Are premium IOLs suitable for patients with Fuchs’ endothelial dystrophy?
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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 we focus on the controversy surrounding the use of advanced-technology IOLs in patients with Fuchs’ endothelial dystrophy. Due to the significant visual effects of the corneal guttata, as well as the risk for potentially needing endothelial keratoplasty, many surgeons have concerns about these patients being able to tolerate advanced-technology IOLs. Therefore, monofocal IOLs have been the most common choice, providing excellent distance vision. However, these patients may desire better vision for near and intermediate tasks and more spectacle independence. Are current IOL options suitable? Keith A. Walter, MD, and Audrey R. Talley Rostov, MD, express their points of view. Enjoy the debate.
– Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Fuchs’ endothelial dystrophy (FED) is a progressive disorder that affects the corneal endothelium, leading to corneal edema and reduced vision.
For individuals requiring cataract surgery, the choice of IOL is crucial to achieve optimal visual outcomes. While multifocal IOLs offer the potential for reduced dependence on glasses for near and distance vision, their use in patients with FED has sparked controversy among ophthalmologists.
First, there are visual quality concerns: FED is characterized by corneal guttata and endothelial cell dysfunction, which can compromise visual quality. Multifocal IOLs divide light into multiple focal points, which may exacerbate visual disturbances such as halos, glare and reduced contrast sensitivity, particularly in eyes with compromised corneal integrity. Patients with FED may experience amplified optical aberrations, leading to dissatisfaction with visual outcomes. In addition, multifocal optics inherently compromise contrast sensitivity compared with monofocal lenses. In patients with FED who already experience reduced contrast sensitivity due to corneal changes, the use of multifocal IOLs can exacerbate this issue, leading to decreased visual acuity in low-contrast situations such as night driving, playing golf or reading in dim lighting conditions.
FED also predisposes individuals to postoperative complications such as corneal decompensation and persistent corneal edema. The implantation of multifocal IOLs in eyes with compromised corneal health may further elevate the risk for adverse events, including delayed visual recovery, exacerbation of corneal edema and increased susceptibility to corneal endothelial cell loss. Ophthalmologists must carefully weigh the potential benefits of reduced spectacle dependence against the risk of exacerbating corneal pathology, especially if an IOL exchange is needed for an unhappy patient.
Given the variability in the severity and progression of FED among patients, a personalized approach to IOL selection is imperative. Factors such as corneal thickness, endothelial cell count and the presence of corneal guttata should be carefully evaluated to determine the most suitable IOL option for each individual. While multifocal IOLs may be appropriate for some patients with mild FED and minimal corneal involvement, it is better to err on the side of caution as the predictability of outcomes and the long-term results are questionable.
The decision to implant multifocal IOLs in patients with Fuchs’ endothelial dystrophy remains a subject of controversy within the ophthalmic community. While these lenses offer the potential for reduced spectacle dependence, their use in eyes with compromised corneal integrity poses challenges and may exacerbate visual disturbances and postoperative complications. I think it is best to bow out and educate your patient on why you do not recommend a multifocal solution.
- For more information:
- Keith A. Walter, MD, of Atrium Health Wake Forest Baptist Eye Center – Davie in Bermuda Run, North Carolina, can be reached at kwalter@wakehealth.edu.
Patients with corneal pathologies, like any other patients, deserve to obtain the best vision that their eyes can achieve.
If they have preexisting regular astigmatism or if they desire a wider range of vision, nowadays there are IOL options that we can offer them at the time of cataract surgery.
Upfront, we have to establish how advanced their Fuchs’ dystrophy is. Fuchs’ and even a small cataract are an indication for endothelial keratoplasty before or in combination with cataract surgery and IOL implantation. Descemet’s membrane endothelial keratoplasty has shown to lead to better visual outcomes as compared with Descemet’s stripping endothelial keratoplasty, with a shorter time for visual recovery. If the patient is a good candidate for DMEK, then we can consider several premium IOL options. With DSEK, the stromal layer can lead to more variability in visual outcomes, and premium IOLs are a risk I would not recommend taking. With significant Fuchs’, DMEK should be performed first, letting the cornea normalize before making decisions on IOL type and power to achieve a better, more precise refractive outcome.
Not all premium channel IOLs are appropriate for patients with Fuchs’ dystrophy. I would not recommend multifocal IOLs due to the decreased contrast sensitivity, but the Light Adjustable Lens (LAL, RxSight), which has some extended depth of focus (EDOF) properties, can provide these patients with precise, personalized vision correction and a focus range that includes near and intermediate as well as distance vision. I have implanted the LAL in some patients after DMEK with satisfactory outcomes. I would not consider the so-called enhanced monofocal IOLs such as the Eyhance (Johnson & Johnson Vision) because the results are variable, and it is more difficult to determine how much of an EDOF effect the patient would achieve. There is a risk that the patients would pay extra without having their expectations satisfied.
Toric IOLs are a good option in Fuchs’ patients who need astigmatic correction, and I have used them following DMEK. In the past, I used to perform PRK if the patients desired to correct the residual refractive error after toric lens implantation. This is still a possibility, but the less you touch these corneas, the better, and I have done much less PRK since the LAL became available.
In patients with mild Fuchs’ dystrophy and some guttata that does not require corneal transplantation, I would still not use multifocal IOLs if I think that DMEK might be needed sometime in the future. But I would have no doubts about implanting a toric lens, and I could also consider an EDOF such as Vivity (Alcon) or an LAL. In those patients, I always plan for a small amount of myopia, explaining that I do this because they might need DMEK at a later stage.
Whatever the IOL choice, I always make sure that patients understand that they have a corneal disease and that they should not compare themselves to their friend, neighbor or relative who had cataract surgery and a perfect outcome. I make it clear that their cornea can be a limiting factor in their ultimate visual results, although, like we do with any other patient, we are looking for the best options to optimize their vision.
- For more information:
- Audrey R. Talley Rostov, MD, can be reached at audreyrostov@gmail.com.
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