In a recent conversation, Dr. Shultz discussed his experience with the IC-8® Apthera™ lens, particularly in patients with up to 1.5 diopters (D) of astigmatism.
At the outset, he noted that “onboarding with Apthera has been fairly easy because I've been following this technology for several years and I was eagerly awaiting its availability in the US. I was one of the early adopters and I've certainly been very happy with my experience.”
“The Apthera IOL allows surgeons to be successful in patients who are looking for presbyopia correction and patients for whom other technologies are just not a good fit, for example, as a result of damage from previous surgeries. There really aren't any other options for the latter group of patients, and Apthera is a great innovative technology that we're able to offer these patients to get them excellent quality of vision that couldn’t be achieved any other way.”
“Many patients with astigmatism, in general, are great candidates, which is good because 82% of all cataract patients present with 1.5 D of corneal astigmatism or less.1 One of the nice features of this lens is the fact that we can treat patients that present up to 1.5 D of astigmatism without putting a toric lens in, which saves time. You don't have to worry about toric alignment. The pinhole effect of the technology eliminates the effects of astigmatism in the central cornea. Therefore, we can use this for patients that have low to moderate astigmatism and provide them a continuous range of vision from distance to near. This is a great option for patients who are looking for presbyopic correction, especially for those who may not be able to afford a premium lens in both eyes.”
“We implant Apthera only in the nondominant eye. We can give patients excellent distance, intermediate, and near vision.”3
UCVA Comparison by Astigmatism Group at 3 Months in a Prospective Multicenter Study2
“You do have to be careful with patients with larger pupils because you can run into problems with some night vision aberration. If their mesopic pupils are larger than 4.5 mm when they dilate, light comes in around the light-filtering mask. These patients can get some monocular diplopia associated with that because there's a dissociation with the image coming through the center and from the periphery, unlike a multifocal or trifocal lens. We can control the extent of pupil dilation with drops like Vuity® or pilocarpine, if necessary, to avoid those problems. Note that patients with large pupils are not great candidates for other lens technologies either because they have a poor ability to focus in dim light. Additionally, they typically have more problems with aberrations, particularly with the diffractive optic IOLs. In my opinion, Apthera is a better choice for these patients, as long as we are careful to control their pupil size postoperatively to achieve the best effect.”
Why Choose IC-8 Apthera Instead of Another IOL?
“As I said earlier, implanting the Apthera lens saves us time versus a toric lens because we're not doing a toric alignment and we just implant it in the natural position. Additionally, we’re not worrying about the lens rotating postoperatively. However, in my practice, we choose this lens primarily because of its precision. We often have patients who don't necessarily need toric correction in one eye, but the other eye has more toric power. For these patients, we can put a monofocal lens in one eye and Apthera in the other to manage their astigmatism and near vision bilaterally.”
“For the patient with astigmatism, this lens has advantages over a lot of the existing presbyopic options in toric patients because you don't have to rely on alignment. When an EDOF lens, trifocal lens, or typical multifocal lens rotates or isn't exactly on the right axis, the resulting residual or refractive error can degrade both distance and near vision. When that happens, we have to manage those issues, whether that's rotating the lens or switching lenses.”
“We've had excellent results with the Apthera lens. I haven't had an unhappy patient yet. That may be due in part to the care we take in patient selection.”
“I'm not seeing dimming of night vision with my patients, largely because Apthera is implanted in only one eye. Consequently, patients are not noticing any decrease in night vision associated with the pinhole effect of the lens.”
“We've had excellent results with the Apthera lens. I haven't had an unhappy patient yet. That may be due in part to the care we take in patient selection.”- Dr Mitchell C. Shultz
“We typically see patients the day after surgery and a week to 2 weeks after surgery. I'm seeing them further out from surgery (which isn't normal for me with other technologies) just because I know that their vision does continue to improve with Apthera, interestingly enough.”
“This improvement in vision over time is due to several factors. The cornea isn't fully healed until 3 months post-surgery, and when we do cataract surgery, we're relying on the final position of the lens to get the best effect. That's not necessarily present on day one, and it can take a month to 3 months for the capsule to compress around the lens. There's a neurologic adaptation factor as well. Because we're still early in the experience, I want those extra data points, so I see them at one day, one week, one month, and 3 months.”
"There is a little bit more sensitivity to posterior capsule opacification with this lens, so performing the capsulotomy properly is very important. We do counsel patients that their vision is going to be good initially, but it may deteriorate a little bit if their capsule opacifies. For that reason, we watch them very closely, and when it's safe to perform capsulotomy, we do so. Doing a capsulotomy on these patients properly requires adequate dilation of the pupil. Therefore, you need to be able to get the patient’s pupil larger than the ring — at least 4.3 mm.”
“You need to be able to see around outside of that to perform the capsulotomy properly because it's very challenging to do a capsulotomy through the center of this lens. And you want to do everything possible to minimize damaging the light-filtering mask, which is what gives patients this excellent vision. For these reasons, it’s important to choose patients that can dilate well enough to perform the capsulotomy postoperatively.”
How Colleagues Are Using Apthera
“Early on, surgeons were reserving Apthera for more complicated patients; now there is a mindset change as surgeons realize that they can use it in typical presbiopic patients and get excellent results. This includes patients who may have had a monofocal lens placed in one eye years ago and don't want to have to wear reading glasses now. This is a great technology to consider for patients that are pseudophakic in one eye from previous surgery and now want to have surgery on their second eye. For these patients, this lens should certainly be a consideration as a technology that's going to give them good distance, intermediate, and near vision3 without compromise.”
Dr. Mitchell C. Shultz is in private practice in Northridge, California. Dr. Shultz received his medical degree from New York Medical College. He completed his residency in ophthalmology at the University of California, Irvine, and a fellowship in refractive surgery at the Instituto Zaldivar in Argentina.
Financial disclosure: consultant to Bausch + Lomb