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    Cataract & Refractive (page 2)

    1, 2, 3, 4, 5, 6, 7

    The rise of the multifocals
    The multifocal lenses have also been hailed as one of the most outstanding developments in the field of cataract and refractive surgery this year. In the past, surgeons only had one multifocal lens at their disposal. Now, they have a choice; not only can they provide a solution that matches the professional needs of the patient but they can also take their hobbies and interests into account.

    "The arrival of the new generation of multifocal IOLs has meant that we can guarantee our patients good near and far vision, whilst preserving vision quality. In fact, these lenses seem to have resolved the problem of loss of contrast sensitivity in scotopic conditions and the other symptoms of dysphotopsia that were apparent with the first generation of lenses," said Alessandro Franchini, MD.

    The multifocal lenses have undeniably changed the practice of cataract surgery. It seems, however, that they are either in the end stages of development or are commercially available, which means that we have probably seen all that this class of lenses has to offer. Nevertheless, they are still not without their limitations. Surgeons are constantly urged to select patients very carefully for multifocal IOL implantation and to then manage the expectations of that patient in order to increase the chances of a successful implantation.

    "I began mixing and matching multifocal
    lenses this year and have seen
    good results. This was very
    surprising to me because I had many
    doubts at the beginning.
    Unexpectedly my patients feel good,
    really good."

    While refractive multifocal lenses are proven to provide good intermediate vision, excellent distance vision and 100% light transmission, they fail to provide good near vision. Meanwhile diffractive multifocal lenses offer excellent near vision, very good distance vision but not so good intermediate vision.

    It has, therefore, been hypothesized that the combination of the advantages of these two multifocal IOL technologies would allow surgeons to fully meet patients' needs, in terms of near, intermediate and distance vision under different light conditions. According to researchers, the processing of two different types of images is completely accepted by the patient and the brain, hence the mix and match concept (whereby a refractive IOL is implanted in the dominant eye and a diffractive multifocal IOL in the non-dominant eye) has been accepted by some surgeons as a feasible treatment modality.

    "This year I performed my first mix and match case and, in my opinion, it is the best option that we have available to us today that helps us resolve the problems linked to the loss of accommodation in pseudophakic eyes. I do, however, believe that we are still waiting for the best solution to come along," conceded Dr Franchini. "Using these lenses has forced me to make a few changes to my surgical technique; I pay more attention to the tunnel construction and location in order to avoid inducing astigmatism, and I perform a smaller capsulorhexis to avoid any anterior lens postoperative movements," added Dr Franchini.


    "I began mixing and matching multifocal lenses this year and have seen good results. This was very surprising to me because I had many doubts at the beginning. Unexpectedly my patients feel good, really good," remarked Carlos Vergés, MD, PhD.

    Christoph Faschinger, MD on the other hand, is not convinced by the multifocal lenses and instead argues that surgeons do not know exactly how the patient, particularly the older patient, will adapt to the lenses. "Nobody knows how the capsular bag reacts when healing/sealing, moving forward or backward and changing refraction. If these lenses are so perfect, why does the community of cataract surgeons not implant them in the majority of patients?" questioned Dr Faschinger.

    Although all experts agreed that multifocal IOLs have come a long way, they admitted that their popularity would be somewhat short-lived. In short, everybody is waiting with baited breath to see if the new generation of accommodating lenses can render many other IOLs obsolete.

    Accommodating lenses could render all others obsolete
    "I don't expect any further improvements to be made to multifocal lens design because, basically, everything that can be offered in terms of design and optics, is already available. Meanwhile, development of accommodating lenses continues and I sincerely believe that implantation of these lenses will become common practice in the next five years, completely replacing multifocal IOLs," predicted Dr Alió.

    No one can argue that, although multifocal lenses effectively provide a wide range of vision, nothing is better than restoring true accommodation. Although the current generation of dual optic accommodating IOLs is better than its predecessors, Dr Alió believes that they have yet to make their mark and further development is still necessary before they achieve market dominance. "In my opinion, implantation of the current models of dual optic accommodating IOLs is cumbersome and these lenses, in some cases, simply provide similar accommodation to the partial accommodating IOLs. Variability is an issue in all of today's available accommodative lenses, either simple or dual optics. I remain to be convinced," he said.

    "Variability is an issue in all of
    today's available accommodative
    lenses, either simple or dual optics.
    I remain to be convinced."

    Professor Dick disagrees. He feels that the latest generation dual-optic Synchrony lens (Visiogen), which is undergoing FDA and European trials, has demonstrated superb long-term results so far. "I didn't honestly expect this because I feared lenticular opacifications between the two lenses, which would then be tricky to treat, but this was not the case," he said.

    According to Professor Dick, although the two lenses are made from silicone and although a little fibrosis is notable around the capsulorhexis rim after long-term implantation, the capsules are "crisp and crystal clear", even after three years. "Our mean accommodative amplitude after three years now with this lens is 1.8 and, with regards to side effects, none of these eyes required a YAG capsulotomy after three years," he confirmed. According to Professor Dick, this lens presents a viable option for refractive and presbyopia correction.

    In addition, Dr Kuchynka admits that he has been surprised by the accommodating IOL Tetraflex (Lenstec) and claims that this is one of the exciting new technologies for presbyopia correction.

    In contrast, Dr Faschinger referred to a recent study published by Oliver Findl, MD and Christina Leydolt, MD, in which three types of accommodating IOLs were compared following a meta-analysis of peer reviewed studies: 1CU (HumanOptics), BioComFold (Morcher), and AT-45 Crystalens (eyeonics).1 Overall, Findl and Leydolt found that improvements in near visual acuity were moderate or non-existent in accommodating IOL-implanted eyes compared with controls and they felt that more evidence-based medicine was required to prove the benefit of accommodating focus-shift IOLs.

    "We ourselves took histological sections of ciliary bodies from different age groups and found marked differences: there are wonderful muscles in young and few in elderly people but there is a significantly greater amount of connective tissue in old people, so it's not the lens alone that ages. How then can an 'accommodative' IOL work when the ciliary body is weak or not functioning anymore?" argues Dr Faschinger.

    Although the excitement surrounding innovations in accommodating IOLs is not resonated by everyone, one thing is certain: if a lens is developed that can safely and effectively restore accommodation in presbyopic patients, cataract surgery will witness one of the biggest breakthroughs of this century.

    Aspheric lenses failed to win the hearts of surgeons
    Aside from the toric, multifocal and accommodating lenses, the impact made by the aspheric lenses has been less than spectacular this year. Because they are not customized to an individual's asphericity, some question whether a small gain in contrast sensitivity translates into a real improvement in quality of life for elderly patients. "I would not consider them as premium lenses, although some surgeons might think that they deserve this title. Rather I would consider them as standard lenses," admits Dr Alió. "Admittedly, aberration-correcting lenses have been important this year, particularly in cataract patients who have previously received corneal refractive surgery. These lenses have been effective in compensating for the positive aberrations of the cornea," added Dr Alió.

    "How than can an 'accommodative'
    IOL work when the ciliary body
    is weak or not functioning anymore"

    Although the aspheric IOLs have failed to excite as many surgeons as their manufacturers had hoped, nothing can compare with the disappointment felt by the developers of the angle-fixated phakic IOLs. Specifically, the Vivarte/GBR (Ioltech) and ICARE (Corneal Laborotaries) lenses, which have now been withdrawn from the market because of safety concerns pertaining to endothelial cell loss.

    "The angle-fixated phakic IOLs have been very disappointing. To me, their withdrawal from market was a horror story," said Professor Dick. "First, they rose like a star. Everyone was happy and started implanting the lenses. Then, just three years on, the star disappeared. Despite the manufacturers' attempts to improve lens material and design, the lenses were removed from the market because of poor endothelial cell results and keratoplasties. This was a disaster for the patient and for the doctor," noted Professor Dick.

    Notwithstanding the highs and lows experienced by the IOL industry this year, exciting developments are on the horizon. Research and development is moving in the right direction and it is hoped that, in time, one clear winner will emerge in the race to develop the perfect IOL type.

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    Jorge L. Alio, MD, PhD

    Jorge L. Alió, MD, PhD is Professor & Chairman of Ophthalmology and the Medical Director of VISSUM, Instituto Oftalmologico de ...

    Carlos Verges, MD, PhD
    Carlos Vergés, MD, PhD is Professor and Head of the Department of Ophthalmology at C.I.M.A. Universidad Politécnica de Cataluña, ...
    Professor Alessandro Franchini
    Alessandro Franchini, MD works in the Optical Physiopathological Department at the University of Florence, Eye Institute - Azienda ...
    Pavel Kuchynka, MD

    Pavel Kuchynka, MD is Professor of Ophthalmology at the Vinohardy Teaching Hospital, Prague, Czech Republic. He may be reached by ...

    Professor H. Burkhard Dick, MD, PhD

    Professor H. Burkhard Dick, MD is Chairman of the University Eye Hospital Bochum, Bochum, Germany. He may be reached by E-mail: ...

    Christoph Faschinger, MD

    Christoph Faschinger, MD is a Clinical Professor at the Medical University of Graz, Clinic of Ophthalmology, Graz, Austria. He may be ...

    Fedra Pavlou
    Fedra Pavlou is the Editor-in-Chief of Ophthalmology Times Europe. She may be reached by Tel: +44 (0)1244 393 420 or E-mail:

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