Eyeworld Daily News

EW SHOW DAILY 46 Meeting Reporter Tuesday, April 21, 2015 by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer T he progress of surgical options for presbyopia cor- rection is comparable to the development of the tennis racquet. In the early days of tennis, the racquet had a tiny "sweet spot"—the point on the string surface that gave the best bounce, providing the greatest return for each stroke. Over the years, racquet design has improved, expanding the sweet spot to cover almost the entire string surface. The IOL sweet spot has also expanded over the years to the point that "it's hard to miss" excellent uncorrected visual acuity and "20/ happy" patients are more the rule rather than the exception when using IOLs with moderate and high use. This includes toric, monofocal, and, increasingly, presbyopia-cor- recting IOLs. Richard Tipperman, MD, Bala Cynwyd, Pa., made the analogy in his talk on "Surgical Options for Presbyopia Correction: Expanding the Sweet Spot," at the EyeWorld CME Educational Symposium on "Tipping Points in Refractive Cataract Surgery: Status Report on Presbyopia Correction Without Compromise." Dr. Tipperman said that mono- vision is a viable option for improv- ing near vision, "especially in pa- tients who have been 20/happy with contact lens monovision." While tradeoffs include compromised stere- opsis and range of vision, he pointed out that patients don't have to pay out of pocket for the procedure. The current generation of presbyopia-correcting IOLs are also quite successful. These include sin- gle-piece diffractive multifocals like the AcrySof ReSTOR series of lenses (Alcon, Fort Worth, Texas) and the Tecnis multifocal family (Abbott Medical Optics, AMO, Abbott Park, Ill.), as well as the "accommodating" Crystalens AO (Bausch + Lomb, B+L, Bridgewater, N.J.). Over the years, surgeons have grown skeptical of these lenses, particularly multifocals, but Dr. Tipperman attributes this more to surgeons judging the technologies by their rare misses rather than the more frequent hits. While most patients are happy, he said, people tend to remember only the negative. The next generation of pres- byopia-correcting IOLs are being received more positively today than the current generation. These include the lower add versions of the AcrySof and Tecnis MF IOLs, the extended depth of focus and ex- tended range of vision IOLs such as the Tecnis Symfony (AMO) and the AcuFocus small-aperture IOL (AcuFo- cus, Irvine, Calif.), and toric presby- opia-correcting IOLs such as the B+L Trulign and the Alcon ReSTOR toric. Meanwhile, future accommo- dating IOLs are variously promising, from the FluidVision fluid-controlled IOL (PowerVision, Belmont, Calif.); dual optic IOLs such as the AMO Synchrony, the NuLens (NuLens Ltd., Herzliya, Israel), and the Akko- Lens (AkkoLens International, Breda, the Netherlands); and the Tetraflex (Lenstec, St. Petersburg, Fla.). Other options include corneal inlays and scleral modifications. In addition, Dr. Tipperman said, many of the technologies can be combined with micro-monovision (from –0.50 to –0.75 D) to further improve near vision. Even with today's presbyopia- correcting IOL technology, he said, at least 92% are very happy and only 1–2% unhappy with the quality of vision. Significantly, unhappy patients are "100% fixable." "Each successive advance in IOL technology increases the size of the sweet spot," Dr. Tipperman said. Accepting the fact that current technologies are not present, he said, should surgeons wait for the perfect presbyopia solution? Relevant to the problem is the fact that the definition of "great vision" is actually different for patients and physicians. Steven J. Dell, MD, Austin, Texas, said that while patients are looking for full range of vision, no contrast loss, and low to no problems with glare and halos, physicians are looking for "high patient satisfaction, reliable outcomes, and no significant addi- tional chair time," he said. Dr. Dell said that the next gen- eration of presbyopia solutions get closer to achieving parity between these definitions. New multifocals show promise for improving inter- mediate and distance vision, while extended range of vision IOLs show promise with less compromise. Finally, John A. Vukich, MD, Madison, Wis., addressed residual refractive error. Before considering any enhancement procedure, Dr. Vukich recommended considering ocular surface and tear film health. Surgeons should also be sure of accurately refracting their patients; intraoperatively, they should avoid flap cuts overlapping surgical inci- sions. EW Editors' note: This symposium was supported by unrestricted educational grants from AMO and Alcon. Expanding 'sweet spot,' reducing compromise in presbyopia correction Dr. Tipperman discusses the expanding "sweet spot" for presbyopia correction. Now live at www.EWrePlay.org

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