Individualizing vision could mean mixing and matching lens technology

(Image Credit: AdobeStock/Mohammed)

Owing to the broad range of IOLs currently available, increasingly an emphasis has been on personalizing visual outcomes to match patients’ needs for their specific lifestyle. To achieve truly tailored vision, I often combine or mix and match lenses to maximize each one’s specific
optical properties.

My approach to individualizing all parts of the patient’s journey starts well before IOL selection with a comprehensive preoperative workup that pays close attention to the ocular surface. Many studies have highlighted both the prevalence of dry eye disease in patients presenting for cataract surgery and the importance of a healthy ocular surface for accurate preoperative measurements.^1-5 A healthier ocular surface helps ensure a better postoperative visual recovery as the procedure itself can also cause some dry eye.

Screening protocol

Our practice’s screening protocol includes asking patients about symptoms such as tearing, fluctuating vision, double vision, dry eyes, or a gritty feeling. Those who say they do have symptoms will have osmolarity testing. If one of the eyes is greater than 320 mOsm/L or there is a more than 20-point difference between the eyes, we stop the workup and send the patient for an ocular surface examination. This protocol avoids wasting staff and patient time on a cataract workup.

If the ocular surface is clear centrally, we get measurements. Otherwise, we treat the patient for 3 to 4 weeks on average, then bring them back for the measurements. Osmolarity and clinical findings guide treatment, and we follow a stepwise algorithm approach based on the severity of the ocular surface disease (see sidebar).

We obtain a host of preoperative measurements for cataract surgery: basic biometry, basic topography, higher-order aberration analysis, and several keratometry readings from different devices, making sure that they match in terms of magnitude of astigmatism and axis of astigmatism. If they match, we are ready to go to surgery.

IOL selection

To start the process of investigating patients’ visual goals, which will help us select the IOL, we mail them literature about their options. We let the patient know that we will have a discussion, based on the clinical exam, about what the best option is for their eyes. We offer 3 choices: (1) traditional cataract surgery, after which patients can expect to wear bifocals; (2) distance vision correction with reading glasses for everything up close, which includes the use of a femtosecond laser with or without a toric IOL; and (3) a visual outcome that provides less dependency on spectacles or contact lenses for distance and near.

It is imperative that we listen to the patient’s desires and marry that with clinical and diagnostic findings to make a lens recommendation. We are considering their history, higher-order aberrations, their lifestyle needs, the ocular surface, the health of the eye, and whether any previous pathology would rule out a type of lens (eg, a patient with an epiretinal membrane is not a good candidate for a multifocal lens). With no contraindications regarding higher-order aberrations, angle K, and a healthy cornea and retina, my preferred choice is a multifocal IOL. I believe it provides the best combination of distance, intermediate, and near vision with the technologies that we have today.

Mix and match

In my practice, we tend to use blended or tailored vision for patients with low myopia to small amounts of hyperopia. I estimate about 80% of our patients receive some form of blended vision vs 20% who receive the same lens bilaterally. Our preferred lenses to blend are the Tecnis Symfony OptiBlue (Johnson & Johnson Vision) in the dominant eye, and the Tecnis Synergy (Johnson & Johnson Vision) in the other eye. In my experience, the Symfony provides very good distance and intermediate vision, and the Synergy offers excellent near vision with very good distance and intermediate vision. These lenses capitalize on each other’s strengths when used together. We
take care to counsel patients about the possibility of dysphotopsias, such as halo, with any lens option.

I have been doing a form of blended or tailored vision for several years, and today’s technology of combining a high-quality extended depth of focus (EDOF) lens in the dominant eye with another EDOF or a trifocal in the nondominant eye is the latest iteration. There are great data that show that a mix and match strategy works to provide optimal visual acuity, is safe, and is very well tolerated by patients.6-9

Conclusion

Being a meticulous surgeon is also required to provide optimal results to patients. We believe that a femtosecond laser should be used for multifocal IOL candidates to ensure excellent centration and an even capsulorhexis. Thoroughness in cortical cleanup is critical to prevent long-term issues such as posterior capsular opacification. Thoroughly managing the postoperative course with high-quality brand-name drugs as well as continuing to take care of the ocular surface for the long term ensures that patients are getting their very best visual outcomes.

Ivan Mac, MD, MBA

E: ivanmac@gmail.com

Mac is founder and managing partner at Metrolina Eye Associates in North Carolina and South Carolina. He is a consultant for Alcon, Allergan, Johnson & Johnson Vision, STAAR Surgical, Santen, and Trukera; an investor for RxSight, Tarsus Pharmaceuticals, Visionary Venture Group, and Visiox Pharma; and a medical advisory board member for NovaBay and Bruder Healthcare.

References:

1. Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430. doi:10.2147/OPTH.S120159

2. Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41(8):1672-1677. doi:10.1016/j.jcrs.2015.01.016

3. Hovanesian J, Epitropoulos A, Donnenfeld ED, Holladay JT. The effect of lifitegrast on refractive accuracy and symptoms in dry eye patients undergoing cataract surgery. Clin Ophthalmol. 2020;14:2709-2716. doi:10.2147/OPTH.S264520

4. Venkateswaran N, Luna RD, Gupta PK. Ocular surface optimization before cataract surgery. Saudi J Ophthalmol. 2022;36(2):142-148. doi:10.4103/sjopt.sjopt_190_21

5. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery. J Cataract Refract Surg. 2018;44(9):1090-1096. doi:10.1016/j.jcrs.2018.06.026

6. Breyer DRH, Kaymak H, Ax T, Kretz FTA, Auffarth GU, Hagen PR. Multifocal intraocular lenses and extended depth of focus intraocular lenses. Asia Pac J Ophthalmol (Phila). 2017;6(4):339-349. doi:10.22608/APO.2017186

7. Hayashi K, Yoshida M, Hirata A, Yoshimura K. Short-term outcomes of combined implantation of diffractive multifocal intraocular lenses with different addition power. Acta Ophthalmol. 2015;93(4):e287-e293. doi:10.1111/aos.12591

8. de Medeiros AL, de Araújo Rolim AG, Motta AFP, et al. Comparison of visual outcomes after bilateral implantation of a diffractive trifocal intraocular lens and blended implantation of an extended depth of focus intraocular lens with a diffractive bifocal intraocular lens. Clin Ophthalmol. 2017;11:1911-1916. doi:0.2147/OPTH.S145945

9. Song JE, Khoramnia R, Son HS, Knorz MC, Choi CY. Comparison between bilateral implantation of a trifocal IOL and mix-and-match implantation of a bifocal IOL and an extended depth of focus IOL. J Refract Surg. 2020;36(8):528-535. doi:10.3928/1081597X-20200616-01