Integrating presbyopia-correcting intraocular lenses (IOLs) into everyday cataract practice requires a strategic approach that balances advanced diagnostics with patient-specific solutions. On Day 3 of the 42nd Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2024), a panel of renowned experts in a session headed by Prof. Oliver Findl, explored the latest strategies for incorporating presbyopia-correcting IOLs into routine cataract procedures.
Mastering preoperative diagnostics and intraocular lens (IOL) calculations is crucial for avoiding refractive surprises and ensuring patient satisfaction, especially in presbyopia IOL patients. During his presentation, Dr. Joaquín Fernández (Spain) emphasized the importance of precise diagnostic measurements and accurate IOL calculations to minimize residual refractive errors, which significantly affect patient satisfaction and uncorrected visual acuity (UCVA).
He noted that addressing ocular surface issues, such as higher-order aberrations (HOAs) caused by dry eye or other conditions, requires meticulous attention. To achieve optimal results, he advised capturing accurate diagnostic information by optimizing the ocular surface and validating data with multiple measurements.
“Also, it is important to ensure a healthy ocular surface, and to know that 60% of routine cataract patients are asymptomatic dry eye patients,” he added.
“There are no clinically relevant differences between the current formulas in normal eyes. Our main recommendation is to work with an optimized constant formula instead of averaging formulas without prior adjustments,” he concluded.
Overcoming barriers to presbyopia-correcting IOL procedures
According to the 2023 ESCRS Clinical Trends Survey, the top 3 concerns against performing more presbyopia-correcting IOL procedures are: cost to patient (62%), concern over night time vision quality (52%) and concern over loss of contrast visual acuity (39%).
Dr. Ramza Diamanti (Greece) addressed key barriers to the adoption of presbyopia-correcting IOL procedures and provided practical solutions to overcome them. For access to advanced technology, she recommended pursuing partnerships or seeking investor support. To enhance surgical training and expertise, she advocated for attending specialized courses, participating in wet labs, and engaging in conferences. Regarding integration into clinical practice, Dr. Diamanti emphasized the importance of training staff, preparing informative patient leaflets, and creating comprehensive medical history forms to streamline workflow.
To address skepticism about new technologies, Dr. Diamanti noted that it’s important to read evidence-based data, understand patient satisfaction surveys, have peer discussions and attend conferences. Lastly, it’s crucial to stay informed about regulatory and safety requirements, and participate in clinical trials.
Addressing cost concerns, she stressed on the importance of discussing a cost-benefit analysis with the patient. “We need to tell patients about the benefits like improved quality of life, improved visual acuity and range of focus, and spectacle independence,” she said. She also noted the importance of discussing out-of-pocket expenses, including the fact that multifocal and extended depth of focus (EDoF) lenses are often not covered by private insurance. Additionally, considerations should include the patient’s years of life, independence, and societal impact.
“Presbyopia-correcting IOLs aim to accomplish ambitious goals in visual and refractive outcomes. It is more than just visual restoration. We aim to improve the quality of life of our patients by helping them to achieve spectacle independence. Because we change the physiology of vision, there’s a need for neuroadaptation that might take months to a year,” she said, cautioning that it’s not for everyone, therefore careful patient selection is essential.
Matching patient needs with evolving presbyopia-correcting lens technologies
Meanwhile, Dr. Ramin Khoramnia (Germany) discussed the wide range of monofocal plus and EDOF presbyopia-correcting IOLs, such as non-diffractive EDoF IOL TECNIS PureSee (Johnson & Johnson Vision) and small aperture IOL IC-8® Apthera™ (Bausch and Lomb), available for patients who want to reduce their dependence on spectacles while minimizing dysphotopsias. However, he cautioned that these IOLs may not be ideal for patients who demand full spectacle independence at near distance. Hence, “understanding the technologies and matching them to patient needs, such as their risk tolerance, lifestyle, visual demands, personality and ocular health, is essential,” he noted.
Meanwhile, according to Dr. Florian Kretz (Germany), trifocal or full visual range (FVR) IOL are the largest single category of IOLs implanted for presbyopia correction in Europe, offering the widest range of continuous vision with best near. “Good candidates include: patients with strong desire for spectacle independence at all distances, strong need for near vision tasks, and are willing to accept compromise (dysphotopsia) for best near functionality,” he said. However, there’s a need to rule out irregular astigmatism or aberrations, retinal diseases, severe dry eye and dry eye masquerade (e. g. Salzmann’s, corneal scars), corneal dystrophies and glaucoma, he cautioned.
Expanding on his approach, Dr. Kretz advocated for mixing and matching extended depth of focus (EDoF) and multifocal intraocular lenses (MIOL) to achieve overall vision with reduced dysphotopsia, providing a broad intermediate range of vision. Alternatively, blending monofocal plus lenses with EDoF offers a full range of vision while minimizing dysphotopsia. For those focused on distance vision, EDOF lenses offer minimal dysphotopsia and allow for spectacle independence up to around 55 cm, whereas MIOLs provide excellent visual acuity for both distance and near vision, especially benefiting true binocular near vision, he noted.
In summary, successfully integrating presbyopia-correcting IOLs into cataract surgery requires a meticulous approach that combines precise diagnostics, careful ocular surface management, and individualized IOL selection. By addressing these factors and clearly communicating the benefits and potential drawbacks to patients, surgeons can enhance visual outcomes and overall satisfaction.
Editor’s Note: Reporting for this story took place at the 42nd Congress of the European Society of Cataract and Refractive Surgery (ESCRS 2024), held from 6-10 September in Barcelona, Spain.
