With recent advances in cataract surgery technology and instrumentation, the procedure has become more streamlined and incredibly efficient. Surgeons likely spend more time having preoperative conversations with patients about which intraocular lens (IOL) will meet their visual needs and give them the spectacle independence they desire. Patients also have higher expectations for postoperative results than ever before, so surgeons are feeling the pressure to get it right. In order to address the individual needs of each patient, surgeons can benefit from having a full spectrum of IOLs in their arsenal.
Rayner (West Sussex, United Kingdom) offers a wide selection of IOLs, including monofocal, enhanced monofocal, toric, supplementary (Sulcoflex) and trifocal (RayOne & Sulcoflex). These are created with exceptional materials, optics and haptic designs for dependable centration and stability, all of which support the optimization of visual outcomes.
Rayner recently hosted the Rayner Trifocal IOL User Meeting in Seoul, South Korea, showcasing a line-up of exciting speakers, sharing their clinical expertise and experience with Rayner’s trifocal IOLs – with a particular focus on the RayOne Trifocal capsular bag IOL.
RayOne Trifocal: A Unique Trifocal Technology
Among the unique features of this IOL is the 16 diffractive step trifocal technology, which reduces light loss to only 11% in a 3.0 mm pupil, with the remaining 89% split to 52% for distance, 22% for intermediate and 26% for near vision. By comparison, other trifocal designs have been associated with around 14% loss in light transmission, resulting in reduced contrast and more scattered light. Additionally, the RayOne Trifocal optical design reduces visual disturbances and was developed to be less dependent on pupil size or lighting conditions.
Dr. Jung Wan Kim, MD, PhD, of the BGN Jamsil Lotte Tower Eye Clinic in Seoul, South Korea, shared analysis of his long-term clinical outcomes using RayOne Trifocal IOLs in 580 eyes. “One year postoperatively, 87% of RayOne Trifocal patients had 20/25 or better uncorrected distance visual acuity, 98% were better than 20/25 corrected and 80% of patients reached J2 or better for uncorrected near visual acuity. These results were very similar to those at two months postoperatively, which demonstrates the great long-term refractive stability of RayOne Trifocal.” Dr. Kim has been using Rayner IOLs his entire career, and the RayOne Trifocal since 2019, sharing, “Rayner has an IOL suitable for every patient.”
Dr. Hyung-Goo Kwon of Keye Eye Center in Seoul, South Korea also reported excellent outcomes from a large series of 410 eyes implanted with the RayOne Trifocal IOL. He shared that 277 eyes in his series had reached their 6-month follow-up, demonstrating a mean uncorrected distance visual acuity of 0.01 ± 0.04 (LogMAR) and uncorrected near visual acuity of 0.03 ± 0.05 (LogMAR). Dr. Kwon reported outstanding mean refractive accuracy of -0.03 D ± 0.34 for this case series using the Barrett Universal II formula.
“When emmetropia was perfectly focused, RayOne Trifocal provided great visual acuity for near, far, and even intermediate vision,” said Dr. Kwon.
Professor Gerd Auffarth, MD, PhD, chairman of the Department of Ophthalmology at the Heidelberg University Eye Hospital in Germany, has been researching and implanting Rayner IOLs for 25 years. “Rayner has evolved tremendously, in biomaterial, in design, and optical development, having a large range of IOLs, offering a full range of opportunities to the surgeon,” explained Professor Auffarth.
Sulcoflex Trifocal: Supplementary IOL for Reversible Trifocality
More recently, Professor Auffarth’s experience has included reversible trifocality with the Rayner Sulcoflex Trifocal supplementary IOL. Sulcoflex Trifocal is uniquely designed with an undulating round edge haptic design with 10° angulation for stable fixation in the ciliary sulcus, minimizing the possibility of contact with the primary IOL or the pupil. “In Europe, we have been using supplemental lenses for a long, long time, but the Sulcoflex Trifocal is the first IOL really designed using materials for this delicate space, with the same optic as the RayOne Trifocal IOL,” shared Professor Auffarth.
Professor Auffarth continued his presentation and explained the clinical indications for reversible trifocality, using a supplemental trifocal IOL. “Young patients with cataract that may develop other ocular pathologies in the future … if I put in this combination of IOLs [monofocal plus Sulcoflex Trifocal] I can be sure that at a later stage, I can adapt. Over the next 20 years, if the patient becomes myopic or hyperopic, or newer IOL technology becomes available, we can change it,” he said.
A supplemental IOL combination may also be the perfect option for the patient that has subtle morphological changes that contraindicate capsular bag fixated trifocal IOLs, or those that are unsure of their tolerance for photic phenomena and would be more comfortable with a reversible option. Patients with a history of strabismus surgery, borderline binocular function and mild amblyopia may develop problems with routine IOL implantation, so having the option of reversibility may be a tremendous benefit.
Goodbye Piggybacking, Hello DUET
With the DUET procedure, using a monofocal capsular bag IOL and Sulcoflex supplementary IOL, designed to allow ~ 500 microns between lenses, eliminates previous challenges associated with ‘piggybacking’ IOLs. First, the capsular bag IOL is implanted, targeting emmetropia to achieve optimal uncorrected distance vision. Then, in most cases, a plano Sulcoflex Trifocal is simultaneously implanted with a +3.50 D add for near and +1.75 D add for intermediate vision. This combination of lenses in a single procedure can provide a spectacle free solution for the patient. The DUET procedure can be performed in three different ways;
- Simultaneously: implanting the primary IOL in the capsular bag and the plano Sulcoflex Trifocal during the same surgery.
- Sequentially; a few weeks apart if the surgeon wants to gauge and correct for possible residual refractive error.
- Pseudophakic: patients with a monofocal IOL already implanted who desire complete spectacle independence.
In a recent publication in the Journal of Refractive Surgery, a study of the optical performance of a two-IOL system (Sulcoflex Trifocal and monofocal capsular bag IOL) was matched with that of a single capsular bag trifocal IOL (RayOne Trifocal).1 The supplementary IOL demonstrated high tolerance to misalignment and minimal light attenuation. “The quality of vision is absolutely identical,” shared Professor Auffarth, one of the authors of the study.
More recently, the visual outcomes of patients who had primary lens implantation in the capsular bag and simultaneous DUET surgery to create reversible trifocality, were reported in the American Journal of Ophthalmology.2 The DUET procedure demonstrated excellent visual outcomes for far, intermediate and near distance, comparable to capsular bag fixated trifocal IOLs, with the added advantage of an exit-strategy in cases with a future loss of function or side effects associated with the optics. Professor Auffarth added this about utilizing this reversible technology, “If anything goes wrong, we can redo it in a way that it minimizes any harm to the eye,” unlike the challenges associated with capsular bag IOL removal or exchange.
What else is in the pipeline at Rayner?
These are exciting times at Rayner, as CEO, Tim Clover shared: “Rayner recently acquired OMIDRIA in the United States, and a new strategic partnership with HASA Optix (Bruxelles, Belgium). Rayner will soon be launching the new RayOne EMV Toric, and other exciting projects focused on polyfocality and accommodation are in development by our R&D team.”
Rayner is uniquely positioned, explained Mr. Clover, “One of our important roles is to be the partner of choice for surgeons, academics and universities who are innovators. We are small enough to care about their individual ideas, but big enough to commercialize it on a global basis.” When asked how Rayner differentiates itself on the market, Mr. Clover explains, “It is the clinical outcomes, and because we only make IOLs, that is our primary focus, our passion, and our responsibility to be better at that than anyone else.”
Editor’s Note: The Rayner Trifocal IOL User Meeting was recently held in Seoul, South Korea. Reporting for this story took place during the event.
1. Łabuz G, Auffarth GU, Knorz MC, Son HS, Yildirim TM, Khoramnia R. Trifocality Achieved Through Polypseudophakia: Optical Quality and Light Loss Compared With a Single Trifocal Intraocular Lens. J Refract Surg. 2020;36(9):570-577.
2. Baur ID, Auffarth GU, Łabuz G, Khoramnia R. Clinical outcomes in patients after duet procedure for reversible trifocality using a supplementary trifocal IOL. Am J Ophthalmol. 2022:S0002-9394(22)00175-1.