2oon01e ogg Mooi eo Fae REE n Walter Bethke, Managing Editor Bringing Monofocal IOLs into Focus ‘The most recently approved crop of monofocal lenses has features worth exploring, say surgeons. ‘The products that make the biggest promises gel the most stlenon, as anyone whe has marveled a he amount of Information gonerated about mulifocal and accommodating Ls can atts That boing the caso, in cataract surgery, monofocal intraocular lanses are so ubiquitous theyre almost taken fr granted, ye they're the lenses most othe pationts who need cataract surgery are likely fo gel. Since 2010, four new menofoca intraocular lensas have been inraduced inthe United Slates, and surgeons have been gradually amassing experience with thar, geting a ‘0 for how to put thot features to use inthe operating room. Her, several surgeons axperienced inthe use of ‘these !OLs discuss the naw deviees. ‘Aaron's EC-2 PAL. one's dosign may be less Aaren Scientifio’s EC-3 Lenses ‘Aaron's Enduring Clay tne of lenses is composed of two modes, the EC:3 and the EC:3 Precision Aspheric Lens. Both are thee-place loses made of a hydrophobic cry, with a square-edged optic to reduce the incidence of Posterior capsuie opaciicalion, They each have a G-mm optic and coma in powers ranging fom +4 1a #34DinOS- Dincrements ‘According tothe company, the bisgn aspheric lens uses two diferent curvatures within the Ins Itself in ordor to balance out aberrations in the ons with misalignment, arge pups and dferent comoal shapes. The lons produces ‘spherical aberration of an opposite sign in the central 3mm zone vs. that in the periphery outside the central zone, | ‘Tha lane's maker says that by having both postive and negative asphorcy within the lens, it ay beless impactod bya misalignment tan If the aspheccty was all one sign, "The lens balances out te aberrations so, Inthe presence of a lens misalignment ort, youl find 2 more consistent image quay, contrast sensiviy and expanded depth of focus,” says Kim Dyer, marketing manager for Asren, ges temo cnvoridongng nabs soinro ergot ts Fosse "However, alot of the advantage ofthe expanded toric range is that the ea of treating higher levels of astigmatism sms to make more ganso to surgeons just stating with the technology. It might not make alot of sanee to some peopl to use a lens fo reat tor 1.25 D of astigmatism, However, they know tat Ia patlont has 21a 4D of ‘actigmatism, fits let untreated the uncorrected vision Is going te be very poor. So, for almost al surgeons, using the higher power toric Intuively makes more sense, end tyre more comfortable using ior that, “The one thing a surgoon may encounter on occasion with higher power toric that in' sliays an issue with ower power toric lenses is the potenti fo “ppg or overcorrecting @ patient” Dr. Tipperman continues, “The wey the lenses wor, for every 10 dogroes they're off ans, you lose a third of tho effect ofthe implant unl, st 30-degrees misalignment, they'e effectively neu in terms of aslgmatsm correction. But, if you Implant a T3 toric, the lowest Power availabe inthe United States, and overcorec the patient by 60 porcont, the patint wil only have 0.5 D of Induced astigmatism 90 dagrecs away from where it was orginaly. However, I you do this wth a T8 of T9, the patient wil have 1.75 102 D of astgmatiem oriented 90 degrees avay trom te cxiginal astigmatism, and that wil be vety manifest to him, So, ts crucial tha the axes line up” (Fora discussion of te fner points of implanting tres, 00°37 Ways fo Gel Great Outcomes with Tors," on p. 26.) In the cnical study ofthe Aer tori, almost 90 parcont ofthe lenses did't rotate or rotated only 5 degrees or ese, However, Dr. Tlpperman says there are station where rotation can cccur spentaneoksy. “Some surgeons have @ fealing that very high myopes with very large anterior segment and very large capsular bage are at ak for ‘spontaneous rotation," he say." light ofthis, when faced with patients who are very nearsighted or who have high ‘axial lengths, there are surgeons who wil counsel them preoperatively, saying, ‘Loo, this is the best lens for your nearsightedness and astigmatism. However, you're eware that you have an unusual, Vety lage eye, So, though this lens works wel for everybody most of the tne, even in highly nearsighted peopl, there's a very smell chance it wil shi for you Hit does, though, there's a way we can fix that.” Hoya Optics iSymm LensiiSert ‘The clear (88 opposed to containing yellow chromophore) Sym IOL and the iSet preoaded inserter were actualy marketed by Hoya for moe than a year bofre the FDA requested that they be removed from te maka in lune 2011, pending the results of additonal testing. Since then, the company has submtod that data, and sls look postive forthe lens regaining ts markatng slats before February 2012, so its woth ifor U.S, surgeons to be Feacquainted wih the [OL before iis the markel again. (The yelow version ofthe ens is currently available fe sale.) ps entiainkaycanadeinggntcnseincanLen, Majid Moshifar, MD, ofthe Moran Eye Center atthe University of Utah, says the lens has some features that sett apart from other monofocals, “The main reason | lke fo use itis because is got relatively the same design as other lenses we've workod with—one place aeryio—but I can order it in 0.25-D steps in certain ranges," he says. "So, ‘when it comas to the lta magnitude of errar ar tno spharical equivalent after surgery, | may be abla to got palonts loser to emimetropia with this lens because ofthese smaller increments, For instance, if do two or three A-scan And the lens I need is 19.2, | an uso a 19.25-D lan; Im net forcad to choose batwoon a 19-D and a 19.5-D lons. AL the end ofthe day the mast important optical errs the spherical equivalent, because the closer you get to plano, the better the result il be,” The lene ie algo available in whole doplor powers from +6 to +36 D and in 0.5-D Incramonts between +10.5 and +29.50. Dr. Moshirfar says thatthe lens can easily go through @2.2- or 2.-mm incision, though many surgeons use a 2.8- ‘mm incision, “The process of folding It al be familar to surgeons who've been working with these one-piece ‘gummy lenses or one-piece acrylic lenses," Dr. Moshirar says. “There's no real learning curve in terms of centration Inthe eyo, As hydrophilic lens, I's got very good biocompatibility and has less of a chance of getting cloudy and veloping gistenings, though atthe same time i's more resent as you touch, manipulate and fold it, As itunfolds Insia the eye, you don't soo creases init” ‘The other unique aspoct ofthe Softec HD ists biaspheric design. “thas a symmetrical, b-canvex pattem from the anterior surface on one side tothe posterior surface an the other,” explains Or. Mashifar, “Because of ths, t's abit ‘mare foriving when it comes to tit, decantation and in terms of not creating coma or higher-order aberrations by ise. has zero aspheric in otal, moaning It dovstt have a plus or minus magnitude on is own Ate evaluating the lens's specifications, some surgeons might question the opt size of 5.6 mm. Dr. Moshirar understands this cancem, but doesn't think its warranted, "Fr if you're @ surgeon used to doing large ‘capsulorhexis, | don't think this wil be any different for you. But you're used to making your capsulorhexis in the range of § mm or so, you may not have @ problem with this because is sil going to be completely covered 360 grees around; he anterior capsule is sil going to cover the IOL optic | haven't had pholopsia issues, and I think Its because of tha lans's symmetrical design is water content andthe fact that its more forgiving when it comes to tit and decantration in the bag.”