What is the Best Cataract Surgery Option and Intraocular Lens for 2019

The vast majority of surgeon globally believe that the Femtosecond Laser-Assisted Cataract Surgery (FLACS) is the best way to remove a cataract. I fully agree. FLACS has a long track record of decreasing complication risks and there is data to show the recovery time is faster, particularly in advanced cataract cases.

But there are many differing opinions on which intraocular lens implant is the best worldwide.

Most eye surgeons try to communicate to all their cataract-surgery or clear lens exchange patients the fact that while it is the best time in history to have cataract surgery, there is no guarantee of being glasses-free with any implant in the world. There is NO perfect implant (ie, intraocular lens or IOL) to help with all one’s visual needs.

Often a patient cannot process this idea. We live in the 21st Century where so many ills can be fixed. Surgeons often tell patients multiple times in a visit of this “no guarantee,” but still patients can be very disappointed as they thought they would be “glasses free” forever after the cataract surgery.

The natural lens when we are young (ie, normally younger than 40 years old) has an amazing ability to focus for distance, intermediate, and near–sometimes very near. As we get older our natural lens loses the ability to focus. This leads to the need for reading glasses.

The first IOL was a Monofocal IOL.
The Monofocal IOL allows patients having cataract surgery to focus the light entering onto their macula from 1 visual plane. The ability to see intermediate distances and reading distances is limited; thus patients need glasses for these distances.

If a patient has astigmatism (ie, the cornea is shaped like a football instead of a soccer ball’s surface), a patient’s vision even in the distance will be blurry and require glasses.

Advanced Technology IOLs:
Newer implants such as the Multifocal (ie, Tecnis Multifocal, Restor, Active Focus) and Depth of Focus Lenses, such as the Symfony,  are all trying to find the Holy Grail of giving a patient perfect distance, intermediate, and reading without the need for glasses.

The newest IOL is the Panoptix which hopes to be the best of them all. The Panoptix was recently approved by the FDA but has been used in Europe for the last 1.5 years. The initial data coming from Europe and the FDA trials look promising.

Still, however, none of these implants have a 100% guarantee. There is still always a chance that even with the best implant, a patient will need glasses.

The numbers below show the risk of needing glasses in the best two implants currently available in the USA.  The PanOptix appears to have better rates of “being glasses-free” for distance and reading. But note, none of the numbers approach 90%. If one is looking for perfection of 20/20, the rates are lower. The PanOptix may be the best the world has for now.

Highlighted in Yellow: better outcome variable between Panoptix and Symfony.

Halos and Glare:
The issue of Halos and Glare is an important issue as well. Some patients have perfect vision for distance, intermediate, and reading but are debilitated with halos or glare. It is very hard to determine before surgery whose brain will be unable to cope with the added aberrations all implants give, even monofocals IOLs.
All the implants can be explanted but often patients are loathed to find out the alternatives. Every choice has its positives and negatives and when one chooses an implant that gives you better distance, it takes away from the reading. No one has created the God-given natural human lens. 
Thus patients need to make the best decision they can with the current technology and data we have available. Often there is an adjustment period after. 
Do Not Forget About the Tear Film and the Meibomian Glands:
It is crucial for the tear film to be stable and for the meibomian glands to be working beautifully. If you not know what your meibomian glands look like before surgery, I would highly recommend you find out. The most common complaint after cataract surgery is foreign body sensation and surface dryness: this is mainly due to meibomian gland dysfunction or dry eye. 
Thus most surgeons have been loving the Symfony IOL for many years now. The distance and intermediate vision is excellent, but I tell all my patients they will need reading glasses. 

The new PanOptix hopes to be the best IOL for cataract patients (who meet inclusion criteria). But these patients too need to know that 100% spectacle-independence is not guaranteed. 

Studies comparing the two in the same patient are not available. There have been many surgeons globally who have mixed and matched these lenses trying to help the patient be happy with their vision needs. Sometimes we get it right; sometimes we do not.

Every patient needs to know that there are no quick fixes in terms of being “fully-glasses free” without a give and take or haloes and glare in some cases. It sometimes takes time to help your brain to adjust or to decrease astigmatism manually or with the help of another laser or even changing out the implant. Working with your surgeon to explain your needs before surgery is crucial. Trying to work with your brain and its ability to accept the new lens and communicating with your surgeon about this struggle is key as well.

Sandra Lora Cremers, MD, FACS

1. FDA studies for Symphony and Panoptix

2.  2016 Jun 2;10:1031-8. doi: 10.2147/OPTH.S106646. eCollection 2016.

Optical bench performance of a novel trifocal intraocular lens compared with a multifocal intraocular lens.

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