Since the landmark CMS ruling in 2005 that reversed decades of policy on reimbursement for cataract surgery and allowed practices to bill patients for the additional costs associated with presbyopia-correcting IOLs,1 premium lenses have played a crucial role in revolutionizing patient care. This group of IOLs not only offers an advanced solution for refractive cataract surgery but provides an avenue for customization and personalized care.
The latest generation of premium IOLs aims to reduce the incidence of dysphotopsias and other bothersome visual side effects. This discussion highlights how continued evolution in lens materials and designs reshape how ophthalmologists approach cataract surgery, setting a new standard for postoperative outcomes and patient satisfaction.
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Priya M. Mathews, MD, MPH: We are so fortunate to have myriad premium IOL options to fit our patients’ visual and lifestyle requirements. What are some of your favorite things about the new generation of premium IOLs?
Karolinne Maia Rocha, MD, PhD: For me, there is no question that quality of vision is the most impressive attribute. We see more patients achieve not only 20/20 vision but also a full range of vision.
George O. Waring IV, MD, FACS: One of the most exciting aspects of newer-generation IOL technology is the improved tolerance to refractive error. To credit Karolinne with her landmark editorial describing the concept of extended depth of focus (EDOF) with the legacy Tecnis Symphony (Johnson & Johnson Vision),2-4 we started to realize the tolerance to refractive error with that technology. I think this feature ranks among other important advanced optical design features such as correction of spherical and chromatic aberration. It’s going to help patients long-term because we still can’t truly predict effective lens position or eradicate the proliferation of lens epithelial cells.
Joaquin O. De Rojas, MD: With presbyopia-correcting IOLs of the past, downsides like dysphotopsias, limited forgiveness to postoperative refractive error, and less-than-stellar performance under low contrast and light were important factors to consider for every patient. With the newest-generation lenses, however, I think that significant improvements have been made on all these fronts. It’s an exciting time for presbyopia correction because the downsides seem to be getting less and less.
Dr. Mathews: Another positive is a reduced rate of enhancement procedures. In the past, you might have been nervous to implant presbyopia-correcting IOLs unless you offer LASIK at your practice. Now, you can have more confidence because hopefully patients are less likely to need an enhancement, expanding indications to a lot more patients.
Dr. De Rojas: I’m curious how everyone explains premium IOLs to patients so they can digest that information and make the best choice. Do you talk about toric IOLs and astigmatism, or do you talk about what the end goal is?
Dr. Rocha: It’s important to keep it simple. I don’t give a lot of options. I narrow it down to two options, which are distance correction or a full range of vision option.
Dr. Waring: We use analogies rather than technical terms. We explain that your eyes are like a camera. To take a great picture, your camera must be in focus, the lens must be clear, and the film needs to work. I show our clients that their camera may be out of focus (topography), and their lens may be cloudy (Scheimpflug lens image). We go on to explain that we can help with both issues and restore their reading vision and reassure them that we can do as little or as much as they like, but this is our recommendation.
Dr. De Rojas: We do not promise an outcome but rather a target depending on the vision correction package they choose—custom (ie, distance vision) or advanced (ie, full range of vision). There’s a fine line between setting expectations low and setting realistic expectations. How do you approach patient expectations?
Dr. Rocha: It’s important to tell patients exactly what to expect with the technology. You don’t want to promise glasses-free vision, but it’s OK to explain they’re going to be independent from glasses for most daily activities. I explain functional vision. For example, a high myope needs to know their sweet spot for reading is going to change and if they need more magnification they can get reading glasses.
Dr. Waring: One of the most critical aspects of the consultative process is setting proper expectations. We explain to patients they have had their eyes for their entire life and although they are not working well anymore, they have gotten used to it. After the procedure, the eyes will work great, but they will not be used to how they work, and that requires understanding. They will see their new lenses working—possibly with a mild halo or starbursts that tend to improve over time—as opposed to their aging lens that will continue to get worse over time. We go on to explain that these lenses restore their range of vision, but they are not designed to magnify microscopic details or illuminate low light reading. We let them know good light and occasional magnification will be needed in certain circumstances.
Dr. De Rojas: What lenses are you using, Priya?
Dr. Mathews: More recently, I use the Tecnis Odyssey (Johnson & Johnson Vision) for patients who opt for the full visual range package. Like Karolinne, I explain patients are likely to achieve spectacle independence for functional vision and social situations. I even say to my monovision patients that they can be glasses-free for most of their life.
Dr. De Rojas: I’ve had a great experience with the full range of vision Odyssey, too. Now the question becomes this: What about the category of IOLs such as monofocal, monofocal plus/enhanced monofocal, and EDOF lenses?
Dr. Rocha: In this quest to simplify things for patients, enhanced monofocal IOLs are an excellent option for patients who are not good candidates for presbyopia-correcting lenses. Now we can offer a premium technology to these patients such as those with dry eye disease, mild drusen, or an epiretinal membrane. They can achieve excellent distance vision with a slightly extended depth of focus. It is a game-changer. When do you do an enhanced monofocal versus a diffractive optic, full range of vision IOL?
Dr. Mathews: For more of a visual range with some reading, I would use an EDOF such as the Tecnis Odyssey. For monofocal patients in whom I want to give an extra boost, I use an enhanced monofocal such as the Tecnis Eyhance (Johnson & Johnson Vision).
Dr. De Rojas: I use an enhanced monofocal on many of my monovision patients. Instead of having one sweet spot, it gives approximately 0.50 to 1.00 D of range. I’ve also used an enhanced monofocal such as the Eyhance for blended vision to preserve more stereopsis. I also like the enVista Aspire IOL (Bausch + Lomb) and the Light Adjustable Lens (LAL) and LAL+ (RxSight).
Dr. Waring: I have primarily used the Tecnis Symphony OptiBlue (Johnson & Johnson Vision) for most post-myopic refractive surgery patients because of the excellent contrast, tolerance to refractive error, and the additional benefit of extended range of focus. I typically target -0.35 D in the nondominant eye. Patients may sacrifice a line of distance in the nondominant or less healthy eye, but they get an extra line of reading. These patients, like all patients, must be counseled about occasional magnification requirements.
We do not routinely recommend enhanced monofocal IOLs for blended vision, even for historic monovision contact lens wearers. I think if a patient’s eye is healthy enough for full vision range—even if they’re a historic monovision patient—they’re generally healthy enough for a diffractive lens. There are exceptions, including mild to moderate pathology or prior refractive surgery, where we may use an EDOF IOL. For highly aberrated eyes, we decide between a small-aperture lens like the IC-8 (Bausch + Lomb), a spherical aberration neutral lens like the enVista (Bausch + Lomb) or, if they are hyperprolate, the RayOne EMV (Rayner), depending on magnitude of radial asymmetry. We have been using the Odyssey more often for so-called regularly irregular post-myopic LASIK patients with good success in our early experience.
Dr. Rocha: It’s so exciting right now that we have a lot of fantastic options for our patients. Matching the technology to the patient’s needs is key. Most of our monofocal patients receive an enhanced monofocal, but I use an aberration-free lens like enVista for post-hyperopic LASIK (eg, with negative spherical aberration) and patients with a decentered ablation with significant higher-order aberrations such as coma.
Dr. Waring: Have you started using Odyssey in post-myopic LASIK patients?
Dr. Mathews: I typically use the LAL.
Dr. De Rojas: I typically use the LAL for these patients, but I have done a handful of Odyssey cases. The landing zone is pretty wide. I’ve started to feel as much confidence as I do with the Tecnis Symphony OptiBlue.
Dr. Mathews: We use the Odyssey if there is no prior history of refractive surgery and LAL if they’ve had laser vision correction (eg, LASIK, PRK, radial keratotomy).
Dr. De Rojas: For monovision RLE patients, the LAL is great because they’re used to a big offset. RLE patients want a full range of vision. Sometimes during the third adjustment, however, they realize they want more reading. Therefore, for patients who haven’t had LASIK, I almost feel better with bilateral Odyssey. I feel so much more confident with the reading and that I’m going to hit the target with our modern IOL formulas and the lens’ landing zone.
Dr. Rocha: Patients are always happier if you preserve distance vision in both eyes. With these new IOLs, the quality is so good. The steps are smoother and lower, and patients are happier.
Dr. Waring: Some of us on this panel participated in the Odyssey clinical trial. We were so impressed with the subjective and objective outcomes data, we almost immediately, moved all our non-post–refractive RLE patients to same-day bilateral Odyssey and have not looked back.
It’s an exciting time in cataract surgery. Today’s premium IOLs are moving the needle. It’s so much fun to trade ideas and thoughts with other surgeons to advance our field.
