OD News Articles

3rd April 2006

Baby Boomer Tsunami—and IOLs for Presbyopia

by Shaun Coombs, OD Olympia, WA

The first wave of baby boomers (born 1946–1964) is beginning to wash ashore and the wonderful days of paternalistic patient care are coming to an end. As educated and demanding baby boomers think about refractive lens exchange, or start getting cataracts, they may arrive in your office armed with information downloaded from the internet—wanting to know all about presbyopia-correcting lens implants.

Click here to learn how cataract surgery for baby boomers is becoming more like refractive surgery.

Pre-op Evaluation

Patient selection and pre-op education are critical to successful use of presbyopia-correcting IOLs. Following are desirable traits for people considering these implants. They should:

  • not have compulsive personalities or be strong perfectionists
  • have a strong desire to be less reliant on spectacles
  • be willing to live with glare and halos, even though they usually diminish with time
  • have less than 0.75 D of corneal cylinder, or be willing to have treatment for astigmatism
  • be willing to allow ample time for the brain to adapt to the new vision
  • be willing to have the lens exchanged, or undergo LASIK, to maximize the outcome
  • be willing to pay extra for the IOL and additional care involved
Lens Options

Patients must understand the limitations of lens implant technology and have realistic expectations for recovery and vision after surgery. Discussion of the pros and cons will go a long way toward ensuring successful outcomes.

Crystalens Accommodating IOL
This lens is made by Eyeonics and theoretically works by moving within the capsular bag to induce accommodation. The apparent movement is possible due to the hinged design of the haptics. Click here to see animation. Some members of the ophthalmic community suggest the near vision effect is not achieved by movement but due to the increased depth of focus achieved by the lens optic being near the nodal point of the eye.

Pros

  • Does not rely on multifocal optics to achieve near vision effect so glare and halos are minimized.
  • According to the manufacturer’s study submitted to the FDA:

° 92% of binocular implant patients saw 20/25 at distance

° 96% could see 20/20 at intermediate distance

° 73% could see 20/25 at near

Cons

  • It may take patients as long as a year to adapt and achieve their best near vision.
  • Although tested in the laboratory, unknown problems may develop over time.
  • Exceptionally accurate IOL power calculation is required.

Our Experience
Our post-op results do not match those of the study submitted to the FDA. It has been difficult to predict those likely to be successful with the Crystalens because our results have been variable. Patients have good distance vision but only about half achieve good near acuity. This lens seems best suited for patients unlikely to tolerate the glare and halos that are associated with multifocal lens implants, particularly at night—such as truck drivers, pilots, etc.

ReZoom Multifocal IOL
This lens design, made by AMO, is based on the acrylic monofocal lens our surgeons normally like to use. But it incorporates five concentric refractive zones to provide near, intermediate and distance focus. The ReZoom implant presents multiple focal planes to the eye and requires the patient to develop the ability to attend to the focal plane of interest. In contrast to multifocal contact lenses, patients have far more success adapting to the glare and halo phenomena associated with these optics. Click here to read a case study.

Pros
According to a recent study:

  • 93% of patients never or only occasionally felt a need to wear glasses for intermediate vision
  • 83% stated similar results for near vision
  • This IOL does not rely on movement to achieve its effect.
  • The lens is constructed of a standard and well tolerated design.

Cons

  • It may take patients time to adapt to achieve their best near vision. But, from our early experience, it is shorter than with the Crystalens.
  • Patients see glare and halos that usually diminish with time. However, the literature suggests that a small number of patients will not tolerate it and will require explantation.
  • Successful utilization of the lens requires pupils of at least 3mm in order to have optimal access to the near concentric zones.
  • Exceptionally accurate IOL power calculation is required.

Our Experience
This is currently the presbyopic IOL our surgeons prefer. In our experience a higher proportion of patients have achieved reduced dependence on spectacles with the ReZoom lens implant compared to the Crystalens. All patients are aware of glare and halos in the early post operative period, but note steady improvement over time.

ReSTOR Multifocal IOL
The ReSTOR lens, made by Alcon, combines diffractive and refractive zones to achieve near and distance vision. This IOL benefits from apodization, which represents a blending between the diffractive steps. The goal of apodization is to optimize the delivery of light energy between near and distance focal points while lessening the glare and halos associated with multifocal optics.

Pros
A recent study claims the following % of patients can perform the following functions without correction:

  • 99% drive a car
  • 97% read the newspaper
  • 90% shave or put on makeup
  • 74% read stock quotes in the Wall Street Journal

This IOL does not rely on movement to achieve its effect.

Cons

  • This lens does not provide optimal intermediate vision.
  • Patients experience mild loss of contrast sensitivity.
  • Other downsides are similar to those noted with the ReZoom lens.

Our Experience
We have not had any experience with this lens. Other members of the ophthalmic community suggest that it has a higher effective near power than the ReZoom. We had concerns that the diffractive optics of the ReSTOR lens might induce more glare and halo issues than the ReZoom, but this does not seem to be the experience of surgeons who have used it so far.

Extra Fee

Our fee for presbyopia-correcting IOLs is $1350 per eye—in addition to the standard fee for cataract surgery or refractive lens exchange. This covers extra pre-op care, surgery, the cost of the lens implant, lens exchange when needed, and enhancement surgery if it should be required.

Conclusion

Presbyopia-correcting IOLs provide wonderful benefits to highly motivated and carefully selected patients, but they are not for everyone. While baby boomers may be attracted to this new technology by sophisticated ad campaigns, they need your help to sort through the pros and cons and make good decisions.