EyeWorld Asia-Pacific December 2012 Issue

16 December 2012 EWAP FEATURE Views from Asia-Pacific Robert ANG, MD Senior Consultant, Asian Eye Institute 8th Floor Phinma Plaza, Rockwell Center, Makati City, Philippines Tel. no. +632-8982020 Fax no. +632-8982020 RTAng@asianeyeinstitute.com I t is ironic that while we view multifocal IOLs as a premium product, we are actually trying to find preoperative clues on who not to implant it in. Factors such as personality, dry eye, PCO, preoperative and possible postoperative retinal problems, postoperative refractive error and possible dissatisfaction from unwanted visual phenomena are difficult to predict and quite bothersome to deal with. It does not help that expectations are definitely higher because of the additional cost. And it seems like a unanimous recommendation that if preoperatively there is some uncertainty, go for the “safer” alternative of putting a monofocal lens. I believe these are the reasons why multifocal IOL use will continue to encounter a steep climb towards universal acceptance. When using multifocal IOLs, there are crucial decisions that need to be made by patient and doctor. First, patients have to understand that there are advantages such as good reading vision but likewise drawbacks such as decreased contrast, glare and haloes. When patients have accepted the compromise and decided on a multifocal IOL, the second decision is which multifocal IOL to implant. There are many models to select from, and now there is a further classification of bifocal or trifocal. Over the past two years, it has gotten a little more confusing owing to the introduction of newer brands and iterations of older models. Third is refractive targeting. We cannot overemphasize the importance of IOL power selection and achieving the correct refractive outcome to get the best visual performance. Last but not least is postoperative intervention. When there is dissatisfaction, a decision has to made whether to explant the lens, perform YAG capsulotomy, perform Lasik or to wait it out and intervene at a later time. It may seem cumbersome, but I believe multifocal IOLs will remain an important part of the spectrum of IOL options we can offer patients. In my practice, 50% of patients choose a presbyopia-correcting IOL. Out of the non-toric premium IOL cases, approximately 60% choose an accommodating IOL and 40% choose a multifocal IOL. I present the advantage of a greater range of vision for premium compared to a standard monofocal lens. I also spend a lot of time explaining the possible downsides such as needing +1.0-D reading glasses for accommodating IOLs or suffering from glare and haloes for the multifocal IOLs. In the end, the decision usually boils down to which is the more acceptable compromise. And that’s where we are now. Striving to give the best to our patients but managing their expectations by making them understand that we do not have the perfect lens yet. Editors’ note: Dr. Ang is a consultant for Carl Zeiss (Dublin, Calif., USA/Jena, Germany) and Bausch & Lomb (Rochester, NY, USA), and receives travel support and research funding. has developed what he terms a multifocal lens funnel. “I would try to keep people in a monofocal lens if they had a lower chance of great uncorrected visual acuity or if they had clinic-busting personalities,” he said. Also being funneled toward monofocal lenses are those with a preference for reading glasses and occupational night drivers, as well as those with bad corneas, retinas, or tear film. Dr. Foster sees remaining patients as excellent candidates. “If they make it through that funnel then I’m quite enthusiastic about what a multiple focus lens could do for them,” Dr. Foster said. On the treatment track Still, some patients may end up unhappy. To offset those cases, Dr. Colin calls for practitioners to treat any complication that may diminish outcomes with multifocal lenses immediately. Dr. Colin also suggested employing careful prophylaxis to avoid difficulties. He recommended treating dry eye and blepharitis in anyone being considered for a multifocal lens. He also urged use of OCT to identify those with exfoliation syndrome, which brings the risk of secondary IOL decentration. Cystoid macular edema can be a worry in multifocal lens cases. Bonnie An Henderson, MD , assistant clinical professor, Harvard Medical School, Boston, Mass., USA, pretreats high-risk patients with NSAIDs for 3 days prior to surgery. “After surgery, I continue the NSAIDs for 3 months for high-risk patients and for patients who had a complicated, prolonged surgery,” she said. Likewise she urged practitioners to guard against decentration in multifocal lens cases. “I recommend operating under topical anesthesia in order to accurately center the IOL with the visual axis of the patient,” Dr. Henderson said. “If the IOL is centered based on the pupillary center, angle kappa errors can occur, and if centered on the limbus, angle alpha errors can occur.” Therefore, if the patient is under topical anesthesia she suggested having him focus on the microscope light and centering the light reflex together with the innermost ring of the multifocal IOL. Of course, in some cases it may become necessary to consider an IOL exchange. “If there is a large refractive surprise, I will perform an IOL exchange for either monofocals or premium IOL types,” Dr. Henderson said. “The sooner the IOL exchange, the easier it is to remove the lens.” Dr. Henderson will only bring the idea of doing an early Nd:YAG capsulotomy into the equation if she is certain that there will be no need for such an IOL exchange. “If there is a possibility that an IOL exchange will be needed, I avoid a YAG capsulotomy until after the IOL exchange is performed,” she said. Overall, as a backstop, Dr. Henderson believes in testing for eye dominance and operating on the non-dominant eye first in bilateral premium IOL cases. “If the patient has difficulty or is dissatisfied with the outcome of the first eye, then a different type of IOL can be implanted in the dominant eye to address what was lacking or disappointing with the first eye’s outcome,” she said. EWAP Editors’ note: Dr. Colin has financial interests with Alcon (Fort Worth, Texas, USA/Hünenberg, Switzerland), Abbott Medical Optics (Santa Ana, Calif., USA), Addition Technology (Des Planes, Ill., USA), Thea (Clermont- Ferrand, France), Optical Express (Glasgow, UK), and Bausch + Lomb (Rochester, NY, USA). Dr. Foster has financial interests with Alcon and AcuFocus (Irvine, Calif., USA). Dr. Henderson has financial interests with Alcon and ISTA Pharmaceuticals (Irvine, Calif., USA). Contact information Colin: 33-05-56-79-56-08, joseph.colin@chu-bordeaux.fr Foster: 970-221-2222, gjlfos@aol.com Henderson: 781-487-2200, bahenderson@eyeboston.com At the multifocal - from page 14