The San Diego View

Intraocular Lens Options in 2023

By Rakhi Melvani MD and Julio Echegoyen MD PhD
Gordon Schanzlin New Vision Institute

Dear SDCOS Colleagues,

It is my pleasure to introduce you to an amazing new Cataract and Refractive Surgeon in town, and our new associate, Dr. Rakhi Melvani. Dr. Melvani is a native of Southern California, who grew up in Apple Valley. She attended undergraduate and medical school at Virginia Commonwealth University, trained in ophthalmology at the world renown Wills Eye Hospital in Philadelphia and is finishing her Cornea, Refractive Surgery and External Disease fellowship at my alma mater UC Irvine. She comes with the upmost, highest recommendations from all her mentors. We are so pleased to have her join us starting in Summer 2023! She can be reached anytime by cell or email and I am sure she would love to hear from you all so she can get to know our wonderful community. Dr. Melvani volunteered to write this month’s article on an exciting and everchanging topic in the field of anterior segment surgery – intraocular lens options and patient selection for cataract surgery. Your patients may ask you about what their options are for cataract surgery, and so this is an excellent summary that should empower you to start these conversations with them. Of course, you can always reach out to us for more details. Take care everyone!

Hi everyone, thank you Dr. Echegoyen for the kind introduction! I am thrilled to be discussing the exciting topic of intraocular lens selection with you. One of my favorite challenges as a refractive cataract surgeon is helping patients discover their full visual potential with cataract surgery. Until the 1990s, the decision was fairly simple- you have cataracts? Time for surgery with implantation of a standard monofocal intraocular lens (IOL). However nowadays, the choices are endless thanks to the many incredible advances we have made in intraocular lens technology. It has taken plenty of trial and error, but today we are able to truly customize a patient’s vision better than ever before. That being said, it can be overwhelming for our patients to have to learn that they need surgery, set expectations, understand the process and recovery, AND choose the appropriate intraocular lens to implant in their eyes, all in one short office visit. It’s important to gather from the patient a thorough examination, as well as their preferences and visual goals after surgery, to help them decide which intraocular lens is best for them.

The tried-and-true monofocal IOL continues to be an excellent choice for patients. For patients with moderate to advanced glaucoma, or retinal disease such as PDR or AMD, monofocal IOLs allow the maximum amount of light to the retina with minimal light energy lost in comparison to other intraocular lenses. They give the best contrast sensitivity and the lowest risk of higher order aberrations and are covered by insurance. One of the newer monofocal options on the market is the Eyhance one-piece monofocal lens from Johnson & Johnson Vision, that provides about 0.5 diopters of additional range. This IOL has been a real game changer in that it gives us an opportunity to provide even our patients who opt for monofocal IOLs some additional range, without compromising on contrast sensitivity or causing side effects of increased halo and glare due to lens design. The Eyhance IOL has been an excellent addition to our armamentarium especially for those patients opting for monovision- in many circumstances these patients can achieve spectacle independence given the additional 0.5 diopters of range in each eye. Eyhance does also come in toric options which can correct up to about 4 diopters of regular astigmatism in the corneal plane.

For those patients who prefer to achieve full spectacle independence, multifocal IOLs are an excellent option. By definition, these IOLs provide more than one focal point. They were previously only available as bifocal lenses, which lacked intermediate range vision, however now the most commonly used multifocal IOLs are either trifocal or extended depth of focus lenses. Trifocal IOLs such as Synergy by Johnson and Johnson Vision and Panoptix by Alcon give a range of distance, intermediate and near but are considered sharpest at near. In contrast to trifocal IOLs, extended depth of focus IOLs such as Symfony by Johnson and Johnson Vision give excellent sharp distance, as well as intermediate and some near. A popular choice among patients who want full range of vision with no dependence on spectacles is to mix and match multifocals such as placing a Symfony in the dominant eye and a Synergy in the non-dominant eye.

While multifocals are a fantastic example of IOL technology helping achieve spectacle independence, patient selection is crucial to success when it comes to utilizing this technology. Multifocal IOLs rely on a perfect optical system in order to function. Therefore, if a patient has other ophthalmic disease such as significant retinal pathology affecting the fovea, glaucoma affecting their visual field, or corneal scarring causing irregular astigmatism and higher order aberrations, multifocal IOLs may not work as well and can often cause more side effects than a monofocal IOL. The exception to this rule is the Vivity IOL by Alcon which has a non-diffractive profile compared to other multifocal IOLs and can be used in cases such as mild glaucoma or dry AMD. It’s also important to counsel patients that multifocal IOLs will cause halos and glare when looking at a point light source, especially at night, with the lowest risk of these side effects with use of the Vivity IOL.

The newest IOL technology available in the US are Light Adjustable Lenses by RxSight. The light adjustable lens is a silicone IOL that can be implanted during the time of surgery and later adjusted to the appropriate power the patient desires. The IOL power that is chosen is within the ballpark of the patient’s desired power, either distance or near, and can later be treated by up to 2 diopters of sphere and 2 diopters of astigmatism. This allows patients to achieve highly customizable vision, and even have a chance to “try out” their new vision before locking it in place. The IOL is filled with unpolymerized macromers that become photopolymerized upon treatment with UV light. This causes unpolymerized macromers to move into the exposed area, causing precise changes in shape, and ultimately power, of the lens. Up to three treatments can be completed to adjust the IOL power. Once the patient is happy with their vision, two additional treatments are done to expose the entire IOL to UV light and polymerize all remaining macromers, resulting in a “locked in” lens. The treatments can typically be started about two to three weeks after the IOL is implanted, when the patient has a stable refraction, and the IOL can be locked in as early as 3-4 weeks post operatively. While awaiting treatments, the patient must wear UV protective glasses to ensure there is no inadvertent treatment of the IOL from natural UV light. While the light adjustable lens has truly been revolutionary for the field of cataract and refractive surgery in general, the patients it has been most applicable for are those who have undergone laser vision correction. Notoriously our calculations are imprecise for these patients and they are more prone to having myopic or hyperopic shifts after standard IOL implantation despite our best efforts to prevent this. The light adjustable lens allows us to precisely “dial in” these patients desired prescription and avoid these shifts commonly seen with LVC patients. By the way, Dr Echegoyen underwent refractive lens exchange utilizing the Light Adjustable Lens!

To summarize, IOL selection is exciting and challenging with our amazing advances in the field of cataract surgery! IOL selection should be tailored to each patients’ unique exam, history, and visual goals.

I am so excited and privileged to be joining Gordon Schanzlin New Vision Institute this summer! I am greatly looking forward to getting to know and work with you all in the coming months. If I can answer any questions or if there is ever anything I can help with, please contact me anytime.

Best wishes,
Rakhi Melvani, MD
Gordon Schanzlin New Vision Institute
Cell: 760-887-5981
Email: Rakhi.melvani@gmail.com