IOL options for very high myopia
Posted , 8 users are following.
As far as I know there are just four FDA-approved IOL options available to me in my Rx, which is approximately +4.0D OS and +3.0D OD.
They are:
- Zeiss CT LUCIA 621P, a 1-piece hydrophobic acrylic monofocal lens launched in 2023. This is the first offering in Zeiss' new hydrophobic acrylic platform, with more to come. This iol is supposed to be very stable in the capsular bag thanks to its thick wide optic haptic junction. It is glistening free, aberration correcting and available in 0.5D increments in my Rx. Since it is so new, very few US surgeons have begun using it, and I would need to travel to another state to get it.
- Bausch & Lomb enVista MX60E. Launched in 2017, this 1-piece hydrophobic aspheric acrylic monofocal boasts a scratch resistant optic and is available in 1.0D increments in my Rx. It is glistening-free. For some reason it is not used very widely as a standard monofocal. When I search for information about it I find a lot of videos of surgeons using the eyelets in the haptics to suture it into the eye for a scleral fixation. To get this iol I would have to seek out a surgeon who implants it, there are a couple near me.
- J&J Sensar AR40E A 3-piece hydrophobic acrylic. Available in 0.5D increments from +2.0 to +5.5D. Launched in 2000, this iol is older than my children.
- Alcon Acrysof MA60MA Another 3-piece hydrophobic acrylic, available in 1.0D increments. Requires a large 3.2-3.4mm incision, has spherical aberration and may develop glistenings. This iol has been around since 1999 and is still a favorite for surgeons to use in high myopia, thanks to its angulated PMMA haptics making it stable both in and out of the bag.
So those are my choices in the US. Anyone have any of these iols in their eyes and have advice?
My last option is to travel to Europe. I've considered the Zeiss hydrophilicplate haptic iols but I'm now leaning towards the HumanOptics Aspira-axA XL because it has a 7mm optic that not only looks cool, it also helps prevent optic edge dysphotopsias in the case of iol decentration as can easily happen in high myopia. My pupils dilate to at least 4.7mm in mesopic conditions so I like the idea of a larger optic. Also it gives my opthalmologist a better view of my retinal periphery during exams.
Thanks for any advice from those who have had any of these iols implanted or who have traveled for surgery.
0 likes, 17 replies
trilemma ka76787
Edited
RxLAL. 1 D seems rather granular, but remember there is adjustability.
trilemma ka76787
Edited
Here is the link that I copied that Power number from.
https://eyewiki.aao.org/Light_Adjustable_Intraocular_Lenses
ka76787 trilemma
Edited
Wow! I had no idea that the LAL came in such a low spherical power! I have been researching this on my own for over a year now and thought I'd exhausted the options. I am so glad I found this forum. You all are the best!
RonAKA trilemma
Edited
Not sure that the LAL has been FDA approved to go quite as low as +2.0 D. I did find a Pre Market Approval for a change to increase the range by including +4 to +9 lenses, but unless I missed it, nothing after that.
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https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P160055S015
RonAKA ka76787
Edited
My message went into moderation due to including a FDA link, but the most recent FDA premarket approval request I could find was for an extension in the range down to +4.0 D.
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"Approval Order Statement
Approval for (1) a simplified fixed output beam aperture in place of the current motorized aperture, (2) update to LDD lock-in treatment profile to reduce ocular exposure, (3) update to the Windows 10 operating system, (4) extension of dioptric power range to include +4.0 to +9.0 diopters, (5) introduce an additional UV-A absorber to the anterior portion of the LAL, and (6) updates to manufacturing work instructions, LDD Graphical User Interface (GUI), and user labeling to reflect all modifications."
ka76787 RonAKA
Posted
yes, it appears to be a typo on that website. I think they must have meant to type:
Power: +10.0 D to +15.0 D and +25.0 D to +30.0 D in 1 D increments : +16.0 to +24.0 D in 0.5 D increments
RonAKA ka76787
Edited
You have probably considered these issues already, but here are some thoughts that come to mind.
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Zeiss CT LUCIA 621P - "This iol is supposed to be very stable in the capsular bag thanks to its thick wide optic haptic junction. It is glistening free, aberration correcting" - Some claim a thick wide haptic junction promotes PCO. SA correction is good and bad. If the lens is perfectly positioned it can provide better visual acuity at the peak focus point. But, it can be more sensitive to being tilted or off position. Does it really fully correct the average +0.27 um SA in the cornea? Everyone now says their lenses are glistening free. I think glistenings in today's lenses are a thing of the past.
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Bausch & Lomb enVista MX60E - This is an SA neutral lens that does not attempt to correct the +0.27 um of SA in the average cornea. There are pros and cons to this, as it is more position tolerant, but results in a slight reduction in peak visual acuity.
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J&J Sensar AR40E - Due to the narrow diopter range it covers, it may be the most optimized design for this range of extreme myopia.
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Alcon Acrysof MA60MA - As discussed before I believe Alcon has resolved their issues with glistenings. Most lenses except for the enVista have intentional spherical aberration. J&J uses -0.27 um, and enVista none. Not sure about this specific lens but the Alcon philosophy is to partial correct cornea SA with about -0.20 um in the IOL. They consider that the ideal tradeoff. If they are not taking this approach with this specific lens and it is a "spherical" design it may have more in the order of -0.37 um of SA, and would have more peak visual acuity loss.
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This said no personal experience with any of these lenses other than I have one eye with AcrySof material. I see no difference between it and my other eye which has the "new and improved" Clareon material. Both eyes are unfortunately showing early signs of PCO though.
ka76787 RonAKA
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Thanks Ron. As usual I am blown away by your extensive knowledge and generosity in sharing it.
Given my extreme myopia and relatively young age, PCO is inevitable-- it's just a question of when. Thankfully both my PVDs are now complete because having an incomplete PVD raises the risks of both the initial cataract surgeries and the subsequent YAG.
For high myopes, implantation of a CTR along with the IOL has been shown in some research to delay the onset of PCO, so that may be an option, but I will defer to my surgeon's opinion on whether to implant a CTR based on his or her intraoperative findings.
I don't have enough understanding of my corneal topography measurements to know whether aberration correction would be beneficial, but I'd prefer to avoid the spherical Alcon MA60MA IOL because it does add additional SA, although probably not very much with a low lens power of +4.0D. I think I'd prefer a neutral aspheric IOL like the enVista, which other high myopes on this forum have received.
What about PD? I read a study by Alcon scientists that said the enVista and LUCIA have smaller usable portion of the optic due to a thick edge that causes PDs. They lumped those IOLs with the Tecnis which I know other folks on this forum have experienced PDs with. I apparently do have large pupils so I'd like to avoid PDs.
I called a local surgeon's office today to ask for a consultation about the enVista and they said I couldn't make an appointment without a referral. No self referrals allowed. I'm so tired of being treated like a child by the US medical system. I'm leaning more and more towards traveling to Europe for my surgery. I've had two different private practice European surgeons actually respond to my emails, before I even scheduled my initial consult.
RonAKA ka76787
Edited
Don't know the specs on the Alcon lens but it may only add 0.10 um of positive SA compared to the enVista. As you suggest, probably less with a low power lens.
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PD is hard to predict. I don't think 4.7 mm is an overly large pupil size. If over 6 then it starts to be more of a problem. A pupil that will not dilate with drops to about 6.5 mm is a bit of a problem with the LAL. They need to get full access to the lens diameter to do the light adjustments.
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In Canada optometrists can do referrals. That is not much of an issue. Getting to see the ophthalmologist in a reasonable period of time can be an issue though.
ka76787 RonAKA
Posted
4.7mm was just one of the many different pupil measurements I found on my optical biometry that was taken before they dilated me with drops-- my pupils can dilate more than that naturally but I have not been measuring them at home. As a high myope the pupil dilating drops really affect me -- my pupils get HUGE and stay that way for the rest of the day. And my WTW has been measured as large as 12.5.
It would make more sense if the referral was required for insurance reasons but this practice just didn't think patients were clever enough to refer themselves. I had the same problem when I needed ovarian surgery and wanted to go to a minimally invasive surgery practice -- one refused me without a referral-- I didn't have a primary care doctor at that time and the urgent care had misdiagnosed me with a bladder problem. I analyzed the ultrasound images myself, self referred to a different MIGS practice and got the laparoscopic surgery I urgently needed.
A lot of doctors mean well but they are just too busy to spend the time needed to give the best care so we have to do our own research and advocate really hard for ourselves.
Lynda111 ka76787
Posted
I am curious how you were able to read your ultrasound image. Do you have a medical background?
jo61855 ka76787
Posted
"I called a local surgeon's office today to ask for a consultation about the enVista and they said I couldn't make an appointment without a referral. No self referrals allowed. I'm so tired of being treated like a child by the US medical system. I'm leaning more and more towards traveling to Europe for my surgery. I've had two different private practice European surgeons actually respond to my emails, before I even scheduled my initial consult."
I suggest getting that referral and then going to a local specialist for consultation about your eye condition.
pershoot ka76787
Edited
For a data and reference point, although the lens you are considering is newer and a 1 piece, I have a Zeiss CT Lucia 602 Monofocal (3 piece), am a high myope and do experience the gamut of Positive Dysphotopsias. The specific lens power is about half or thereabouts of what is needed for the eye, in terms of refraction. Opacification has started forming (somewhere between 6 weeks post-op to current; I am currently ~5.9 months post-op).
ka76787 pershoot
Posted
Thank you for your feedback. So nice to connect with other extreme myopes on this forum. Having vision loss due to myopic degeneration and now early onset cataracts has been a socially isolating experience.
It's my understanding that the CT LUCIA 602 is made from the same hydrophobic acrylic material as the newer CT LUCIA 621P, although the optic design is quite different as well as the haptics. The CT LUCIA 602 is more commonly used by retinal surgeons than by traditional cataract surgeons because it can be implanted in the sulcus as well as in the bag. I had seen that when the CT LUCIA 602 is scleral fixated with sutures, the optic haptic connections can become loose causing optic tilt, so much so that there is a technique for going back in and using laser lock technique to repair the IOL. I know from your previous posts that your IOL has been checked for position and I also don't know if your IOL was sutured using the Yamane technique, but if it was it's possible with this IOL that it may be slightly tilted. Search Intraoperative Laser-Lock Technique to Fix Lens Tilt AND Intraocular lens tilt due to optic-haptic junction distortion following intrascleral haptic fixation with the Yamane technique
pershoot ka76787
Edited
The lens was successfully placed in the capsular bag and not scleral fixed / sutured in-place.
ka76787 pershoot
Posted
That's great! I'm glad to hear that! They've told me there's a chance my bag will be unstable and I'd need scleral fixation. I think if it got to the point where I needed sutures I might just go aphakic. My Rx is so close to 0 anyway.
pershoot ka76787
Edited
Yea, there were concerns over the potential state of things there, in my case. This is due to me having an RD (Mac off) a few years prior in the eye which required a Vitrectomy and Scleral Buckle placement.