EyeWorld Asia-Pacific September 2013 Issue

39 EWAP CATARACT/IOL September 2013 Comorbidities with multifocal IOL implantation by Ellen Stodola EyeWorld Staff Writer When selecting patients for multifocal IOLs, physicians must consider conditions that could cause complications or impact the effectiveness of the IOL W hen it comes to considering patients for multifocal IOLs, comorbidities are factors that need to be weighed, along with a patient’s motivation and goals for changes to his or her vision. “The first and single most important thing to me is what the patient’s visual goals are,” said John Berdahl, MD , Sioux Falls, SD, USA. Depending on whether a patient wants to be glasses-free or doesn’t mind wearing glasses helps to shape his approach. If patients are visually picky, Dr. Berdahl said, then they may not be satisfied with the tradeoffs that can come with the IOL. In addition, he said the eye’s condition has to be good to implant a multifocal IOL. “The eye has to be pretty pristine,” he said. Both Richard J. Mackool, Sr., MD , and R.J. Mackool, Jr., MD , Mackool Eye Institute, Astoria, NY, USA, agreed that a patient’s motivation for wanting a multifocal IOL plays a large role in determining who is a good candidate. At their practice, patients fill out a detailed questionnaire beforehand. “Educating patients first and having them express interest in the lens, I think that is important,” Dr. Mackool Jr. said. Oftentimes, patients will want a specific lens because they know it is special or a friend has it, he said, so it’s important to determine patients’ motivation and to give them as much information as possible about the different lenses. Ocular surface disease Rick Wolfe, FRACS, medical director, Peninsula Eye Centre, Melbourne, Australia, said the tear film is particularly important because it is the principal refracting surface. “A quick assessment of the tear film is easy in all patients presenting for cataract surgery,” he said. However, multifocal IOLs require a closer and more careful assessment. Dr. Wolfe said knowing a patient’s history of dry eye symptoms is helpful, although that should not necessarily disqualify someone from getting a multifocal IOL. “In cases with ocular surface problems, preoperative treatment might be required if there is likely a reversible element,” Dr. Wolfe said. “Management includes AT A GLANCE • Physicians agree on the value of discussing options with the patient and exploring each individual’s motivations for wanting a multifocal IOL. • The way comorbidities affect a patient’s eligibility for a multifocal IOL depends on the severity of the issue and ability to treat the condition before implantation of the IOL. • A patient’s compliancy with treatment is an important factor in deciding if he or she is an ideal candidate for a multifocal IOL. Views from Asia-Pacific Hiroko BISSEN-MIYAJIMA, MD, PhD Tokyo Dental College Suidobashi Hospital 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo, Japan 101-0061 Tel./Fax no. +81-3-5275-1912 bissen@tdc.ac.jp T he management of presbyopia is a long-term dream for both ophthalmologists and patients. There are two major approaches for presbyopia, one is corneal surgery and the other is lens surgery. Within these approaches, the implantation of multifocal intraocular lens (IOL) achieves the most reliable and stable results and is widely used. We all know that the diffractive design provides both distance and near foci; however, the drawback of this design is the loss of contrast sensitivity. In addition, the impact of ocular diseases is a concern when we consider the multifocal IOL. In this article, the conditions of the ocular surface, cornea, and retina are individually discussed. Why do we need to consider these conditions more carefully than for patients who would receive a monofocal IOL? I believe that the slight loss of contrast sensitivity impacts the visual function more obviously in eyes with multifocal IOLs when the patient has dry eye, corneal guttata, or macular problems. Every ophthalmologist wants to see a happy patient, and not a dissatisfied one. That is why we try to exclude patients who have these problems from implanting multifocal IOLs. On the other hand, even patients who have dry eye or pre-macular membrane, some are very happy with multifocal IOLs. As Dr. Mackool mentioned at the beginning of the article, the patient’s motivation and expectation play important roles in the success of the multifocal IOL. Since the patients who wish multifocal IOLs are in their 50s and 60s, we should also consider the possible problems which may occur with aging. In addition to the problems mentioned here, glaucoma is well known to occur with age. If the patients have early signs of any of these problems, it is safer not to implant a multifocal IOL. However, we should also consider that even patients showing early signs of corneal or retinal problems can enjoy spectacle independence with sufficient distance and near visual acuities until the problem becomes symptomatic or it may not ever manifest itself. It is very hard for us to estimate the progress of any type of ocular disease. I believe we should be careful enough to select the appropriate patient for the multifocal IOL; however, we should listen to the patient’s motivation and be flexible, too. Understanding the patient’s needs and giving the best options is our job! Editors’ note: Prof. Bissen-Miyajima has no financial interests related to her comments. treatment for lid problems, lubricants, anti-inflammatories, cyclosporine, and punctal plugs.” He said this problem would need to be assessed until the tear film proves to be adequate, and if it does not improve, a multifocal IOL may not be the best option. Dr. Berdahl said ocular surface disease can be worked around for those wanting a multifocal IOL. “If they have ocular surface disease, that doesn’t automatically disqualify them. But I want to see continued on page 40