Next-gen lasers and IOLs for every patient: the year ahead in cornea

Ophthalmology Times Europe spoke with Dr Amir Hamid, medical director of Optegra, London, UK, about the year ahead in cornea care. In his words, here are the biggest challenges and most innovative techniques coming in 2024.

New lenses present opportunities for more patients

We still have our trusted refractive IOL technologies which, for the right patient, can give great levels of spectacle independence. But there are newer technologies; for example, the enhanced monofocal lenses, which bring a level of presbyopia correction without some of the issues that you may get with a diffractive type of IOL. You still maintain that monofocal quality of vision and it’s not detrimental. Someone who may have some other ocular pathology, such as macular degeneration or glaucoma, can still get some level of presbyopia correction.

The other even more exciting development is a non-diffractive type of presbyopia-correcting intraocular lens. That started with the Alcon Clareon Vivity IOL, but now you can also see it with the Johnson & Johnson TECNIS PureSee refractive extended depth of focus (EDOF) lens, which we will start using as well. You get monofocal light quality, with an extended depth of focus to varying degrees. What you were able to give to your patients previously, provided they didn’t have any other ocular comorbidity, you can now give to a broader selection of people. Now, with cataract surgery, almost every procedure can be a refractive cataract procedure. You are improving visual performance without sacrificing quality of vision. That’s probably the most exciting thing that’s happening. It started with the enhanced monofocals, but will continue with the newer generation of EDOF lenses.

At Optegra, we have been able to use and evaluate newer technologies. I look forward to next year, when we’ll get to present those results. We performed two different lens evaluations this year, and we’re probably going to do a couple next year as well. I’m most excited to compare them with investigators elsewhere in the world – you learn things from everyone. This industry is accelerating, especially in IOL technology. The best lens right now, in a year’s time, will no longer be the best.

Training remains a challenge for seasoned pros and new ophthalmologists

There are many options now for a surgeon trying to adopt new technologies into their practice, whether it’s corneal refractive surgery or lens-based refractive surgery. For a long time, there was only one manufacturer who produced a laser that could perform lenticule surgery, Zeiss. In the last few years, other manufacturers came on board – Schwind, Ziemer [Ophthalmic Systems] and now Johnson & Johnson. Almost everyone is in the game, and this competition within the marketplace can only be a good thing for innovation. But it can be challenging if you’re a new surgeon. You have a lot of questions to ask: “What do I do? Which platform is best for me?”

In Europe, refractive surgery is not as well formalised into our training programs. Most of our training programs are geared toward therapeutic ophthalmology: you’re dealing with pathology, but not so often refractive errors, even though they’re a huge burden on the population. At Optegra, we’ve taken some steps toward offsetting that. Even though we’re a commercial organisation, we’re involved in training junior doctors in cataract surgery. We’ve invested in an [artificial intelligence] software, working with Zeiss as one of the pilot sites for the surgery optimiser app. The software records the surgery and uses artificial intelligence to segment each part of the operation. It provides analysis as to how long surgery takes per step, how smooth it was, and where the steps have been configured, and you’re able to compare that data [with] a reference case. As trainers, we can help improve each step in the surgery. A training doctor can view their trainee’s cases remotely, and very quickly provide feedback. I use it as well, to look at my own cases and see what I can do better. The next step is for that technology to be integrated into the devices we use, and guide doctors during the procedure. In the future, we’ll have technology that uses those past reference cases to guide your actions during surgery.

Corneal tissue implantation is promising across a range of issues

Something that is in its early stages, but that we need to keep in mind, is the the use of allografts for the implantation of corneal lenticules for correcting a refractive error. They move away from the previous issues with implanting foreign bodies in the cornea, such as inflammation, infection, rejection, glare and halos, by using corneal tissue to correct the refractive error. For hyperopia or presbyopia, for example, that’s quite good, and it’s also being used to treat things like keratoconus and ectasia. Though this technique is still in the early stages, the results are very, very promising without a lot of the disadvantages that we’ve seen before.

Lenticule extraction shifts into overdrive

The use of small incision lenticule extraction (SMILE) for treatment of hyperopia is due to be approved in Europe and rolled out to the rest of the world. There are two major issues when treating hyperopia with LASIK. One of them is regression. You get lots of regression afterwards, particularly in higher prescriptions. And the other problem is loss of best-corrected visual acuity, because with LASIK, you aren’t able to treat on the patient’s visual axis.

The new hyperopic SMILE gets away from that. We know SMILE is very, very stable. It’s not sensitive to regression; there are lots of data on that when we look at myopic patients, so I can’t see that it would be different for hyperopia, because of the technique used. We know with the latest version of the Visumax, the Visumax 800, you’re treating on the visual axis when you create your lenticule. In a couple of years, we should have a look back and ask, “Has hyperopic SMILE fulfilled its promise?” I think it’s definitely something that will make a big change.

That’s going to be a major focal point at meetings throughout 2024. For those of us who perform lenticule surgery, there is a growing understanding that we need to be working together to enhance outcomes. We can learn from each other, based on different techniques and the different platforms we use. There will be some form of convergence. That’s due to happen in lenticule surgery. There’s talk about standardising the terminology, because everyone’s got their own name for the same procedure. It also happened in LASIK: There were many different approaches, and eventually, things converged.

Photo courtesy of Dr Amir Hamid.

Even 10 years ago, we wouldn’t have imagined we would get to this stage of corneal refractive surgery. We’re just continuing forward, and the progress is accelerating nonstop. You just have to keep ahead of it.

Amir Hamid, MD, BMedSci BMBS FRCOphth CertLRS

E: Amir.Hamid@optegra.com

Dr Hamid is a cataract and refractive surgeon and medical director of Optegra, London, UK. He is an honorary senior lecturer for the University of Manchester’s Refractive Surgerymaster of science course.