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Cataract Surgery: Choosing a Premium Lens (IOL)

Aging is not for the faint of heart, as my mirror likes to remind me. And it can be particularly tough on your vision. 

Cataracts and presbyopia are two conditions that reduce eye function as we age. Up until about 15 years ago, they had to be addressed separately - cataracts with surgery, presbyopia with glasses or contacts. If a patient wore glasses to correct for near- or far-sightedness before cataract surgery, they’d continue to wear them afterwards. 

Thanks to impressive advances in lens implant technologies, however, cataract surgery can now address both problems with one procedure. Specialty intraocular lens (IOL) implants can now correct for presbyopia and other refractive conditions like myopia and hyperopia. More and more, patients can live life free of glasses.

A cataract is an ocular condition where the lens inside the eye has become cloudy and hardened over time, allowing less and less light to enter the eye. Slowly but surely the world looks dimmer and blurrier. Daily activities become increasingly difficult. 

During cataract surgery, this clouded lens is removed and replaced with a new artificial lens to improve visual function. It’s similar to implanting a contact lens inside your eye.  

Presbyopia is a different issue related to normal aging. The lens inside a youthful eye is springy and flexible, easily adjusting its shape when we shift our gaze from a far object to a near object. As we reach our forties, however, the lens hardens somewhat, losing this flexibility, and can no longer shift into focus for near objects. Presbyopia is the name for this loss of smooth transitioning. 

When you decide to have cataract surgery, you need to choose which type of IOL will be implanted in your eye – and whether you want a high-performance implant that can reduce or eliminate your need for glasses.

No single IOL is best for everyone. To choose the right one for you, we evaluate four key factors:

Reviewing these factors will help us decide on a standard monofocal lens, or a premium presbyopia-correcting lens, of which there are several types.

Standard monofocal lens implants correct for one vision range only, near or far – patients will need glasses for the range not chosen. Presbyopia-correcting lens implants can correct for distance, intermediate, and/or near ranges. Currently, the  three leading lens technologies are multifocal (e.g., the Panoptix Trifocal Intraocular lens), extended depth-of-focus (the Symphony EDOF lens), and accommodative (the Crystalens Accommodative lens). If you have astigmatism, you’d require a special toric version of one of these lenses.

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THE DEEPER DIVE

· IOL categories: Single vision vs. Presbyopia-correcting

· Four Factors in Choosing a Lens

· High-performance IOLs: Panoptix, Symphony, Crystalens, and Toric

 

IOL Categories: single vision vs. presbyopia-correcting

As described above, presbyopia causes a loss of lens flexibility and a resulting inability to shift our visual focus from, say, the tv across the room to a book on our lap. 

A standard monofocal IOL is designed to provide the best possible vision without glasses at one of those distances– the tv or the book. Most monofocal lens patients opt for glasses-free distance vision, understanding that they’ll still need glasses to see up close after surgery. Should you have astigmatism, you’ll likely require glasses for both distance and near.

By contrast, specialized presbyopia-correcting IOLs enable the patient to see clearly at multiple distances: far (driving, watching television), mid-range (computer, tablet), and/or close up (reading). They can also correct for astigmatism.

Four Factors in Choosing a Lens

No single lens is best for everyone. There are multiple presbyopia-correcting IOL technologies, and they have significant differences. To choose the right one, you need to consider four important factors: 

1. Desired range of vision. When selecting which IOL meets your needs, I discuss with patients their goal for which ranges of vision they want to maximize: far distance, mid-range, and/or close up vision. We discuss possibilities for eliminating the need for glasses.

Think about the lifestyle activities that are most important to you. Are you an avid surfer, birdwatcher, theater lover? These activities rely upon the ability to see clearly from afar, so distance vision is important to you. Does your work require spending hours in front of a computer or tablet each day?  This means that enhanced mid-range vision is a priority. Are you a tattoo artist, voracious reader, jewelry maker?  If so, you need to see clearly close up and you’ll want to maximize your near-range vision.

2. Is astigmatism a factor? Astigmatism is an ophthalmic condition in which the cornea is somewhat oval-shaped rather than round. Astigmatism requires a specific type of IOL called a toric lens in order to see clearly without glasses or contact lenses after surgery.  

If you have astigmatism, a monofocal toric lens will correct for one vision range only – you can choose near or far, but you’ll still need glasses for the other range.

Conversely, a presbyopia toric lens can correct for both near and far vision, enabling you to see both ranges clearly without glasses. It will also correct for your astigmatism. All the presbyopia-correcting specialty lenses described below are available in toric versions.

3. Consider cost. Monofocal (single-focus) lenses come standard with cataract surgery - they are covered by insurance.

Toric, multifocal and accommodative lenses, on the other hand, are high-performance upgrades. Most insurance companies will not cover the cost of a specialty lens. However, it’s worth considering that a pair of prescription glasses can cost anywhere from $300 to $1000. A multifocal implant costs more up front, but may be more cost-effective over time – they are designed to last for the rest of your life.

4. Do I have any ocular diseases? Some lenses may be contraindicated if you have certain ocular conditions, such as diabetic retinopathy or macular degeneration. This is something we would discuss thoroughly preoperatively and account for in your plan. 

High-performance IOLs

At time of writing, the three leading presbyopia-correcting lenses are:

- Panoptix Trifocal Intraocular Lens (Alcon)

- Symphony Extended Depth-of-Focus Lens (Johnson & Johnson)

- Crystalens Accommodative lens (Bausch & Lomb)

In 2019, the FDA approved Alcon’s Panoptix Trifocal Intraocular Lens, which provides clear vision at all three visual ranges: distance, middle, and close-up. This represents a pretty astonishing technological advancement. Patients who opt for this lens usually enjoy full independence from glasses post-surgery, though they may need a slightly brighter light when reading at night. Occasionally, a patient may require glasses for reading very small print. Some patients have reported seeing a small amount of glare or haloing around nighttime lights; most patients become accustomed to this shortly after surgery and tolerate the lens very well. 

The Panoptix Trifocal can also correct for astigmatism. Note that in certain eye diseases like macular degeneration, these lenses are contraindicated.

Johnson & Johnson’s Symphony Lens is another multifocal technology, extended depth of focus (EDOF), that works very nicely. It provides excellent field of vision in the far-distance (e.g. watching television, driving) and intermediate (computers, tablets) ranges. As with the Panoptix IOL, patients occasionally report a certain amount of glare or haloing around lights at night, with most patients becoming accustomed to this shortly after surgery and tolerating the lens very well. Patients who opt for this lens occasionally need glasses for reading up close. A Symphony toric lens can also correct for astigmatism. Contraindications for this lens are similar to those of the Panoptix lens.

Bausch & Lomb’s CrystaLens represents a third type of lens technology, called an accommodative intraocular lens, which allows you to see distance and intermediate (computer/tablet) range. Patients who opt for this lens may require glasses for reading closer objects, as it offers a more narrow range of near vision. However, for certain eye diseases such as macular degeneration, the Crystalens can sometimes be a better option than other multifocal lenses. Crystalens implants are also free of any haloing or glare effects.

All three specialty IOLs – the Panoptix, Symphony, and Crystalens – are available in toric versions.

In sum, cataract surgery provides impressive bang for the surgical buck. When successful, it is quick, involves almost no down time, and improves a patient’s quality of life dramatically. Communicating successfully with your eye doctor, understanding your options and medical condition, and setting strategic goals are the keys to a great outcome.

Author
Eduardo Besser, MD Eduardo Besser, MD is an eye doctor and surgeon specializing in cataract and refractive surgery. He practices comprehensive ophthalmology in Culver City.

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