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Today's Practice | Jan 2013

Update on the Premium IOL Markets in the United States and Asia

Surgeons divulge their current preferences and reveal what lenses are on their wish lists.

The IOL markets in the United States and Asia differ drastically from the IOL market in Europe, especially with regard to premium IOLs. For example, many US surgeons express interest in various multifocal and toric multifocal lens designs that are not available in their country due to the US Food and Drug Administration (FDA) approval process. To provide readers with an update on premium IOL availability and use in these markets, CRST Europe invited surgeons practicing in either the United States or Asia to comment on their current preferences and reveal which premium IOLs are on their wish lists. We asked surgeons from these outside markets two questions:

Question No. 1: What are your current preferences for premium IOLs? Describe the frequency with which you implant premium IOLs, your patient-selection criteria, and any advice you have for surgeons just beginning to implant premium IOLs.

Question No. 2: What premium IOLs that are not currently available in your country do you wish you had access to?


Hong Kong
Response to Question No. 1: In our practice, 70% of patients presenting for cataract surgery or refractive lens exchange select a premium IOL. Among the premium lenses we offer are the Tecnis Multifocal (Abbott Medical Optics Inc.) for 80% of our multifocal patients; the AT LISA bifocal toric (Carl Zeiss Meditec), which is very good for high myopes; the AcrySof IQ ReStor (Alcon Laboratories, Inc.); the FineVison trifocal (PhysIOL); and the Lentis Mplus (Oculentis GmbH). We also offer two piggyback IOLs, the Sulcoflex (Rayner Intraocular Lenses, Ltd.) and the Add-On (HumanOptics AG). My early results with these two lenses are very encouraging.

My advice for surgeons just beginning with premium IOLs is:

  • Familiarize yourself with the monofocal version of the IOL first, such as the Tecnis ZCB00 for the Tecnis ZMB00 or the Micro AY for the FineVision;
  • Make sure the continuous curvilinear capsulorrhexis is round and well centered;
  • Use the IOLMaster (Carl Zeiss Meditec) or immersion biometry;
  • Develop a good nomogram for astigmatism control;
  • Spend a lot of chair time with your patients, making sure that their expectations are in line with the likely results; and
  • Take a good look at the fovea to make sure there is no disease and avoid patients with very dry eyes.

Response to Question No. 2: I am looking forward to using the Tecnis Multifocal Toric 1-Piece ZMT and the AT LISA trifocal IOLs.

John S.M. Chang, MD, is Director of the GHC Refractive Surgery Centre, the Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong. Dr. Chang is a member of the CRST Europe Global Advisory Board. He states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +852 2835 8885; fax: +852 2835 8887; e-mail: johnchang@hksh.com.


Colorado Springs, Colorado
Response to Question No. 1: For surgeons preparing to implant their first premium IOLs, I recommend defining a patient’s visual goals and working your way backward from there. The first question to ask a patient is whether he or she minds wearing glasses to see both distance and near. If the answer is yes, ask whether he or she minds wearing glasses for reading. If the answer is no, this does not mean you should stop working toward spectacle independence; it means you should stop trying to sell the patient spectacle independence.

It is paramount to understand where a patient was—for instance 5 years ago—and where he or she is now with regard to BCVA and UCVA. Asking a patient what he or she does with vision (eg, vocations, activities, hobbies) is an absolute necessity. Thinking that visual acuity through a multifocal IOL will equal the binocular vision of a -3.50 D myope for detailed sewing several hours a day will only yield a dissatisfied patient. Alternatively, anything done to relieve a patient with 3.00 D of cylinder will be a tremendous success. Notably, if a patient is particularly close to retirement age, do not let him or her make choices based on occupation, especially if that occupation will have nothing to do with life in retirement.

I prefer patients who tell me what they want and expect from their vision after cataract surgery to those who have already researched specific lens designs and functions before the initial visit. It is easier to discuss the appropriate choices to meet a patient’s goals than it is to discuss the pros and cons of every available option that he or she has researched on the Internet. Additionally, a patient who has done too much research can get caught up in the word premium, expecting that such a lens will inherently provide the best level of vision. When I encounter this type of patient, I typically tell him or her that it may not take an expensive lens to achieve premium vision.

The next key factor in patient satisfaction is surgical execution. Cutting corners or taking shortcuts during a procedure increases the likelihood of a compromised result. The premium IOL patient has high expectations, and surgery may be deemed a failure due to something as simple as delayed visual recovery or an induced refractive change from a tear in the capsulorrhexis.

Finally, as my associate is fond of reminding me, once you have operated on these patients, they are yours. The best successes in this arena are garnered by conscientious follow-up with attention to detail. Listening to a patient report the successes and failures of your original plan is the only way to build the knowledge base of a quality practice.

In my practice, the road to good outcomes has multiple paths. Although the premium IOL component is crucial to delivering impressive results such as spectacle independence, it is not the only option. For instance, toric IOLs compete with limbal relaxing incisions, and multifocal IOLs are compared with monovision. The ultimate goal is patient satisfaction.

I use premium IOLs in approximately 5% of cases, for which the majority is the AcrySof IQ Toric (Alcon Laboratories, Inc.) in higher cylinder powers. I counsel the patient that this correction of astigmatism is more reliable than incisional correction and that I have found results to be highly consistent. The next most commonly selected premium IOL in my practice is the Tecnis Multifocal 1-Piece.

Response to Question No. 2: Regarding IOLs not available in the United States, the most intriguing to me is the Sulcoflex. The design of this IOL allows placement in the sulcus of a pseudophakic pseudophakic patient to correct residual spherical or cylindrical refractive error. Additionally, a toric multifocal version is available. The number of patients who could benefit from this technology in the United States is tremendous.

Steven Dewey, MD, is in private practice with Colorado Springs Health Partners in Colorado Springs, Colorado. Dr. Dewey did not provide financial disclosure information. He may be reached at tel: +1 719 475 7700; e-mail: sdewey@cshp.net.


Lake Villa, Illinois
Response to Question No. 1: Compared with Europe and Asia, surgeons in the United States are more limited in premium IOL options. My preferred toric IOL is the AcrySof IQ Toric, due to its broadest range of astigmatism correction (0.75–4.50 D) and rotational stability. I have started using the Optiwave Refractive Analysis System (ORA; WaveTec Vision) intraoperatively, which has improved my toric IOL outcomes due to realtime rotational adjustments in the operating room. As with any toric IOL, even a small 4º misalignment will cause a 14% reduction of astigmatism correction; a 10º misalignment will cause a 34% reduction. The ORA has helped me reduce misalignment errors and improve visual outcomes with toric IOLs.

As for presbyopia-correcting IOLs, my preferences are the Crystalens AO (Bausch + Lomb), especially in post- LASIK or postradial keratotomy patients, to minimize additional aberrations, and the Tecnis Multifocal, especially in patients with demanding near visual tasks. I have found the Tecnis Multifocal to perform the best in low light conditions for near vision tasks. My average premium IOL capture rate is 40% for both toric and presbyopia-correcting IOLs.

Response to Question No. 2: I look forward to having the Crystalens Toric and the Tecnis One-Piece Multifocal Toric IOLs available in the United States. The Conformité Européene (CE)-approved enVista Toric IOL (Bausch + Lomb) will be my go-to toric IOL once it gains FDA approval.

Mitchell A. Jackson, MD, is the Founder and Director of Jacksoneye in Lake Villa, Illinois. Dr. Jackson states that he is a member of the speakers’ bureau for Abbott Medical Optics Inc., Bausch + Lomb, and Alcon Laboratories, Inc. He may be reached at tel: +1 847 356 0700; e-mail: mjlaserdoc@msn.com.


Eugene, Oregon
Response to Question No. 1: I prefer the Tecnis Multifocal IOL for patients who desire spectacle freedom and who do not mind the idea of seeing halos around lights. In 2012, 26% of my patients opted for premium IOLs. Of those, 77% received the Tecnis Multifocal IOL, 13% received the Crystalens AO, and 10% received the AcrySof IQ Toric IOL. I generally turn to the Crystalens for patients who are averse to halos and who do not mind wearing a thin pair of reading glasses as needed. I also use the Crystalens in eyes that have had previous keratorefractive surgery, especially radial keratotomy.

For surgeons who are just starting with premium IOLs—in particular multifocal IOLs—patients with presbyopia, moderate to high hyperopia, and cataracts are the most forgiving population with the highest chance of postoperative happiness. Patients with mild myopia and presbyopia can be difficult to please because their near vision without glasses is already so good. Be honest about the optical side effects; for instance, 40% of patients with the Tecnis Multifocal see halos at 6 months. Additionally, never perform Nd:YAG capsulotomy until you are absolutely sure the dysphotopsia symptoms are not from the IOL. If symptoms have persisted since the time of surgery, chances are it is the lens and not the capsule.

Response to Question No. 2: The Tecnis Toric Multifocal would quickly become my lens of choice if it were available in the United States. I also miss having access to the Synchrony dual-optic accommodating IOL (Abbott Medical Optics Inc.). I served as a principal investigator in the US study and have many happy patients. I am discouraged that it did not win approval.

Mark Packer, MD, FACS, CPI, is a Clinical Associate Professor at the Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, and President of Mark Packer MD Consulting. Dr. Packer states that he is a consultant to Abbott Medical Optics Inc. and Bausch + Lomb. He may be reached at e-mail: mark@markpackerconsulting.com.


Greensboro, North Carolina
Response to Question No. 1: I currently use the AcrySof IQ ReStor +3.0 multifocal and the AcrySof IQ Toric IOLs. I used to offer all of the available premium lens options to patients; however, I found myself spending more time than I wanted talking about technologies. I now discuss the AcrySof IQ ReStor +3.0 for a premium reading option. For the treatment of astigmatism, I discuss laser relaxing incisions with the LenSx Laser System (Alcon Laboratories, Inc.; Figure 1) for correction of less than 1.00 D and the AcrySof IQ Toric lens for more than 1.00 D of astigmatism. Although there are exceptions when I use other lens platforms, I stick to these three discussions for the overwhelming majority of patients.

I have a premium-oriented practice, and more than 50% of patients choose one of the previously mentioned options. These patients also receive treatment with the femtosecond laser. If a patient has at least 0.75 D of astigmatism, I discuss laser astigmatic relaxing incisions or an AcrySof IQ Toric IOL. I implant a multifocal lens only in patients with a normal optical system; patients with retinal disease, ocular surface disease, or unrealistic expectations are better suited for a monofocal IOL.

My preoperative protocol for every patient includes a work-up for ocular surface disease, a retinal exam including funduscopy, and optical coherence tomography. This approach has made my premium practice successful and profitable without adding to my frustrations in the normal day-to-day practice.

Response to Question No. 2: I think the most exciting platform on the drawing board is the Elenza Sapphire Autofocal IOL (Elenza, Inc.). This option would bring to us true accommodation on a scale that has the potential to supply an experience similar to the crystalline lens.

I would also love to have the Sulcoflex as an enhancement option for the large population of patients we already have treated in our practice. Internal marketing would allow us to offer this premium option to patients who have already trusted us for their cataract surgery.

Finally, on a realistic scale, I would love to have a multifocal toric option become available in a variety of platforms so that we could expand the options for our current premium population. As innovation occurs, so too will our lens options increase, and I am excited about the possibility of an injectable lens for replacement of the natural crystalline lens.

Karl G. Stonecipher, MD, is Director of Refractive Surgery at The Laser Center in Greensboro, North Carolina. Dr. Stonecipher is a member of the CRST Europe Global Advisory Board and states that he is a consultant to Alcon Laboratories, Inc., Allergan, Inc., Bausch + Lomb, and Nidek and serves on the medical board for LenSx. He may be reached at tel: +1 336 288 8823; e-mail: stonenc@aol.com.

Jan 2013