A Redesigned Lens for Presbyopia

James Katz, MD, discusses his experience with the Acrysof IQ Restor +2.5 D multifocal IOL (Alcon) for the correction of presbyopia. Dr. Katz explains why this lens deserves a fresh look from physicians who have used previous Restor IOLs, and he highlights which patients are likely to experience the most positive outcomes with this technology.

Gary Wörtz, MD: Open. Outspoken. It's Ophthalmology off the Grid—an honest look at controversial topics in the field. I'm Gary Wörtz.

On today's episode of Ophthalmology off the Grid, I'm talking to Dr. Jim Katz about a technology that, frankly, I overlooked. It's the ReStor 2.5 with Active Focus. At a recent meeting, I was having a conversation with some colleagues, asking them what lenses they're really liking to use for presbyopia correction, and this lens just kept coming up, the ReStor 2.5 with the Active Focus.

Confession time, this is a technology that I've overlooked. I think I haven't given it a fair shake, and I wanted to get Jim on the program to really talk to me about why he uses it, how he uses it, and how his patients are benefiting from this technology. Listen in, it should be a good time.

Well, welcome to Ophthalmology off the Grid. Today I have Dr. Jim Katz with me. Jim and I have known each other for quite a while. Jim has actually come down to Lexington a number of times and given talks, and we see each other frequently at meetings. Jim, I just want to say thank you for taking some time to talk to us tonight about something that I know you've been enjoying using, which is the ReStor 2.5 with Active Focus. Give us a little bit of a blurb about your experience maybe with this lens. Maybe some compare and contrast with this lens with some other things you're doing. Where do you find this working with your patients in your setting?

Jim Katz, MD: Well, thanks Gary, and thanks for inviting me to speak with you today. I want to talk about, again, this multifocal Active Focus lens, the 2.5 lens. I've been using it for over a year now, and I've really found a nice spot for it for patients who want to reduce the dependency on glasses, especially for that intermediate vision. These are patients who want to stay connected.

Gary: Right.

Jim: These are patients who want to stay active, and they're patients who want to stay independent. These are patients who kind of want it all and have a lifestyle that they feel they deserve to have these areas of their vision corrected well. I found the 2.5 Active Focus lens fits for all these patients.

Gary: It's interesting to me because it seems like all the companies sort of backed into the intermediate range of vision. It seems like what we're finding is that as we back into intermediate vision, we're getting happier and happier patients. Have you found that to be true with this lens and with your patients?

Jim: I think that's absolutely true. We're finding our patients are using more, as I said, staying connected, using more tablets, computers, smartphones. Those technologies, where they use the intermediate vision as well as they want really sharp, crisp distance vision. I think these groupings of lenses help to fulfill these needs. In addition, I think specifically this Active Focus lens, I've found to have a lot of benefits beyond just another multifocal. I can go through with you how we and I have determined this.

Gary: Give me a little bit of background on that because, to be honest, my background, I finished training in 2008, got out, got busy and was doing a fair number of ReStor lenses. That's really generations of lenses ago.

Jim: That's right.

Gary: It's kind of hard when you had to, maybe ... I have to be honest, I had a lot of really happy patients, but it's the few ones that were headaches that you remember and they come to mind easier than the ones who were happy. For me, when I think back about ReStor, I didn't have the greatest experience, just to be perfectly honest.

Jim: I understand.

Gary: Now, re-evaluating this lens, give me some pearls about why you think this lens deserves maybe a fresh look for people who used the older products.

Jim: This is the reason, and I found this on my own because, really, as a company, as an Alcon lens, this really wasn't discussed when the lens was first introduced. What I found initially was, I completely agree with you, that a lot of my early ReStor patients 3.0 and 4.0 add, were happy, but I definitely had some patients who did have some quality of vision issues and patients that also the near point was too close. I was more concerned with the patients that had some quality of vision issues.

Gary: Right.

Jim: Why were they having those issues, and how could we avoid those? I started using the 2.5 Active Focus lens in terms of trying to improve the intermediate vision, but what turned out is, that not only did the patients see better intermediate, but they had a better quality of vision, and I didn't really know why. The reason why is the following: It turns out that this lens is a completely redesigned lens. It's not the same multifocal as other lenses. For example, it's really a hybrid design monofocal lens, meaning the lens without the diffractive portion is a monofocal lens. That's unlike any other multifocal or extended depth of focus lens, meaning the central portion of that lens, the part without the diffractive surface, is a distant-dominant lens.

Gary: Okay.

Jim: Not just dominant, but 100% of the light is dedicated to distance. To my understanding, none of the other multifocal lenses, including the Alcon ReStor lens, has a distant focus in the center to intermediate.

Number 1 is the whole lens, without the diffractive ridges, is a distance-based lens. Then, the diffractive surface is set to improve the intermediate range. It has less rings overall so there's less glare or halo, but when the pupils fully dilated, you actually get less glare and halo than previous multifocals. Actually, the contrast sensitivity was comparable to the AcrySof IQ lens, or their monofocal lens, which is interesting because that has not been shown with other lens technologies.

Gary: Right.

Jim: Contrast sensitivity is, at all spacial frequencies, equal to their standard lens, in this case IQ ReStor lens.

Gary: Yeah. I have seen data that's similar with this Symfony, and that's kind of a different ... I guess you call it a hybrid as well, but the tagline is it's a hybrid multifocal with monofocal like distance vision. I look at that, and I think, "Well, it's a multifocal, it's a multifocal, and if it's not, then it's not." Maybe we are starting to figure out where we can make compromises in terms of either the range of vision or the amount of rings or how we do distance versus near splits, where we're getting patients who actually are going to be happier.

We're not trying to necessarily give them 20/10 vision at all ranges of vision, but we're actually giving them usable vision across a spectrum, or across the range, with the limitation of symptoms. Is that where you're seeing this? You're not necessarily shooting the moon, but you're making patients really happy because you're giving them something that they haven't had in years.

Jim: I think that's a great summary of what we're trying to do. We're trying to give them the focus at different depths, at different distances, depending on if it's a distance, intermediate and near. I'm not saying that's becoming secondary, but rather the quality of vision is becoming so much more important at each of these phases because that's, we're finding out, what really creates happy patients.

Gary: Right. Well, and what's also interesting is when you look at the defocus curve on this, it actually, in some ways, mirrors what's going on with the Symfony lens. If you compare their defocus curves, it's very similar because this really doesn't have that second peak. It really is more like an extended depth of focus lens, where you're getting a large area under the curve. Honestly, that's how I've been having this conversation with patients now. I'm saying, "With a monofocal lens, we can ... right now, maybe you're at 20/50, or maybe you're at 20/50, and we want to raise that peak up to the 20/20 level, in that range."

You're still missing all this vision that is intermediate and near, but with a multifocal, we give you that hump near the near, then it drops off intermediate, and then it goes back up for distance. Then, with these extended depth of focus, and maybe this fits in that category, you're extending the area under the curve, almost like a plateau of vision and I get about, maybe, 2.00 D of continuous vision. I think that's very attractive to patients.

Jim: They're not missing. There's no void.

Gary: Right.

Jim: Like you said, it's almost seamless from distance to intermediate and some reading, which I think is a huge benefit to the patient as well as, again, these quality vision differences, for example, minimizing visual disturbances. If you look at point-spread functions.

Gary: Right.

Jim: If you look at pupil sizes of 3 mm versus 5 mm, often there's more symptoms at night with headlights coming towards you because the pupil is larger.

Gary: Right.

Jim: With this design, we're getting less quality differences in a larger pupil than a smaller pupil. It did not have that in the previous versions, or iterations, of the multifocal lenses.

Gary: Right, right.

Jim: Like you said, these hybrid designs may be advantageous, not just because of the improved intermediate vision, but rather the quality of vision improvements.

Gary: Right, right. The other thing is, you still have the opportunity to mix and match this lens with other technology. Maybe you could give us and example if this is a technology that you like to use with other technologies. Have you had patients who maybe do their first eye and say, "Well, I really like the quality of vision, but I'd like it to just be a little bit ... I'd like to have a closer near-point?" Are you doing any mixing and matching? Tell us about that if you are.

Jim: Yes, I have, and it's a great point because I think that we really need to individualize these types of lenses for patients. Already, I told you what types of patients: the active patients, those ones that are connected. Those types of patients, but I evaluate each of my patients approximately 1 week after the first eye, and I proceed with this really one eye at a time. Preferably, I would prefer to do the distant dominant eye first.

Gary: Okay.

Jim: Whichever eye I'm okay with.

Gary: Sure.

Jim: If I do the distance dominant eye first with an Active Focus 2.5 lens, for example, I reevaluate the patient's satisfaction at approximately 1 week after the original procedure. I do one of three things. In the second eye, a good 50% of patients—and that is an increasing number of patients—I will place the same, 2.5 that is, Active Focus lens in the second eye, targeting the same approximate plano result.

Gary: Sure.

Jim: I think with the both eyes set at that, they get excellent distance and excellent intermediate vision. And I keep on emphasizing that quality of vision is what is so great, especially a distance, beyond, again, what it was before on average with the multifocal lenses. That's 50% and increasing.

A smaller percent of patients, at approximately 1 week, would like or prefer a closer near point for focus than achieved with the first eye. For those patients, I may choose a closer near point with a multifocal lens—for example, a ReStor 3.0, which gives a better near 16 inches focus point. Together, again we talked about defocus curves, it covers from distance to intermediate to near.

That's been working really well for those patients that do want improved near vision.

Gary: Sure.

Jim: Then finally, the third way is to choose the 2.5, again, Active Focus lens, for the second eye but target about -0.50 D of spherical equivalent in that.

Gary: I see. Okay.

Jim: We'll leave a little near, and we learned that from lenses such as Crystalens, where we're targeting especially the nondominant eye for a little -0.50, -0.75.

Gary: Sure.

Jim: Those are the three ways to proceed, and I've done actually all three of those. Over time, over this years' period of time, for my patients, my 2.5 lens Active Focus in both eyes has been somewhat increasing, but it is far from 100%. I think we need to individualize this for each patient to satisfy them as well as we can.

Gary:

Well, and that's the joy and the benefit of having two eyes to work on. After you do the first eye, you can sit down and have a conversation with them. They have a much better understanding of what they're actually in for after they've had one eye to try it out. It's really nice to have that conversation after the first eye is somewhat healed up and functioning well, at a week to say, "All right, here we are. This is what we were trying to model and talk about in the preop lane, and this is where we're at. We can either up the ante. We can double-down with the same technology, or maybe make a little tweak." This sounds like all those things, are technologies or rather are techniques that you're employing with great success.

Jim, just in summary, you've been giving us some great pearls on this, if you're a surgeon who is ... maybe you've sworn off multifocals, maybe you've sworn off other types of lenses in the past, what's some final takeaways to get started? Who's a good patient to try this on first to sort of dip your toe in the water, so to speak, if you're wanting to maybe give this brand or this new lens a fresh start?

Jim: I think it's important for all surgeons to understand the patient's activities and their visual goals, so I'd start there. Then I think it's the responsibility of the surgeon to make sure the patients understand what their IOL options are, because patients are absolutely more informed.

Gary: Yes, that's true.

Jim: Simply recommend the best option based on the fit of the patient.

Gary: Okay.

Jim: The ideal patient is one that isn't too obsessive or neurotic.

Gary: Right, like most ophthalmologists would be.

Jim: That's true.

Gary: Yeah.

Jim: It's amazing how much easier it is to fit this type of lens, such as the 2.5, this Active Focus ReStor lens, because it is more forgiving than it has been in the past. I don't think, and I haven't been caught up with patients who otherwise looks like everything is fine but they're unhappy with it.

Gary: Right.

Jim: I think it has to do with all these things we've talked about.

Gary: Right.

Jim: Better intermediate vision, defocus curves make more sense, less visual disturbances due to the design of this less, the 100% distance dominant in the center. These are what people want. They can't express these things to us, but this is what they want by being more connected. Those patients that work more on the tablets, computers, smartphones, and read less. They say, "No, I read all the time." You ask them what they read, "Are you reading magazines, newspapers, books?" They say, "No, I'm reading it all on an iPad."

Gary: Right.

Jim: “I read those everyday.” Wow, so that's a little more intermediate vision, and those patients are excellent for these technologies.

Gary: That's great. Well, Jim, I appreciate you coming on and giving me a little bit of an information dump on this new lens because, to be honest, I've been a little stuck in my ways. I have my lenses that I use, and I haven't really ... I don't think, personally, just to be honest, confession time, I haven't really given this lens a fair shake. It's really nice to know that are some differences about this lens that make it stand out maybe over and above the ReStor lenses of the past.

Jim: Correct.

Gary: This is really another option, another tool we have on our tool belt. Just as an aside, I saw you and I saw Quentin Allen down at MillennialEYE last weekend, and it seems like there's great content but sometimes the real meeting happens out in the hallway. I walked by Quentin, and I said, "Hey man, what are you using these days?" I said, "What's your favorite lens that you're using?" He said, "Oh, I am using the Active Focus." I said, "Really? Out of all the lenses, you're using the ReStor 2.5?" He's like, "Man, that's my fastball. If you're not using it, you've got to try it."

That really kind of took me back. I said, "Man, maybe I've overlooked a diamond in the rough here. Maybe this is something that I need to think about." I really appreciate all the information. It was great to talk to you, it was great to see you last week and also thank you for coming on tonight and giving us all this great information.

Jim: Gary, it's my pleasure. Go ahead, try the lens. I think you'll be happy.

Gary: Awesome. Thanks, Jim. I appreciate it.

This has been Ophthalmology off the Grid with Jim Katz and Gary Wörtz.

Our field is so exciting. It's ever-evolving, it's ever-changing, and as soon as you think you know everything, it's a good sign that you're in for a surprise. Tonight's episode, I really feel like I learned something. Hopefully you felt the same way, and I'm actually excited to learn a little bit more about this technology and perhaps try it on a few patients in the near future. This has been Ophthalmology off the Grid. I'm Dr. Gary Wörtz. Thanks.