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Small-Aperture Premium IOLs

The growing number of premium IOL options available to surgeons offers both opportunities and challenges, according to Karl Stonecipher, MD. More options means better customization for patients, but it also equates to potentially more confusion when making a lens recommendation, Dr. Stonecipher told host I. Paul Singh, MD, in an episode of Innovation Journal Club. The two physicians discussed the perennial challenge of finding the most suitable IOL for each patient’s needs amidst the plethora of options available. Dr. Stonecipher said a good number of patients come to him for a lens recommendation that will offer glasses-free reading vision. Most of these patients, he said, have had a prior procedure.

“We are all trying to figure out an IOL that works for these patients,” Dr. Stonecipher explained to Dr. Singh. “We don’t want to create dysphotopsias.”

One recently available option—and one that may have broader applications than currently appreciated—is the small-aperture IC-8 IOL (Apthera; AcuFocus). These lenses work on the same pinhole-effect principle as the small apertures used in camera lenses and telescopes. By blocking peripheral, defocused light, they alter the eye’s depth of focus and depth of field at all ranges, something not possible with monofocal IOLs. And although these lenses are meant to be paired with a monofocal or monofocal toric IOL in the contralateral eye, Dr. Stonecipher has tried them bilaterally in certain patients.

Dr. Stonecipher described a study in his clinic in which the small-aperture lens was used with patients with complex corneas: those who have undergone LASIK or other refractive procedures; those affected by keratoconus; and more. (unpublished data). He first implanted one in the patient’s worst-seeing eye, and then he offered the option of having it implanted in their second eye. “Everyone really surprised me. Everyone chose to have the small aperture optics in the second eye." While he isn’t advocating that bilateral implantation of small-aperture IOLs is broadly applicable to many patients, Dr. Stonecipher does see a niche for them in patients who are not good candidates for premium IOLs. “If I can attain 20/30 UCVA at near, these people are functional.”

So far, he has not heard complaints about the lens decreasing contrast sensitivity, and no one has asked to have the lens removed. He stressed that there is one caveat with a small-aperture lens: it will mask astigmatism. “So, when you refract these patients postoperatively, you may still pick up some astigmatism, because it’s not treating the astigmatism, per se, like you have with a typical toric lens.“

The two surgeons agreed that the small-aperture lens was surprisingly forgiving about centration, too. But that does not mean surgeons should give short shrift to the typical preoperative protocols. Dr. Stonecipher still treats any symptoms of dry eye disease (DED) to optimize biometry in these patients, and he still calculates the eye’s A-constant as best he can, given its condition after any prior surgeries. In terms of correction, he said, “I target about -0.75 D, and I think that’s the sweet spot.“

Matching IOLs to Patients’ Needs

With the plethora of IOL options now available, the two surgeons discussed how they choose between them. “Do you look at what patients want, and then see how their cornea looks? Or do you say, here’s my go-to?“ Dr. Singh asked Dr. Stonecipher.

Dr. Stonecipher replied that experience has taught him that patients generally want their doctor to make a professional recommendation for an IOL, and so he tends to limit their choice between a premium option and an affordable option. He prefers a monofocal lens in eyes that have less than 0.75 D of astigmatism, and either the TECNIS Toric (Johnson & Johnson Vision), the TECNIS Eyhance Toric (Johnson & Johnson Vision), or perhaps the Aspire (Bausch + Lomb), in astigmatic eyes. He still uses trifocals such as the TECNIS Synergy (Johnson & Johnson Vision) or the PanOptix (Alcon), he said, if the patient has “perfect corneas.“ He added that he implants the Clareon Vivity IOL (Alcon) fairly often: “I find that’s a very forgiving extended depth-of-focus lens.“

Dr. Singh said he’s been using the Light Adjustable Lens (LAL; RxSight) frequently in eyes with DED and glaucoma, and he likes the quality of vision it imparts. And, he added, his patients love the idea of being able to adjust the refraction postoperatively if needed. Yet, the LAL does not address higher-order aberrations, Dr. Singh qualified. For eyes with irregular astigmatism, post-RK incisions, or peripheral irregularities, he said, “I think the IC-8, or the Apthera lens, makes some more sense.“

Both surgeons have performed blended vision implantations, with a standard monofocal lens in one eye and perhaps an Apthera in the other, targeting -0.75 to -0.50 D for a good range of vision.

Karl G. Stonecipher, MD
  • Clinical Professor of Ophthalmology, University of North Carolina, Chapel Hill
  • Clinical Adjunct Professor of Ophthalmology, Tulane University, New Orleans
  • Director of Refractive Surgery, Laser Defined Vision, Greensboro, North Carolina
  • Member, CRST Executive Advisory Board
  • stonenc@gmail.com
  • Financial disclosure: Consultant, research support, and speakers bureau (Alcon, Allergan/AbbVie, Bausch Health, CSI Dry Eye, Espansione Group, Eyevance Pharmaceuticals, EyePoint Pharmaceuticals, InnovaMed, Johnson & Johnson Vision, Lombart, Marco, Nidek, Novartis, Presbia, Rayner, Refocus Group, Strathspey Crown, Tarsus Pharmaceuticals)