Prediction No. 1: Laser-assisted cataract surgery (LACS). Surgeons are interested in using LACS technology because it offers a step forward in the control of some stages of cataract surgery, especially the capsulorrhexis. However, current pricing levels and the lack of consistent evidence of the clinical advantages for cataract patients are an impediment to widespread adoption of this technology. Prices should begin to come down this year, given two factors: (1) The market is unable to sustain the current expense levels, and (2) a number of studies, including those by the European Society of Cataract and Refractive Surgeons (ESCRS)1 and a French group (personal communication, Beatrice Cochener, MD, PhD) as well as our own,2 have demonstrated that there is no clear benefit in the use of this technology versus manual phacoemulsification. Once prices come down, cost-benefit ratios should improve and cost-effectiveness should favor the surgeon and the patient.
My prediction is that no further improvements in LACS technology will be seen except regarding the financial aspect. However, the lasers’ manufacturers will make their performance more complete by adding corneal capabilities. Instruments such as the Victus (Technolas Perfect Vision) and Femto LDV Z8 (Ziemer Ophthalmic Systems) are currently able to perform corneal and cataract surgery. This will allow the surgeon to avoid duplicated technology and extra maintenance costs. Indeed, these machines should be the best positioned in the market, as practical cataract surgeons cannot afford to have one laser for cornea and another for cataract surgery unless they work in a large institution with a large budget.
Prediction No. 2: IOL technologies. Trifocal IOLs, as I previously predicted, have been successful in 2014. This will continue in 2015 with the incorporation of new technologies such as the Tecnis Symfony (Abbott Medical Optics) with its echelette design providing extended range of vision. These technologies will make further advances once adequate customization of the IOL asphericity with the patient’s corneal asphericity value can be accomplished, as even further improvement in quality of vision can be achieved.
Prediction No. 3: Accommodating IOLs. At this time, there is renewed interest in these technologies. The Lumina IOL (Akkolens; Figure 1) is being evaluated in studies performed by my colleagues and me in Sofia, Bulgaria and Alicante, Spain. Other lenses such as the FluidVision (PowerVision), with its microfluidic technology, are making progress in clinical studies, but the outcomes are not clear in the few reports that have been made.3 The Lumina is promising because real accommodation has been demonstrated, as I have reported at several meetings, based on both objective and subjective data obtained in clinical study.4,5
Prediction No. 4: Refractive surgery. Intrastromal small incision lenticule extraction (ReLEx SMILE) will become more prevalent in 2015. The advantage of this approach is clear: Only one device, a femtosecond laser, is needed for refractive surgery. The technique will be more widely adopted once treatment of hyperopia can be accomplished, and these efforts seem to be progressing. The outcomes of SMILE and excimer laser procedures are probably similar for low to intermediate myopia, but several advantages of SMILE for high myopia have been demonstrated, including lack of induction of higher-order aberrations, possibly less biomechanical impact, and fewer dry eye problems. Ongoing clinical studies will further advance this corneal refractive surgical approach.
Corneal inlays will, in my opinion, lose importance in the future presbyopia correction market. No clear advantage has been found for these implants, as indications are limited and they show no clear advantage over monovision. Expectations that arose with the introduction of corneal inlays have not been fulfilled; this is because the complications, which have been under-reported, have limited the use of these devices and problems such as centration and changes in corneal topography remain unsolved. Little progress is expected until these relevant problems are solved.
Concerning phakic IOLs, the withdrawl of the AcrySof Cachet by Alcon will have a negative effect on options for surgical correction of high myopia. Alternatives will include posterior chamber IOLs such as the Carevision lens (IPCL Care Group) and irisfixated foldable IOLs such as the Artiflex (Ophtec). The Carevision lens, made of acrylic material, offers a large power range for hyperopia correction as well as a diffractive optic for presbyopia correction. Presbyopic multifocal optics in phakic platforms have great potential and deserve further investigation, as they provide a less aggressive alternative for the solution of presbyopia than refractive lens exchange.
Prediction No. 5: Corneal collagen crosslinking (CXL). Protocols for epithelium (epi)-on CXL will finally be available for use based on evidence. To date, epi-on procedures have been a standard of care for most surgeons. The only CXL protocol with published evidence is the Dresden protocol. Others, basically those using epi-on techniques, have been misleading in most cases.
Methods to bypass the epithelium without removing it will be employed. The concomitant use of excimer laser for refractive keratectomy, whether or not guided by topography, will be used to treat keratoconus. Keratoconus is a rare disease, but this option has become popular. The use of intrastromal corneal ring segments in conjunction with CXL will be further developed with introduction of new models.
The use of CXL for treatment of corneal infections will become more general, as the coadjuvant effect of this technology is becoming clear and its applications more evident. CXL will not replace antibiotics but rather will be used in patients unresponsive to therapy, in those in whom antibiotic or antifungal agents have not been completely effective, and in cases in which complications such as corneal melting occur.
Prediction No. 6: Presbyopia correction. Phakic IOLs will be on trial for correction of presbyopia and will probably provide options. We published the first paper on a successful phakic IOL with a presbyopic optic some time ago.6 These studies were not accompanied by interest from the industry, but now the company IPCL Care Group, with the IPCL phakic lens, is developing a diffractive presbyopic optic, which in my opinion will be another option for the correction of presbyopia.
Although companies that manufacture intrastromal corneal inlays have been tremendously active in their promotion, these devices have not become popular due to under-reported complications occurring in some patients, including changes in corneal topography, problems with centration, and issues with biotolerance and opacities.
At this time I do not foresee a solution for presbyopia in the cornea
Presbyopic LASIK (presby-LASIK) approaches are showing promise when associated with a micro-monovision strategy. Presby-LASIK approaches that incorporate changes in asphericity with some multifocality and some monovision have shown success with little risk of visual loss. These approaches will increase in popularity during 2015.
Although 2014 was another good year for ophthalmology, 2015 looks to be bright. Some exciting technologies are on the horizon, and other existing ones are sure to get a facelift.
Jorge L. Alió, MD, PhD, is a Professor and the Chairman of Ophthalmology at the Miguel Hernandez University, Alicante, Spain, and the Medical Director of VissumCorporación in Spain. Dr. Alió states that he is a consultant to and clinical investigator for the Elenza, Nulens, and Akkolens projects. He may be reached at tel: +34 96 515 00 25; e-mail: firstname.lastname@example.org.
- Barry P. ESCRS/EUREQUO FLACS study. Paper presented at: the XXXII Congress of the European Society of Cataract & Refractive Surgeons; September 14, 2014; London.
- Alió JL, Abdou AA, Puente AA, Zato MA, Nagy Z. Femtosecond laser cataract surgery: updates on technologies and outcomes. J Refract Surg. 2014;30(6):420-427.
- Roux P. Accommodative capacity of a novel fluid-filled hydrophobic acrylic accommodative intraocular lens. Paper presented at: The XXXII Congress of the ESCRS; September 13-17, 2014; London.
- Alió JL. Accommodation amplitude and visual acuity of the accommodative intraocular lens, the AkkoLens Lumina. Paper presented at: The XXXII Congress of the ESCRS; September 13-17, 2014; London.
- Alio JL, Ben-Nun J. Study of the force dynamics at the capsular interface related to a ciliary body stimulation in a primate model. [In press.]
- Alió JL, Mulet ME. Presbyopia correction with an anterior chamber phakic multifocal intraocular lens. Ophthalmology. 2005;112(8):1368-1374.