Personalized IOL selection starts with expectations

Ophthalmologists continue to emphasize the importance of individualized decision-making when selecting IOLs. In an interview with Ophthalmology Times (OT), Haroon Ilyas, MD, a cornea specialist at Brandon Eye Associates in Tampa, Florida, described key highlights from OT's Case-Based Roundtable® on IOL selection in which he participated. Factors discussed included patients’ lifestyle needs, visual demands, ocular characteristics that influence IOL selection, and reported patient outcomes.

The central conclusion of the discussion emphasized the importance of understanding each patient’s visual needs, considering their age, lifestyle, activities, desire for night driving, and plans. Ilyas addressed 3 considerations through 3 clinical cases.

Cases demonstrating varying patient needs

Case 1

A 69-year-old retired man was engaged in foreign mission work. His visual acuity (VA) was counting fingers in the right eye and 20/200 in the left eye, both with substantial glare; there was a small amount of astigmatism.

Ilyas noted the importance of astigmatism and dry eye correction to achieve the best possible outcomes and the consideration of IOL types other than multifocal.

A discussion of the characteristics of the enVista Envy (Bausch + Lomb), Tecnis Eyhance (Johnson & Johnson Vision), and Tecnis Odyssey (Johnson & Johnson Vision) IOLs led to the selection of the enVista Envy multifocal IOL based on near vision, the ability of the IOL to forgive postoperative refractive errors, and a lower incidence of postoperative halos.

Postoperatively, the patient achieved VA of 20/20 in the right eye and 20/25 in the left eye, with J1 near vision.

Ilyas noted that he selects the enVista Envy IOL for patients who require a broad range of vision, particularly near vision.

Case 2

A 70-year-old female painter reported changes in color perception and declining near vision. She had previously undergone bilateral myopic LASIK. Her uncorrected VA was 20/20 in the right eye and 20/30 in the left eye. She desired spectacle independence and improved color contrast and expressed willingness to consider monovision.

The examination showed higher-order aberrations, prompting Ilyas to discuss the limitations of multifocal IOLs with the patient, . The Light Adjustable Lens (LAL) (RxSight) was the IOL choice for this patient.

Postoperatively, she reported light streaks and underwent a YAG procedure in the right eye. The LAL was locked in after 2 adjustments with 20/20 uncorrected and J7 at near in the right eye and 20/25 uncorrected with J1+ at near in the left eye.

“The LAL is an option for physicians that provides good outcomes,” Ilyas said. However, its cost and the increased chair time surrounding the adjustments are considerations for surgeons using the LAL in their practices, he noted.

Case 3

The patient was a 58-year-old man who was considering LASIK at another practice. His VA was 20/60 in the right eye and 20/250 in the left eye, with bilateral glare. He had a high degree of hyperopia and astigmatism.

A discussion of his situation led to the selection of the enVista Envy IOL. One month postoperatively, the patient achieved 20/20–2 vision bilaterally, with a small amount of myopia in the right eye and mild hyperopia in the left eye. Near vision was J1+ in both eyes.

“In this case, the Envy IOL shines in this younger patient,” Ilyas said.

The group discussed patient expectations and the importance of managing them preoperatively. IIyas believes that patients should be informed ahead of their expected visual outcomes. “Addressing these issues up front pays dividends and reduces issues postoperatively,” he said.

Postoperatively, managing patient dissatisfaction may include addressing ocular surface issues, performing a YAG procedure, or considering a lens exchange.

Take-home messages

Case 1 showed that the enVista Envy IOL was an appropriate choice after a close consideration of the patient’s expectations.

In case 2, previous LASIK procedures and the presence of higher-order aberrations potentially played a role in outcomes in patients with multifocal IOLs. The LAL was a good choice after refractive surgeries.

The patient in case 3 was younger than the patient in case 1, but the enVista Envy IOL can be an option for a broad range of patients with minimal issues resulting in glare and halos.