Insider Perspectives:
How to Navigate IOL Options to Achieve Positive Outcomes
5 minute read
Medical Director and Chief Cataract & Glaucoma Surgeon at Omni Eye Services, Dr. Douglas Grayson and Dr. Dagny Zhu, Medical Director & Partner at NVISION Eye Center, sit down with Alcon to discuss the latest lens innovations in cataract surgery, the impact of IOL selection on efficiency and accuracy, and why they choose PCIOLs time and time again to meet patients’ vision goals.
In the industry today, surgeons are facing more intraocular lens (IOL) options than ever before. Historically, surgeons had limited choices to meet their patients’ post-cataract surgery vision goals. Now, they face the challenge of selecting from a wide variety of lenses that all claim to be “the best IOL” for their patients.
As more IOL choices are introduced, it’s our responsibility as Alcon, the global leader in eye care, to help surgeons evaluate these lens options and consider some of the intangible benefits, such as workflow efficiencies and ease of use that ultimately leads to the best patient outcomes. Without an honest look at the options, it’s easy to end up with unintended consequences for you, your practice or your patients.
To better understand the impacts of IOL selection, Alcon spoke with Dr. Douglas Grayson of Omni Eye Services in Iselin, New Jersey and Dr. Dagny Zhu of NVISION Eye Center in Rowland Heights, California.
Throughout the discussion, both surgeons shared that no matter how often they evaluate their options, they find themselves preferring Clareon® PanOptix® and Clareon® Vivity® IOLs—which are the #1 trifocal and EDOF lenses in the world, with over four million combined implants worldwide.1,2 As a result of these conversations, we have compiled the following key insights for surgeons to consider.
Key Insight #1: Don’t lose sight of patient needs
“The number of IOL options can be overwhelming,” said Dr. Grayson. “As surgeons, it is our job to make sure we are always prioritizing the patient’s needs and vision goals to determine the best lens. Importantly, we need to make a strong recommendation to patients.”
Dr. Zhu agreed, adding, “To ensure patients are achieving outcomes efficiently, and the lenses that are most likely going to deliver exceptional results, I typically stick to recommending presbyopia-correcting IOLs (PCIOLs)—whether it be a bilateral PanOptix® or a mix-and-match of PanOptix® in the non-dominant eye and Vivity® in the dominant eye. This ensures each patient receives a truly premium lens rather than a monofocal lens outcome at the premium price.”3-5
To that end, it’s important to note that adjustable lenses like the Light Adjustable Lens^ (LAL) do not offer true presbyopia correction—and, therefore, cannot be categorized as a PCIOL. These are monofocal toric outcomes, or monovision using a monofocal toric adjustable lens. Monovision can come with visual compromises that impact patients’ daily experiences, including:
- Reduced Stereoacuity: Monovision reduces stereo vision by assigning different focal points to each eye, making three-dimensional vision in fine detail a challenge.6,7
- Impaired Depth Perception: With each eye focused at a different distance, patients may experience difficulties in tasks such as driving or navigating stairs.6,7
I will only do monovision as a last resort,” said Dr. Zhu. “Only if a patient asks for it and has lived with it nearly their whole post-presbyopic life.”
On the other hand, Alcon’s unique PCIOL portfolio helps surgeons offer patients a full range of vision with both diffractive and non-diffractive IOLs.3,4
Patients who receive Clareon® PanOptix® can achieve 20/20 near, intermediate, and distance vision, and 99.2% of them would have the lens implanted again.3 Additionally, the ENLIGHTEN® Optical Technology, only available in PanOptix®, is designed to deliver a full range of vision and exceptional clarity. Thus, giving patients the freedom to enjoy their favorite activities without worrying about vision.3,8
Similarly, Clareon® Vivity® is the first and only non-diffractive wavefront shaping PCIOL with X-WAVE™ technology, providing exceptional clarity, monofocal-quality distance visual acuity, excellent intermediate vision, and functional near vision.4,9,*, †,‡ It was designed to deliver low incidences of visual disturbance, and its X-WAVE™ technology provides a continuous extended focal range.4
A survey showed that nearly 90% of patients obtained satisfactory visual outcomes within a month of PCIOL implantation.10,¶
“I see a lot of working-class patients who aren't working normal hours or are driving a lot at night. I will almost always recommend a bilateral Vivity® for them,” said Dr. Zhu. “I’ve found, out of all my patients, that they can benefit most from the low level of dysphotopsias that Vivity® offers—it's important to remember that this technology can benefit everyone, not just the typical ‘premium’ patient.”
Key Insight #2: Be aware that some IOLs create a heavy burden on the practice
“At my practice, Omni Eye Services, we use Clareon® PanOptix® and Clareon® Vivity® more than any other lenses—especially PanOptix®”, said Dr. Grayson. “There are many reasons for this—low instances of halos, high rates of spectacle independence, the list goes on—but another oft-overlooked reason: it’s the most efficient choice for me, my staff, my practice workflow, and most importantly, my patients.”3,4,11
Dr. Grayson also added that while LAL works well for him in very unique cases, such as post-RK, post-complicated refractive surgery, or abnormal corneas. “It’s very time consuming and utilizes a lot of our resources. It’s not something we used routinely, because it takes months for patients to reach their maximum refractive stability and acuity.”
“With Clareon® Vivity® or Clareon® PanOptix®, patients usually spend less time in the clinic post-op, giving them more time to spend on activities that they love—and giving my team more time to provide care to other patients,” added Dr. Zhu.5,10,12 I always advise my fellow surgeons to consider the time commitment required from each IOL so they can allocate their time to other critical clinic needs, such as meeting with new patients, rather than the burden of multiple post-op adjustments and dilation of patients, and PanOptix® and Vivity® support that.”
Key Insight #3: Don’t wait for the “Wow”
Dr. Zhu shared that with Clareon® PanOptix® and Vivity®, her patients typically don’t require multiple appointments to achieve their desired vision, making it an efficient choice for her practice.10
“Less post-op appointments means that patients can reach their ‘wow moment’—the moment when they realize they are clearly seeing a fuller range of vision—faster,” said Dr. Grayson. “This can make all the difference in patient satisfaction, while also allowing us to move on to new patients more quickly.”
As new technologies emerge, it’s easy to be intrigued by promises of unique or novel outcomes. However, in our current environment of increasing patient demand and volume, workflow efficiencies are key to ensuring that practices can keep up. That’s why Dr. Grayson and Dr. Zhu always recommend PCIOLs, especially Clareon® Vivity® and Clareon® PanOptix®, to their patients who qualify as candidates—ensuring they strike the ideal balance between their patients’ time spent in-clinic and the potentially life-changing outcomes that they can receive.
“Ultimately it comes down to predictability,” said Dr. Grayson. “With PanOptix®, I know I'm going to get fantastic range of vision with minimal dysphotopsias, and I'm going to get it very rapidly.”
IMPORTANT PRODUCT INFORMATION: CLAREON® FAMILY OF IOLS
CAUTION: Federal law restricts these devices to sale by or on the order of a physician.
INDICATION: The family of Clareon® intraocular lenses (IOLs) includes the Clareon® Aspheric Hydrophobic Acrylic and Clareon® Aspheric Toric IOLs, the Clareon® PanOptix® Trifocal Hydrophobic IOL, Clareon® PanOptix® Toric, Clareon® Vivity® Extended Vision Hydrophobic Posterior Chamber IOL and Clareon® Vivity® Toric IOLs. Each of these IOLs is indicated for visual correction of aphakia in adult patients following cataract surgery. In addition, the Clareon® Toric IOLs are indicated to correct pre-existing corneal astigmatism at the time of cataract surgery. The Clareon® PanOptix® lens mitigates the effects of presbyopia by providing improved intermediate and near visual acuity, while maintaining comparable distance visual acuity with a reduced need for eyeglasses, compared to a monofocal IOL. The Clareon® Vivity® lens mitigates the effects of presbyopia by providing an extended depth of focus. Compared to an aspheric monofocal IOL, the lens provides improved intermediate and near visual acuity, while maintaining comparable distance visual acuity. All of these IOLs are intended for placement in the capsular bag.
WARNINGS/PRECAUTIONS:
General cautions for all Clareon® IOLs:
Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting any IOL in a patient with any of the conditions described in the Directions for Use that accompany each IOL. Physicians should target emmetropia, and ensure that IOL centration is achieved.
For the Clareon® Aspheric Toric, PanOptix® Toric and Vivity® Toric IOLs, the lens should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; if necessary lens repositioning should occur as early as possible prior to lens encapsulation.
For the Clareon® PanOptix® IOL, some visual effects may be expected due to the superposition of focused and unfocused multiple images. These may include some perceptions of halos or starbursts, as well as other visual symptoms. As with other multifocal IOLs, there is a possibility that visual symptoms may be significant enough that the patient will request explant of the multifocal IOL. A reduction in contrast sensitivity as compared to a monofocal IOL may be experienced by some patients and may be more prevalent in low lighting conditions. Therefore, patients implanted with multifocal IOLs should exercise caution when driving at night or in poor visibility conditions. Patients should be advised that unexpected outcomes could lead to continued spectacle dependence or the need for secondary surgical intervention (e.g., intraocular lens replacement or repositioning). As with other multifocal IOLs, patients may need glasses when reading small print or looking at small objects. Posterior capsule opacification (PCO), may significantly affect the vision of patients with multifocal IOLs sooner in its progression than patients with monofocal IOLs.
For the Clareon® Vivity® IOL, most patients implanted with the Vivity® IOL are likely to experience significant loss of contrast sensitivity as compared to a monofocal IOL. Therefore, it is essential that prospective patients be fully informed of this risk before giving their consent for implantation of the Clareon® Vivity® IOL. In addition, patients should be warned that they will need to exercise caution when engaging in activities that require good vision in dimly lit environments, such as driving at night or in poor visibility conditions, especially in the presence of oncoming traffic. It is possible to experience very bothersome visual disturbances, significant enough that the patient could request explant of the IOL. In the parent AcrySof® IQ Vivity® IOL clinical study, 1% to 2% of AcrySof® IQ Vivity® IOL patients reported very bothersome starbursts, halos, blurred vision, or dark area visual disturbances; however, no explants were reported.
Prior to surgery, physicians should provide prospective patients with a copy of the Patient Information Brochure available from Alcon informing them of possible risks and benefits associated with these IOLs.
ATTENTION: Reference the Directions for Use labeling for each IOL for a complete listing of indications, warnings and precautions.
^Trademarks are the are the rights of their respective owners
* Defined as modified Miyata grade 0, <25mv/mm2 over 3 years (n=138), and over 9 years (n=20), respectively. PCIOL=Presbyopia Correcting IOL
† Results from a prospective, randomized, parallel group, subject- and assessor-masked, multisite trial of 107 subjects bilaterally implanted with the AcrySof® IQ Vivity® Extended Vision IOL and 113 with the AcrySof® IQ IOL with 6 months follow-up.
‡ Snellen VA was converted from logMAR VA. A Snellen notation of 20/20-2 or better indicates a logMAR VA of 0.04 or better, which means 3 or more of the 5 ETDRS chart letters in the line were identified correctly
¶ Response to the following question on IOLSAT questionnaire (Version 1.0, December 20, 2018) at 6 months post-op “Given your vision today, if you had to do it all over, would you have the same lenses implanted again?”; n=127
References
- Alcon Data on File, 2022.
- MarketScope LLC. 2023 IOL Market Report: Global Analysis for 2022 to 2028. St. Louis, MO: MarketScope LLC; 2023.
- Clareon® PanOptix Directions for Use.
- Clareon® Vivity Directions for Use.
- Light Adjustable Lens (LAL) and Light Delivery Device (LDD) Professional Use Information, RxSight, Inc.
- Xiao J, Jiang C, Zhang M. Pseudophakic monovision is an important surgical approach to being spectacle-free. Indian J Ophthalmol. 2011;59(6):481-485. 5. Burge J, Rodriguez.
- Lopez V, Dorronsoro C. Monovision and the Misperception of Motion. Curr Biol. 2019;29(15):2586-2592.e4.
- Werner L, Thatthamla I, Ong M, et al. Evaluation of clarity characteristics in a new hydrophobic acrylic IOL in comparison to commercially available IOLs. J Cataract Refract Surg. 2019;45(10):1490-1497.
- Maxwell A, Suryakumar R. Long-term effectiveness and safety of a three-piece acrylic hydrophobic intraocular lens modified with hydroxyethyl-methacrylate: an open-label, 3-year follow-up study. Clin Ophthalmol. 2018;12:2031-2037.
- Alcon data on file, 2023.
- Zhu D, Ren S, Mills K, Hull J, Dhariwal M. Rate of Complete Spectacle Independence with a Trifocal intraocular lens: A systematic literature review and meta-analysis. Ophthalmol Ther. 2023 Apr;12(2):1157-1171. doi: 10.1007/s40123-023-00657-5. Epub 2023 Feb 6. PMID: 36745314; PMCID: PMC10011212.
- Zhou A, Liang E. A Retrospective Single-Practice, Single-Surgeon, Multi-Provider Study on the Performance of the Second-Generation Light-Adjustable Lenses. Poster presented at: ASCRS 2023; March 5-8; San Diego, CA.
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