BLOG: Three barriers to the new accommodating IOLs
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Over the next year or so, we will hear more discussion about a new breed of accommodating lens implants seeking FDA approval and how they might alter our practices.
To predict the future of the way these will be received, it’s worthwhile to look backward to 2003 when the Crystalens (then eyeonics, now Bausch + Lomb), the first (and still only) approved accommodating IOL, came on to the market. The idea that an implant could change its shape based on action of the ciliary muscle was long considered possible, but the Crystalens never proved irrefutably that it did so. It did provide some range of vision through a much-debated mechanism. Capsular contraction occasionally caused lens tilting or refractive misses, but many surgeons, myself included, implanted thousands of these lenses for many years with great results.
Following Crystalens, the FDA changed its criteria for granting a claim of accommodation, and no other implant has achieved this designation since. Four new lenses are hoping for this designation, including the Juvene (LensGen), the OmniVu (Atia Vision), the JelliSee (JelliSee Ophthalmics) and the Opira lens (ForSight Vision6).
To achieve widespread adoption, the companies will need to overcome three obstacles:
1. Form factor fear. Surgeons don’t like to talk about their fears of intraoperative complications, but many like to stick with the very familiar single-piece acrylic IOL. I know some surgeons who hesitate to implant any three-piece lenses at all because they do not feel familiar with the haptic design. If that’s a challenge, how much greater will their anxiety be about implanting a much larger lens with a shape and texture like a large squishy flying saucer with multiple parts that must be interlocked in the eye? How much more demanding will be the size and centration of the capsulotomy to even implant these lenses? I have long said that this new breed of lenses may prompt renewed interest in femtosecond or Zepto-assisted cataract surgery (Centricity Vision) to make results more consistent.
2. Refractive accuracy. We are just getting a handle on refractive accuracy with one-piece lenses. If this weren’t already a problem, why would the Light Adjustable Lens (RxSight) be so successful? We’ll need to achieve consistent effective lens position with the new lens designs to achieve high refractive accuracy or otherwise a very high range of accommodation to overcome hyperopic misses. The advantage here may go to lenses like the Juvene and OmniVu that have an exchangeable front optic.
3. Prove it accommodates. The companies will need to provide irrefutable proof that the new lenses actually accomplish what they claim, both to the FDA and to practicing surgeons and patients. Too much history stands in the way of adoption for a lens that people don’t believe in.
I’m truly optimistic for these new lenses and hope they are highly successful. It will be a big win for us and our patients. We have achieved such great results with the modern multifocal IOLs that we and our patients are a little spoiled. But these quality multifocals have also paved the way for even better technology that we truly hope these new accommodating lenses will deliver.
Follow @DrHovanesian on X (Twitter).
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