The optical principle behind the Bausch + Lomb LuxSmart IOL – in addition to monofocal-like halo and glare among his patients – is a major reason why Melbourne cataract surgeon DR MICHAEL SHIU is adopting the lens in more of his patients.
Melbourne cataract and refractive surgeon Dr Michael Shiu is agnostic when it comes to the intraocular lenses (IOLs) he uses. Trifocal, extended depth of focus (EDOF) and monofocol designs – from various manufacturers – are all at his disposal, but ultimately it comes down to the physiology and lifestyle of the patient sitting before him.
Today, around 30% of his surgeries involve an IOL offering vision at varying distances – and the newest design he’s adopted is the LuxSmart Preloaded, a premium hydrophobic IOL from Bausch + Lomb (B+L). Offering an extended range of vision with a monofocal-like visual disturbance profile, he’s found the lens has performed especially well in patients transitioning into retirement.
And with the lens recently released in its toric form (August 2022), its post-operative rotational stability has also been a feature, thanks to B+L’s four-point haptic design.
“For a while I had been using Bausch + Lomb’s monofocal platform, enVista, and have been achieving good results,” Dr Shiu, a cataract and refractive surgeon who works across multiple sites in Victoria, explains.
“I started to build some trust with their product and after reading articles and talking to my rep, I introduced LuxSmart by carefully selecting the patients who I knew would have a strong probability of good results to begin with. I’ve found the lens to be particularly useful in those in the 60-70 age range as they transition out of the working age group. They may be more lifestyle-focused; for example, playing golf or using the computer where there is a demand on their intermediate vision.”
LuxSmart has been available to Australian surgeons since May 2022.
According to B+L, it offers a range of vision required to cover the major needs of cataract patients in their daily activities. The lens has been reported to provide distance and intermediate continuous vision with some spectacle dependence for near tasks. One of the lens’ key attributes is a potentially similar visual disturbance profile to a monofocal IOL.
In Clinical Ophthalmology in 2021, Campos et al., reported the LuxSmart IOL achieved higher performance for intermediate and near vision compared with a conventional monofocal IOL, without increasing the risk of dysphotopsias. They concluded the lens “may be an attractive and safe option for patients who desire spectacle independence for distance and intermediate vision”.
As an adopter of EDOF and multifocal IOLs from various manufacturers, Dr Shiu is particularly fond of the optics in LuxSmart.
The lens is based only on refractive profiles (Pure Refractive Optics Technology – PRO Technology), meaning there are no diffractive areas. The optics comprise a refractive aspheric surface at the periphery, a patented transition zone and a 2 mm elongated focus centre with combination of 4th and 6th orders of spherical aberration of opposite signs.
“In some designs, what we know about the technology isn’t entirely clear, whereas with LuxSmart it’s quite clear about how the optics work, utilising spherical aberration to manipulate the light and offer patients and extended range of vision, it’s easy for us to understand,” he says.
For Dr Shiu, a key feature of LuxSmart is the lack of halo or glare reported among his patients. This could be as high as 5% in other EDOFs he uses, and 10-12% in trifocals, according to the literature.
“With LuxSmart, I’m seeing less visual disturbance risk, in fact in my experience I’ve had no reports of this among my patients so far. It is something that quietly surprised me and the lens stands out for that reason,” he says.
In Dr Shiu’s experience, it may take three to four weeks before the patient realises the final outcome. For patients with a larger pupil size, he is more inclined to choose LuxSmart, in addition to those who prioritise distance visual acuity over their intermediate vision.
“Most of my patients achieved 6/6 to 6/7.5 unaided for distance, N8-N6 intermediate and N8 near too with good lighting,” he adds.
With any premium IOL offering an extended range of vision, he says it is vital to manage patient expectations. The lighting conditions, pre-existing dry eye disease, contrast sensitivity and other visual requirements all play a role.
“These technologies rely on a so-called blur circle, so that means there will be blur at some distance,” he says.
“Therefore, as a clinician, we have to explain to the patient they may achieve 95% distance vision or 90% intermediate with these lenses, depending on the patient. But I think LuxSmart does perform very well in both eyes, especially for distance – they usually see towards 20/20 for binocular visual acuity.”
Toric experience
Since B+L launched the toric version of LuxSmart, Dr Shiu has also moved to implant the IOL in his astigmatic patients too. The LuxSmart toric comes in 0.75, 1.00 and 1.50 D and higher cylinder powers. The additional low power toric (0.75D) allows improved accuracy for the majority of toric patients, who would have otherwise received a 1.00 D lens.
The IOL’s four-point fixation is a key feature. According to B+L, lenses with this haptic design have shown to have good centration,1 and similar postoperative performances in terms of corrected distance visual acuity, inflammation and primary capsule opacification (PCO) compared with the C-loop design.1
Additionally, around 90% of lenses with four-point fixation rotate less than five degrees at six months,2 and are stable in the eye.3
While Dr Shiu says the lens can tend to rotate peri-operatively in his experience – meaning the surgeon needs to wait until the lens sits properly while avoiding over-inflation of the capsule – post-operatively it demonstrates excellent stability and is a more forgiving lens.
“For EDOF and multifocal toric lenses, this is vital, because if there’s any residual astigmatism, even up to -0.50 D cylinder, this will already degrade the quality of vision because you’re adding another aberration on top. And if you reach -0.75 D cylinder, you will not achieve great outcomes,” he explains.
“But it also means you need to have a strategy in place to correct residual astigmatism, whether that be laser refinement or going back in to re-rotate the lens. I tell my patients there’s a 5% chance of refinement due to astigmatic correction.
“But ultimately, it’s vital for any surgeon implanting these types of lenses to ensure the calculation all the way through to post-op care are performed with precision to avoid issues later down the track.”
LuxSmart also features B+L’s 360-degree continuous square edge on the posterior surface. Nixon and Woodcock4 demonstrated this design element had significantly less posterior capsule opacification (PCO) than a square edge that was interrupted at the optic–haptic junction.
In terms of the learning curve, Dr Shiu says he has taken time to adapt to the LuxSmart lens material that can unfold slower than some other IOLs he uses, and he has been methodical in learning how to use the injector system.
For other surgeons considering adopting the LuxSmart, he says first it is important to understand the technology and physical properties of the lens.
“The second piece of advice is that with a lens of this nature, you’ve got to ensure the patient is easy-going and actually requires that particular range of vision to begin with,” he says.
“The third thing is to always talk to a representative to learn how to use the lens and perform the calculations. Sometimes, you’ve got to trust the platform and be patient with the post-op result. You can’t become too disheartened after the first week when they’re not achieving 20/20 like a monofocal.
“But in my experience, the patient doesn’t usually complain with the LuxSmart compared with some other lenses immediately after surgery, especially with glare and halo. So they have more leniency to wait for it to work.”
At the end of the day, Dr Shiu says lens selection is determined by the patient in front of him, taking into account the physiology of their eye, lifestyle and preferences.
LuxSmart is providing yet another important tool in an ever-improving suite of IOLs designed to meet the growing demands patients seeking greater freedom from their spectacles. As an example, research cited by B+L shows the use of digital devices by Australian seniors in the near and intermediate visual range has increased in recent years, with senior internet use also increasing from 68% to 93% from 2017 to 2020.5
“The new generation of EDOF lenses is giving additional choice for the patient that wants distance and intermediate vision, with some near vision, while also minimising the potential of glare and haloes,” Dr Shiu says.
“I’m individualised in my approach. Ophthalmologists using these lenses need to take the time to carefully understand the benefits and limitations so they can go through an appropriate patient consent process. By having a go-to lens approach as opposed to tailoring the lens selection, sometimes you run the risk of increasing dissatisfaction, halo and glare because of the aberration factor with these lenses. We’re fortunate to have access to this technology, however all presbyopia-correcting lenses whether multifocal or EDOF require the same level of care.”
More reading
Bausch + Lomb’s new LuxSmart IOL provides cataract patients with daily range of vision
Bausch + Lomb acquiring Xiidra dry eye drug from Novartis
Bausch + Lomb acquires AcuFocus … and small aperture IOL tech
References
1. Mingels, A., Koch, J., Lommatzsch, A. et al. Comparison of two acrylic intraocular lenses with different haptic designs in patients with combined phacoemulsification and pars plana vitrectomy. Eye 21, 1379–1383 (2007).
2. Kwartz J, Edwards K Evaluation of the long-term rotational stability of single-piece, acrylic intraocular lenses. British Journal of Ophthalmology 2010;94:1003-1006
3. Buckhurst, Phillip J.; Wolffsohn, James S. PhD; Naroo, Shehzad A. PhD; Davies, Leon N. PhD Rotational and centration stability of an aspheric intraocular lens with a simulated toric design, Journal of Cataract & Refractive Surgery: September 2010 – Volume 36 – Issue 9 – p 1523-1528
4. Nixon DR, Woodcock MG. Pattern of posterior capsule opacification models 2 years postoperatively with 2 single-piece acrylic intraocular lenses. J Cataract Refract Surg 2010; 36:929–934
5. Australian Communications and Media Authority. Communications and media in Australia; The digital lives of older Australians May 2021.