New Advances in Cataract Care: Safer Surgery, Better Lenses

BERLIN — Technological advancements and the development of intraocular lenses (IOLs) have significantly improved the care of patients with cataracts, especially for those who would prefer not to wear glasses.

Dr Gerd Auffarth, president of the German Ophthalmological Society (DOG), explained the advancements in diagnostics, surgical safety, and the range of IOLs at a press conference during the 122nd DOG Congress in Berlin.

“A large number of small improvements in individual areas have collectively led to a certain quantum leap,” said Auffarth, who is the medical director of the Eye Clinic at Heidelberg University Hospital, Heidelberg, Germany. Thanks to optimized imaging analysis techniques, such as optical coherence tomography (OCT) and Scheimpflug imaging, the lens opacification characteristics of cataracts and corneal conditions can now be captured effectively. In addition, factors such as glare sensitivity, contrast loss, and light scattering can be quantified.

Enhanced Pathology Detection 

These advancements contribute to the indication and surgical strategy for the procedure. “Diagnostics are particularly important to exclude other eye pathologies that could suddenly cause problems during surgery or that are relevant for the choice of IOL,” Auffarth explained.

Improvements in anterior segment OCT and Scheimpflug technology have enabled early detection of subclinical changes, such as early Fuchs endothelial dystrophy or corneal bulging anomalies (keratoconus). In addition, optic nerve and macular changes can now be identified much earlier. Such conditions can be contraindications to implantation of specialty lenses aimed at dispensing with the need for corrective eyewear.

Increasingly, according to Auffarth, artificial intelligence algorithms are being used for image data analysis and calculation of suitable IOLs.

Innovations in Intraoperative OCT

“The surgery itself has also become even better and safer,” Auffarth said. With the use of novel surgical microscopes combined with 3D glasses and a large screen, the surgeon no longer needs to look through eyepieces but can view the surgical field freely in the room. The image quality and depth perception are impressive, according to Auffarth.

Additional diagnostic options, such as intraoperative OCT, and surgical guidance systems similar to a vehicle’s head-up display have been introduced.

Safer Surgeries 

The gold standard for fragmenting the cloudy lens, ultrasound-based phacoemulsification, and subsequent suction of lens fragments is now performed in a minimally invasive way, according to Auffarth. “Pressure sensors in modern phaco machines measure the pressure conditions directly in the anterior chamber of the eye, allowing for better regulation of the fluid flowing through the eye. The pressure that builds up and is maintained inside the eye during surgery can now be reduced to physiologic intraocular pressures of around 20 mm Hg using specialized handpieces and phaco machines,” Auffarth explained.

In contrast, older systems could generate pressures of up to 60 mm Hg, which have been associated with an increased risk for postoperative corneal damage and a heightened inflammatory response. “With the enhanced safety profile and the broader range of specialty lenses, we can successfully operate on more patients who were previously advised against implantation of a specialty lens for one reason or another,” Auffarth said. In addition, this is now possible for many patients with early glaucoma without optic nerve damage or those with well-controlled diabetes without retinopathy.

More Specialty Lenses

The most commonly used IOLs in cataract surgery are monofocal lenses. These lenses are regarded as having the highest image quality and have a single focal point, which can be chosen on the basis of personal preference for distance, near, or intermediate vision. Corrective eyewear is then necessary for optimal vision in the other areas. 

If the goal is to avoid glasses or contact lenses after surgery, alternative IOLs are available. These include specialty lenses with multiple focal points, lenses with extended depth of focus (EDOF), and lenses for astigmatism correction (toric lenses). In the context of refractive lens surgery, such as for correcting presbyopia (age-related vision loss) without cataracts, these premium or specialty lenses are increasingly being used in younger patients. 

“Recently, there has been so much development in the field of IOLs, and there is such a wide variety of products, that we can now offer almost every patient a personalized solution,” Auffarth said. To avoid postoperative problems, comprehensive patient education about the advantages and disadvantages of the various lens systems is essential, in addition to thorough diagnostics.

Alternative to Trifocal Lenses

For a long time, trifocal lenses — those with three focal points — were the most commonly used specialty lenses. These lenses utilize a specialized optical configuration to disperse light into distinct focal areas, facilitating distance, near, and intermediate vision. This technique results in some loss of contrast and partial overlap of focal lengths. 

Despite advancements that have reduced light loss from up to 20% to below 10%, “trifocal lenses remain susceptible to light-related side effects such as halos or glare and scattering light phenomena, which is why they are no longer the undisputed first choice,” Auffarth said.

The strongest competition now comes from EDOF IOLs, which no longer have clearly defined focal points. Instead, their focus is distributed over a relatively wide range. The biggest advantage is the reduction in light-related side effects, although there may be some limitations in near vision. The growing popularity of these lenses is demonstrated by a survey from the European Society of Cataract and Refractive Surgeons, which found that in 2023, nearly as many depth of focus lenses as trifocal lenses were used. 

Combining Different IOLs

However, both lens systems can also be combined using a mix-and-match configuration. “For example, combining an EDOF IOL in one eye and a trifocal lens in the other eye can be a good option in individual cases to reduce side effects,” Auffarth said.

Monofocal-plus lenses have also been available for some time. These are single-focus lenses with a depth of focus that permits sharp distance vision and some intermediate vision. In the so-called monovision strategy with these lenses, one eye is set to 0 diopters, while the other is slightly nearsighted at minus 1 diopter. 

Another alternative is the “blended vision” approach. “Here, we use EDOF IOLs so that one lens provides distance vision, while the other provides near vision, and together they cover the intermediate range.” According to Auffarth, EDOF and monofocal-plus lenses are increasingly being used in patients with moderate pathologies. 

“Overall, interest in and acceptance of specialty lenses are increasing, and many patients are specifically asking about scientific studies in this area,” Auffarth said. Whether a patient is truly suitable for this option is always determined through thorough diagnostics and counseling.

In Auffarth’s experience, “academics seem to place more value on their near vision and less on independence from glasses than others.”

This story was translated from the Medscape German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.