On Day 1 of the 42nd Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2024) during The Global Refractive Summit, experts laid out the evolving landscape of presbyopia correcting intraocular lenses (PC-IOLs), discussing both the current standards and future innovations.
Rethinking IOL classification
Is it time to rethink our range of cataract surgery options? Opening a session surveying the current landscape of PC-IOLs, Dr. Joaquín Fernández (Spain) made a compelling case for a functional vision-based approach to classifying simultaneous vision intraocular lenses (IOLs).
Dr. Fernández tackled the confusing world of IOL terminology. “It’s crucial to avoid getting tangled in terms like bifocal, unifocal or pentafocal,” he quipped. Also, he championed consistency in scientific literature, noting that, according to ISO 11979-7:2024 criteria, many bifocals and trifocals could be reclassified as full visual range (FVR) lenses—provided they don’t show a monotonous decrease of ≤0.04 LogMAR. “However, enhanced monofocals are still caught in limbo between EDoF and monofocal,” he added.
Dr. Fernández then highlighted the benefits of functional classification using monocular distance-corrected defocus curves. These curves help group IOL models based on what matters most to patients and surgeons. “Keep in mind,” he said, “that the functional classification of an IOL can change depending on data collection methods and biometric parameters”.
New trends in pseudo-accommodation PC-IOLs
Dr. Durval Carvalho, Jr. (Brazil) then took the spotlight with a presentation titled New Trends in Pseudo-Accommodation PC-IOLs, offering an exploration into the world of intraocular lenses (IOLs) designed to tackle presbyopia and other refractive errors. With a wealth of insights, he navigated the latest trends and challenges in IOL technology.
Dr. Carvalho kicked things off by discussing laser blended vision’s role in managing presbyopia along with other refractive errors like myopia, hyperopia and astigmatism. “Laser blended vision is effective for treating patients with presbyopia who also have other refractive errors, and trifocals offer significant advantages”, he noted,
Furthermore, Dr. Carvalho showcased the TECNIS PureSee IOL (Johnson & Johnson Vision), which features an aspheric anterior optic and a modified refractive posterior optic surface. “The TECNIS PureSee IOL reduces the occurrence of dysphotopsia, making it a highly effective option,” he remarked.
He also introduced the RayOne Galaxy IOL (Rayner), which uses a spiral optic to enhance vision and minimize dysphotopsia. “Unlike trifocal IOLs, the RayOne Galaxy’s non-diffractive optic minimizes halos and maximizes light transmission, offering improved visual clarity across all distances,” he said.
Dr. Carvalho addressed the burning question: Can we expand the depth of focus (DoF) without inviting dysphotopsia to the party? “One key question lingers: is it possible to increase DoF without causing dysphotopsia?” he posed. This challenge remains a significant focus in IOL development, as achieving the perfect balance between visual clarity and minimizing side effects is crucial.
Advances in premium IOLs
Renowned anterior segment expert Prof. Dr. Jorge L. Alio (Spain) presented on Advances in Premium IOLs, outlining the critical conditions for successful outcomes in refractive cataract surgery. Prof. Alio emphasized four key elements: “perfect surgery, a good indication, adequate IOL choice and aiming for emmetropia and spectacle independence.”
Prof. Alio addressed the complexities clinicians face due to “huge commercial bias,” which complicates the selection of extended depth of focus (EDoF) and multifocal IOLs. He highlighted that the new ISO 11979-7:2024 and ANSI standards have added to the confusion, stating, “It is therefore important to unravel this premium IOL confusion.”
In his personal approach to selecting premium IOLs, Prof. Alio noted specific preferences for different outcomes. He explained, “To guarantee near-vision performance, I use trifocals (ZEISS ELANA or Hanita Intensity). Suppose I want to guarantee an almost complete absence of photic phenomena and good-quality vision. In that case, I use TECNIS Eyhance by J&J Vision.”
For a more physiological performance with some variability, he prefers the Lumina by Akkolens (Breda, The Netherlands), saying, “If I want a physiological performance even with some variability in outcome, I use the Lumina by Akkolens.”
Monofocal extended range of vision study
Dr. Mayank Nanavaty (United Kingdom) shed light on the ESCRS position statement regarding intermediate vision. He quipped, “The ESCRS position statement on intermediate vision provides guidance on the definition and clinical relevance of functional vision in cataract surgery.”
Dr. Nanavaty made the compelling case that assessing patient vision shouldn’t be limited to just numbers on a chart: “Therefore, beyond the quantitative measurement of visual acuity, it is necessary to analyze the patient’s ability to use vision in activities of daily living.”
In a fascinating comparison, Dr. Nanavaty pitted Rayner’s RayOne EMV, an aspherically neutral IOL, against Johnson & Johnson Vision’s Eyhance, a fully aspheric IOL.
He noted, “Eyhance showed better distance-corrected intermediate vision and a broader defocus curve compared to the RayOne monofocal lens.” Both lenses performed similarly in terms of distance visual acuity and patient satisfaction, with no reported issues of glare or halos: “Both lenses delivered comparable distance visual acuity and patient satisfaction, with no reports of glare or halo.”
Diving into the mysterious world of pseudo-accommodation, Dr. Nanavaty remarked on the recent ESCRS classification of IOLs, saying, “Recent ESCRS classification of IOLs into monofocal, enhanced monofocal, EDoF and trifocal allows improved understanding of defocus curves.”
He explored the factors behind pseudo-accommodation, humorously noting that “against-the-rule corneal astigmatism increased the odds of occurrence of pseudo-accommodation ten times as compared to other types of astigmatism.”
In his concluding thoughts, Dr. Nanavaty emphasized that pseudo-accommodation is a multifaceted puzzle: “Taken together, pseudo-accommodation is multifactorial and a combination of low myopic spherical equivalent, lower eye-to-eye spherical aberration, shorter preoperative axial length and small pupil size.
“Furthermore, these factors interact with one another, and their consideration is vital towards the design of future technologies aimed at improved assessment of pseudo-accommodation.”
Monofocals plus— results from 1000 eyes
Dr. Gerardo Valveccia (Argentina) next took the stage at ESCRS 2024 to share his intriguing findings from a substantial case series titled Monofocals Plus: My Results in 1000 Eyes. His study, involving 1,000 eyes implanted with the Eyhance IOL, aimed to shed light on visual outcomes with this lens.
“Our goal was straightforward,” Dr. Valveccia explained. “We wanted to evaluate how well the Eyhance lenses performed. We designed a unicentric prospective case series focusing on uncorrected visual acuity at both distance and 33 cm. We also kept an eye on spherical equivalence, IOL power and the number of eyes that lost lines of vision.”
He revealed that, over a period of two years, 900 eyes had already been implanted. And there might be much more to come. “So far, the results are in and looking promising. The majority of patients are seeing well enough to handle daily activities without reaching for their glasses.”
Customizing cataract surgery: Tips for the perfect IOL fit
Dr. Fernando Faria-Correia (Portugal) presented a masterclass in the art of custom cataract surgery, and he didn’t mince words. “Cataract surgery has come a long way,” he declared. “And it’s now the most performed surgery globally. The research is booming, and so is the perceived value.”
Turning his attention to the nuances of the procedure, Dr. Faria-Correia remarked, “From a surgeon’s perspective, cataract surgery is a bit like tailoring a suit—it’s all about getting the fit just right. This means customized planning is a must.”
He also highlighted findings from the 2023 ESCRS survey: “Surgeons are particularly focused on costs for patients, scotopic vision quality and how much contrast sensitivity might take a hit.”
When selecting the ideal candidate for simultaneous vision IOLs, Dr. Faria-Correia advised, “It’s crucial to look at a patient’s medical history, profession, personality and expectations. My mantra? Underpromise and overdeliver. The choice of IOL formula, assessing corneal astigmatism and screening for post-op dysphotopsias are all key.”
In his closing remarks, he emphasized, “A proactive approach to preoperative screening isn’t just a recommendation—it’s vital for keeping those post-op complaints to a minimum.”
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.