmeghpara@willseye.org.

Light Adjustable Lens

Multifocal or extended depth of focus lenses are a satisfying option for many patients, but there are some who simply never neuroadapt or cannot get used to the inherent aberrations of multifocal solutions.

What these patients were drawn to in the first place was the desire to have high-quality vision over a range of focus. They want to see well at distance, intermediate and near. Yet, there are other issues with multifocal lenses that might not suit them. For these individuals, the Light Adjustable Lens (RxSight) is an excellent alternative when considering a lens exchange.

We can all but assure them that their distance vision will be crisp. The ability to fine-tune their vision and adjust the refractive power of the lens to achieve macular potential is a real advantage, and we achieve that routinely. We are also able to get a depth of focus improvement with this lens because it introduces a small amount of negative spherical aberration during the adjustment process, which provides solid intermediate vision and in some cases good near vision as well.

This is a lens that does not have issues with glare, halos or rings. These are common visual complaints from people who are dissatisfied with multifocal or EDOF IOLs. An exchange with a Light Adjustable Lens eliminates these problems.

One of the advantages of the Light Adjustable Lens is that you do not have to worry about patient selection. We are all comfortable using a high-quality single-vision IOL, and the Light Adjustable Lens adds the reassurance that we will be able to achieve excellent uncorrected vision.

The reason it is a great alternative is that we know we are going to achieve aberration-free vision. From a practical standpoint, the Light Adjustable Lens is an outstanding option, and I use it on a routine basis.

• For more information:
• John A. Vukich, MD, of Summit Eye Care of Wisconsin, can be reached at javukich@gmail.com.