EyeWorld Asia-Pacific December 2012 Issue

17 December 2012 EWAP FEATURE Time to make a switch by Jena Passut EyeWorld Editor Indications, pearls offered for multifocal IOL exchange T here are papers, seminars, symposia, and articles devoted to unhappy multifocal patients—how to avoid them by careful patient selection, how to deal with them in the office, and how to maintain your cool when they become unbearably dissatisfied and demanding. When waiting, neuroadaptation, and referring them out don’t work, exchanging the multifocal lens may become a necessity. EyeWorld spoke to three surgeons about timing a multifocal exchange and what techniques may make the process easier. “We should strive to never have to exchange anyone for any reason,” said Richard Tipperman, MD , Wills Eye Hospital, Philadelphia, Pa., USA. “The flip side is that it’s not fair to take a patient who says, ‘My vision is not satisfactory. I don’t want to see like this for the rest of my life,’ and tell him, ‘You’ve gotta live with it.’” Dr. Tipperman believes that a change of mindset needs to take place about MFIOL exchanges, one that considers the refractive bonuses of cataract surgery and premium lenses. “For obvious reasons, no one wants to have to do an implant exchange for any patient, but the flip side is that advanced technology IOLs are a refractive procedure,” Dr. Tipperman said. “The ability to exchange the lens turns it into a 100% completely reversible refractive procedure. There are no other surgical refractive procedures that are completely reversible. Less than 1-2% of patients who are implanted are unhappy, but it’s a real phenomenon.” Indications for MFIOL exchange Cathleen M. McCabe, MD , partner and medical director, The Eye Associates, Sarasota, Fla., USA, said an IOL exchange can be avoided at first by performing “meticulous preoperative measurements and patient selection, with special emphasis on setting realistic expectations by fully disclosing the unique benefits and risks, strengths and weaknesses of each lens design.” Even so, patients may become intolerant of glare and halos and their inability to read or focus in the intermediate range. They also might be experiencing changes in the overall health of the eye, such as optic nerve damage or corneal disease. “It is often difficult to determine if the reason for a patient’s dissatisfaction with the function of the lens is due to the lens design or secondary to residual untreated refractive error, dry eye, posterior capsular opacification (PCO), or need for additional time AT A GLANCE • Despite good outcomes, multifocal IOLs remain a question mark for some • Factors such as whether a patient is on an antidepressant medication or has excellent post-op acuity can help to elucidate who will do well • Correct management of the patient before and after lens implantation can influence patient satisfaction Con MOSHEGOV, MD Senior Consultant and Head, Corneal and External Eye Disease Service Singapore National Eye Centre 11 Third Hospital Avenue, Singapore 168751 Tel. no. +65-62277255 lim.li@snec.com.sg T hey can build a presbyopia practice...but they can also demoralize surgeons and staff like nothing else in ophthalmology. Such is the dichotomous nature of multifocal IOL technology. I have been a fan of diffractive multifocal IOLs for almost 10 years. “Accommodating” IOLs, such as the Crystalens, Tetraflex (Lenstec, Inc., St. Petersburg, Fla., USA) and Synchrony (Abbott Medical Optics, Santa Ana, Calif., USA) simply haven’t been able to deliver spectacle independence for both distance and near and, in my experience, are no more than alternative monofocal lenses. As made clear in the article, IOL exchange needs to be considered in patients who aren’t able to overcome the contrast deprivation with diffractive IOLs. My feeling is that this is more likely with some manufacturer’s lenses than others. Even when ocular surface problems, residual refractive error, posterior capsule opacities and folds, macular or other posterior segment pathology have been excluded, some patients simply do not see well. I think Drs. Safran and Tipperman are spot-on in saying that some patients just have poor quality of vision. Glare and haloes are less common reasons for explantation…they simply compound the problem. The terms “Vaseline” or “waxy” vision have been used to describe it. Ghosting, even with the correction of any residual astigmatism, can also be intolerable to patients. As preoperative counseling prepares patients for suboptimal intermediate vision, it is never a reason for explantation in my hands. IOL explantation would not be indicated where a pair of +1.00-D magnifiers relieves the problem. IOLs can be explanted years later but it’s easiest to dial a lens out of the capsular bag in the first few months after initial implantation. It’s amazing how an AcrySof lens, appearing to be totally adherent to the overlapping anterior capsule, is so easily separated from it with the gentle nudge of a viscoelastic cannula and freed form the bag with visco-dissection. True enough, the haptics may be less obedient to manipulation. No matter how small the opening in the posterior capsule is after a YAG, once the viscoelastic goes in to free up the IOL, the opening enlarges and vitreous presents itself. Such is life! In summary, our experience in Australia is much the same as our American colleagues. They’re wonderful when the quality of vision is satisfactory, but diffractive multifocal IOLs can also disappoint. Surgeons using them on a regular basis need to be prepared to exchange them for monofocal ones when the patients are unhappy with their vision. Editors’ note: Dr. Moshegov has no financial interests related to his comments. Views from Asia-Pacific continued on page 18