How do we improve the standard of care in cataract surgery? · Cataract surgery with multifocal IOL...

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How do we improve the standard of care in cataract surgery?

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Expert panel

Prof. Elizabeth Yeu(Chair)Assistant Professor, Ophthalmology, Eastern Virginia Medical School,Norfolk, USA

Dr Ramón Ruiz MesaHead of Medical Department, OFTALVIST Eye Clinic, Andalucía, Spain

Prof. Antoine BrézinProfessor of Ophthalmology, Paris Descartes University School of Medicine, Paris, France

Agenda

IOL, intraocular lens.

What IOL technologies are available for patients with cataracts?

How do we select the most appropriate IOL for the patient and meet patient expectations?

What has been the experience with multifocal IOLs in patients with cataracts?

What IOL technologies are available for patients with cataracts?





Worldwide incidence of presbyopia

OUS, outside US.Source: 2019 Market Scope Estimates. Courtesy of Prof. Elizabeth Yeu.

Contributing factors:

• Aging population

• Longer life expectancies

• Longer working careers

• Near-vision needs

• Growing middle class in emerging markets

People with presbyopia

around the globe in 2019 –

growing to

by 2024

2.0 Billion

2.3 Billion

Presbyopes 2019 2024

US 128.7 M 136.5 M

OUS 1.9 B 2.2 B

Panel Question HereHow have recent developments in IOLs impacted cataract surgery?


US

Japan

Europe

OWN

China

S America

India

ROW

1,000 2,000 3,000 4,000

Thousands of IOLs

5,000 6,000 7,000 8,000

Monofocal Monovision PC-IOL

-

Market Scope (2017 IOL Report)

IOL usage

Current frequently adopted IOL approaches worldwide

IOL, intraocular lens; OWN, other wealthy nations; PC-IOL, presbyopia-correcting IOL; ROW, rest of world.Source: Market Scope (2017 IOL Report). Courtesy of Prof. Elizabeth Yeu.

• The use of PC-IOLs is still limited across the globe in comparison to monofocal or monovision IOLs

Panel Question HereWhat properties and characteristics of IOLs can influence performance, implantation and surgery time?


EDOF IOLs (Diffractive and small aperture)

The evolving landscape of presbyopia-correcting IOLs

EDOF, extended depth of focus; IOL, intraocular lens. Sieburth R, Chen M. Taiwan J Ophthalmol 2019;9:4-17.

• Presbyopia-correcting IOLs comprise an area of active, ongoing development in refractive cataract surgery

Accommodating IOLs Bifocal IOLs Trifocal IOLs

Hydrophobic vs hydrophilic diffractive trifocal IOLs (total 238 eyes/119 patients)

Comparison of two trifocal IOLs in a prospective case series

CIVA, corrected intermediate visual acuity; IOL, intraocular lens.Sezgin AB. J Cataract Refract Surg 2019;45:1539–46.

Mean CIVA At 60 cm: Significantly better in hydrophobic IOL group (p<0.001)At 80 cm: Significantly better in hydrophilic IOL group (p<0.001)

Visual acuity At 1.00 ─2.50 D: Significantly higher in the hydrophobic IOL group (p=0.011 to p<0.001)

Halos Frequency of halo and glare similar (p=0.032)Bothersome rates lower for hydrophobic vs hydrophilic (p=0.004)

Spectacle use Percentage of patients reporting never using spectacles for intermediate vision significantly higher in hydrophobic vs hydrophilic IOL group (p=0.016)

How do we select the most appropriate IOL for the patient and meet patient expectations?





Factors that could influence choice of multifocal IOL implantation

IOL, intraocular lens.1. Alió JL, et al. Survey of Ophthalmol 2017;62:611–34; 2. Mester U et al. J Refract Surg 2014;30:674–8.

Pre-existing conditions, age, visual needs, realistic expectations and knowledge of the different optical designs and visual performances of IOLs1

Key factors correlated with overall satisfaction of the procedure1,2

Low astigmatismGood visual

functionLow spectacle dependence

Fewer halos/less glare

Preoperative refraction

Panel Question HereWhat are the primary goals of cataract surgery in 2020?

High patient satisfaction

rates2

Low rate of Nd:YAG

procedures2,5

Spectacle independence

2-4

Minimal halos and glare3

Best refractive outcome with

minimal complications

1,2

Primary goals of IOL implantation

IOL, intraocular lens.; Nd:YAG, neodymium: yttrium-aluminium-garnet.1. Astbury N, Nyamai LA. Community Eye Health J 2016;29:27–29; 2. RCO. Adult Cataract Surgery. January 2018. Available from: https://www.rcophth.ac.uk/wp-content/uploads/2015/12/Cataract-Commissioning-Guide-January-2018.pdf (Accessed February 2020); 3.Mester U, et al. J Refractive Surg 2014;30:674-678; 4. Olson RJ, et al. Ophthalmology 2017;124:1–119); 5. Ursell PG, et al. Eye 2018;32:1579–89.

Panel Question HereManaging patient expectations is increasingly important: What guides your approaches?

Managing patient expectations through shared decision-making on IOL selection1,2

*e.g., limbal relaxing incisions, toric IOL. IOL, intraocular lens.1. Olson RJ, et al. Ophthalmology 2017;124:1–119; 2. Royal College of Ophthalmology. Correct IOL implantation in cataract surgery. March 2018. Available from: https://www.rcophth.ac.uk/wp-content/uploads/2018/03/Correct-IOL-implantation-in-cataract-surgery-quality-standard.pdf (Accessed January 2020).

Discuss need for enhanced refractive procedures post-implantation*

Highlight risks associated with simultaneous bilateral cataract surgery

Have on-going conversations supported by documented discussions

Discuss factors that could influence postsurgical visual acuity or ocular health

Counsel patient on refractive target, preferred refractive outcome, lifestyle and expectations

Panel Question HereHow does ocular health impact surgical decision-making?

Preoperative ocular health

IOL, intraocular lens.Charters L. How to manage patient’s IOL expectations pre-operatively. Available from: https://www.ophthalmologytimes.com/article/how-manage-patient%E2%80%99s-iol-expectations-pre-operatively (Accessed January 2020).

Ocular health is a primary consideration for IOL candidates and surgeons should be alert to the presence of a number of conditions that can impact surgical outcomes:

Pseudoexfoliation

Advanced glaucoma

Trauma

Retinal diseases

Small atonic pupils

Corneal pathologies

What has been the experience with multifocal IOLs in patients with cataracts?





Experience with modern multifocal IOLs

IOL, intraocular lens; QOL, quality of life.Alió JL, et al. Survey Ophthalmol 2017;62:611–34.

Cataract surgery with multifocal IOL implantation aims to achieve spectacle independence and visual rehabilitation for all viewing distances, so ensuring a better patient QOL

Patient satisfactionis high

Complications can be avoided in most cases

Visual and refractive outcomes are good

Optical side effects and neuroadaptation

can occur

Panel Question HereHow have outcomes in recent randomized controlled studies directed use of IOLs?


Evidence from RCTs

EDOF, extended depth of focus; IOL, intraocular lens; RCT, randomized controlled trial; VA, visual acuity.1. Wang SY, et al. Eur J Ophthalmol 2017;27:387–401; 2. Jin S, et al. BMC Ophthalmol 2019;19:78; 3. Liu J, et al. BMC Ophthalmol 2019;19:198.

Multifocal vs monofocalIOLs

• Multifocal IOLs have higher rates of spectacle independence but higher reported frequency dysphotopsia and worse contrast sensitivity vs monofocal1

Trifocal vs bifocal IOLs

• Trifocal IOLs have better intermediate VA2

• Near and distance visual performance, spectacle independence, postoperative refraction and surgical satisfaction comparable2

EDOF vs monofocal and trifocal IOLs

• EDOF IOLs vs monofocal IOLs offer better intermediate and near VA, but are associated with increased risk of contrast reduction and more frequent halos3

• EDOF IOLs vs trifocal IOLs may offer better contrast sensitivity, but at the expense of near vision3

• EDOF IOLs and trifocal IOLs are comparable for halo incidence and spectacle independence3

Panel Question HereWhat have been the conclusions from meta-analyses of RCTs comparing IOLs in patients undergoing cataract surgery?


Conclusions from meta-analyses

IOL, intraocular lens; VA, visual acuity.1. de Silva SR, et al. Cochrane Database System Rev 2016(12):CD003169; 2. Khandelwal SS, et al. Graefe's Archive Clin Exp Ophthalmol 2019;257:863–75; 3. Cao K, et al. Survey Ophthalmol 2019;64:647–58; 4. Yoon CH, et al. J Korean Med Sci. 2018;33:e275.

Multifocal vs monofocal IOLs

• Multifocal IOLs more effective at improving near vision1-3

- Better uncorrected near vision

- Higher proportion of patients achieve spectacle independence

- Greater risk of unwanted visual phenomena

• Newer diffractive lenses2

- May be better than refractive lenses in near vision and quality of vision outcomes

- Less risk of halos than older diffractive lenses and refractive lenses

Trifocal vs bifocal IOLs

• Trifocal IOLs provide better intermediate VA4

• Trifocal IOLs provide similar or better distance and near VAs without any major deterioration in visual quality4

Panel Question HereWhat has been your personal experience with IOLs?


In the clinic

DFE, dilated fundus exam; MRx, manifest refraction; OCT-M, optical coherence tomography M scan; OD, oculus dexter (right eye); OS, oculus sinister (left eye); PMHx, patient medical history; SCL, soft contact lens.Image courtesy of Prof. Elizabeth Yeu.

• 69-year-old man

• Successful monovision SCL (OD plano; OS: -2.00)

• Prominent commercial real-estatebusinessman

• MRx: - OD -2.50 + 2.75 x 180 (20/30)

- OS -3.50 + 1.75 x 180 (20/50)

• PMHx: unremarkable

• OCT-M: healthy macula and DFE

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How do we improve the standard of care in cataract surgery? · Cataract surgery with multifocal IOL...

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