EyePod: From small-aperture lens technology to pondering a need for premium cataract surgery fellowship


Peter J. McDonnell, MD, and Neda Shamie, MD, consider the transformative landscape of cataract surgery, highlighting the impact of small-aperture IOL technology. The conversation delves into its potential benefits, influence on the market, and the evolving role of cataract surgeons in guiding patients through advanced options.

In this episode, Peter J. McDonnell, MD, and Neda Shamie, MD, explore the transformative landscape of cataract surgery, highlighting the impact of newly available small-aperture IOL technology (IC-8 Apthera; AcuFocus/Bausch + Lomb). The conversation delves into its potential benefits, influence on the market, and the evolving role of cataract surgeons in guiding patients through advanced options.

Audio Transcript

Editor's note - This transcript has been edited for clarity.

Peter J. McDonnell, MD: Hi, everybody. This is Peter McDonnell, and I'm here with my co-chief medical editor for Ophthalmology Times, Neda Shamie.

Neda, I saw you quoted recently saying that you thought IOL surgery/cataract surgery now has needed a fellowship. It's become so complicated in terms of all the different technologies, IOL technologies, informing patients about it, about all their options is quite a challenge. And I thought that was a great insight because it really has evolved substantially in the last 5 years, compared to certainly when I trained.

Now we're talking about a fairly exciting new development with this hydrophobic acrylic, small-aperture IOL [IC-8 Apthera] that has fairly recently been approved [from] AcuFocus/Bausch + Lomb. What are your thoughts about this technology?

Neda Shamie, MD: I am not sure where I was quoted. I hope I didn't use 'complicated' as a term to describe the current kind of climate around cataract surgery. I think it's actually quite exciting. All the different lens options available, as I'm sure you agree. But it is most definitely an art, maybe not a complicated art, but it's one that requires a commitment from the surgeon, a real desire to learn about the different technologies and advances in IOL technology, and a real kind of belief in the value added to our patients and their lifestyles. And I feel strongly about that.

I feel that cataract surgery has become much more than just clearing the vision. It's lifestyle lenses, as we call them, and really kind of engaging patients in conversations to understand what their needs are, what their expectations are from the surgery. It is no longer just I'm going to clear up your vision but you'll be back in glasses but here's an opportunity that we can address your cataract but in a way that enhances your life beyond just clarifying your vision.

And I agree with you. I think this new lens that's become available to us, the IC-8 or small-aperture lens, it's most definitely causing a paradigm shift in the technologies available. It's a new offering, very different than previous lenses that are premium lenses. It's not a multifocal. It's not an extended range lens. These are ones that now we've had multiple generations of. It's not an adjustable lens like the Light Adjustable Lens [RxSight].

This is small aperture, first in its line. And it's exciting. I think the challenge we now have with this lens is to kind of understand where it's going to fit in our offerings. We have gotten comfortable with multifocal lenses and extended-range lenses, how that fits. The light adjustable lens has its wonderful place and it's been a huge addition to my practice.

The small-aperture lens, at first, I think as corneal specialists, our excitement was around offering it to irregular corneas and I think there's definitely value added in those patients because we haven't really had a great option for them. The light adjustable lens has been an interesting option for my patients with irregular corneas. But I think for those who have significantly irregular corneas, the small-aperture lens, hands down is probably the best option. It's approved for presbyopia treatment in a monocular implant meaning implanting it in the nondominant eye to give extended depth of focus. What's exciting is that it's, [and] I don't like the word 'forgiving,' but in a way it's forgiving in that you can have up to, I believe, 1 diopter of astigmatism, corneal astigmatism. And because of the pinhole effect of the lens, it can in a sense correct for that. And so you don't have to worry about alignment and such and aiming about minus 75 would give you enough depth of focus to be able to see to read, but it also won't affect your distance vision and that's what's great about it.

McDonnell: So for people who don't have much experience with it, it's got these carbon nanoparticles in the optic and that essentially creates a small aperture, which, luckily we don't see too many corneas anymore with radial keratotomy or intersecting radial and transverse incisions causing irregular corneas. But we used to see them and that irregular topography can be quite a challenge and the small aperture is very appealing. The technology is the technology that was first explored with a corneal inlay which turned out to not be for a number of reasons, I think, something that was going to be adopted widely by ophthalmologists.

But using this technology in an IOL optic certainly seems to have appeal. The data that I've seen from the trials show, as you said, I think it's up to 1.5 diopters. It's approved 1.5 diopters of cylinder. It's FDA approved for it. As you say, it's monofocal. It's approved for monocular insertion. The other eye gets a monofocal lens. And it's about I guess 3% of patients who received the lens reported some glare/halos at night sort of issue compared to about 1% or less in the control fellow eye.

The other aspects of it are it's not approved for people with any signs of retinal disease or uveitis which totally makes sense and also for people whose pupils don't dilate well, seven millimeters.

It'd be fun to see in the real-world experience how this is appreciated by patients and adopted, and to what degree it's able to grab market share.

Shamie: I think the benefits that it offers is one, as you said, is monocularly implanted. So patients who are cost-sensitive, that could be one way to gain presbyopia correction without the financial commitment that bilateral implantation would have. That would be one benefit.

Another is if patients who are weary of nighttime glare and halos with multifocal lenses or extended depth of focus lenses. As good as they are, they do have photic phenomena and such. This small aperture aspect of it gives less nighttime glare and halos. The rates were, as you mentioned, about 3%.

It's also a great option for patients who've done monovision in the past. I think one way we like [the] light adjustable lens with our patients who have experienced and enjoyed monovision because [the] light adjustable lens gives you that ability to do blended vision but not every patient is willing to commit the time and the financial commitment that [the] light adjustable lens requires nor are they sometimes not a good candidate. This could be one way to address those patients who've done monovision in the past, but they want to have a more kind of reliable way to have depth of focus with IOL technology that's advanced.

So it's most definitely really exciting technology. I think as we get more real-world experience, we'll be able to have more pearls on how to fine tune the offering and surgical pearls on how to fine tune the surgical technique and then postoperative management of these patients.

I love being a cataract surgeon. This is a really exciting era for us. I remember when I was doing my fellowship with you, Peter. It's aging both of us. I started my residency with three-piece lenses only being available and then toric became available when I was a fellow. We were so excited about torics, and now we're talking about multiple different versions of advanced technology lenses.

And yes, I agree, that I think that maybe a fellowship in premium cataract surgery would be really helpful because there is a lot of nuances in how to guide our patients in that decision.

Thank you so much. This has been fun, and maybe we can come back and talk about it after we've had some experience, some more experience with the IC-8.

McDonnell: Sounds good. Always a pleasure, Neda.

Peter J. McDonnell, MD, has no financial interest, owns no stock and is not a paid consultant or otherwise compensated by any IOL manufacturers.

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