Tablao Debates: Cataract-Refractive Edition

You could almost see the heel sparks as Team Abanico and Team Castañuelas pounded the Tablao platform over one of the searing questions in cataract refractive surgery—extended depth of focus (EDOF) lenses or trifocals as the first choice? This unique team debate format was part of an ongoing ESCRS effort to liven up the traditional conference presentation format.

Fans of vision quality

Team Abanico fanned the flamenco for EDOF with their feature of avoiding night dysphotopsias. “In the world of presbyopia correction, there is always a compromise. And halos and night vision problems [are] a compromise that cannot be compensated,” said team leader Francesco Carones MD. EDOF lenses reduce such distortions compared with dif­fractive trifocals, allowing patients to better manage night situations, he said.

He further fuelled the fire by pointing out that technology has changed visual needs. “Intermediate distance is the new near because people use computers, people use tablets. … No one is reading at 30 cm like when newspapers were printed [without a] way for having a bright image.”

EDOF lenses are also more forgiving, Dr Carones said. “If you leave a little bit of residual myopia, that eye can still perform quite well at distance.” So, in most cases, 20/20 distance can still be achieved, plus the extra half dioptre gives an extra boost to intermediate and near vision. “You can really reach the best of two worlds—avoiding night dysphotopsias as well as having spectacle independence—by having one of the two eyes slightly on the myopic side.”

Concluding the first round with a flourish, Dr Carones emphasised quality of vision, especially at night, as key. “Patients are demanding. We do not want them complaining about something that cannot be compensated.” This is becoming ever more important as the average age of cataract patients declines, and they remain more active.

Reading really clicks

Team Castañuelas leader Damien Gatinel MD, PhD, recited several problems with Dr Carones’ EDOF fanfare. Unassisted reading is what matters.

“EDOF lenses are not trifocal. There is a price to be paid,” he said. “There is no near vision that patients can use to read.

In some patients, yes, but it is not predictable.”

Often, patients hear ‘near vision’ and they think ‘reading vision,’ which is still needed for using smartphones, Dr Gatinel said. “If you don’t explain everything, then they are not happy.”

Trifocals, Dr Gatinel observed, give intermediate and near vision without introducing spherical aberrations. “Of course, you will have some halos with trifocals. But how many patients complain about halos severely? If it were so many, no one would use them.” Trifocals are the most-used premium lenses worldwide, he pointed out. Indeed, many patients would tolerate even worse halos in exchange for being able to read without spectacles.

EDOF lenses, on the other hand, always sacrifice some distance vision by deforming the optic to provide depth of focus, Dr Gatinel said. EDOF lenses are also less effective in reducing spectacle dependence. “We must always warn the patient that reading specs will probably be necessary, or we must do monovision. But what is monovision but a myopic shift in the non-dominant eye?” Achieving near vision with EDOF lenses, he argued, requires degrading distance vision in one or both eyes.

Finally, patient studies show that perceived visual quality and satisfaction are as high or higher with trifocal lenses, and halos are possible even with EDOF lenses, Dr Gatinel said. “So, what is the point in having halos and no near vision?”

In the end, he argued, EDOF lenses fail to make the patient fully spectacle independent. If surgeons explain the limitations of trifocals and operate on patients with cataracts, the halos and glare are minimal compared with cataracts, he concluded.

Intermediate is the new near

Reinforcing Team Abanico’s strongest argument with an enthusiastic audience, Basak Bostanci MD dismissed Dr Gatinel’s arguments as mere chestnuts. Patients no longer spend much time quietly reading at home. “We are not doing that anymore. We are doing things that require intermediate vision; more dynamic things like digital streaming, household devices, seeing the car panel when we are driving.” Plus, not everyone is a candidate for diffractive IOLs.

“I have a lot of patients and friends and family who don’t want to wear glasses anytime, anywhere, anyplace,” Margarita Cabanás MD refuted for Team Castañuelas. Counselling patients that any dysphotopsias are going to pass is essential to reach that goal. “It’s very important to convey that to my patients.”

After two more lightning rebuttal rounds, the audience rendered its verdict: EDOFs won more fans than clicks for trifocals.

All comments were made amid passionate flamenco dancing in the innovative Workshop Tablao at the 2024 ESCRS Congress in Barcelona.

Francesco Carones MD is medical director and physician CEO of Advalia-Carones Vision in Milan, Italy. fcarones@carones.com

Damien Gatinel MD, PhD is chief of anterior segment and refractive surgery at the Rothschild Foundation, Paris, France, and associate professor at Abulcasis International University of Health Sciences, Rabat, Morocco. gatinel@gmail.com

Basak Bostanci MD, FEBO is associate professor of ophthalmology at Bahcesehir University School of Medicine and cataract and refractive surgeon at Dunya Goz Hospital, Istanbul, Turkey. drbbostanci@gmail.com

Margarita Cabanás MD is associate professor at Loyola University Andalusia and the University of Seville, chief for keratoconus at Clinic Baviera, and head of ophthalmology at Virgen del Rocío University Hospital, all in Seville, Spain.