EyeWorld Asia-Pacific September 2013 Issue

40 EWAP CAtArACt/IOL September 2013 Pannet PANGPUTHIPONG, MD Director, Mettapracharak Hospital and Eye Institute, Department of Medical Services, Ministry of Public Health 52 Moo 2, Tambon Raiking, Ampur Sampran, Nakornpathom Province, Thailand 73210 Tel. no. +6634-225417 Fax no. +6634-321243 pannetp@hotmail.com E xisting or future developing ocular comorbidities are very important for long- term success of a multifocal IOL. The following conditions are not uncommon: • Dry eye will affect the precision of K readings for IOL calculation as well as visual performance after implanting a multifocal IOL. Corneal topography should be performed in all cases that may be a candidate for multifocal IOL in order to detect a surface problem. • Cases with corneal degeneration or dystrophies that may lead to decreased vision in the near future should be avoided. • In post refractive surgery patients, there may be problems acquiring accurate IOL calculations. • High myopic patients may have problems with residual astigmatism and progression of myopia after surgery as well as progression of myopic degeneration. • A patient with diabetes with DR of any degree or poor control DM without DR may not be a good candidate for multifocal IOL. • Epiretinal membrane (ERM) of any degree may exist in nearly 10% of old cataract patients. Preoperative OCT should be performed in all cases that may be a candidate for multifocal IOL. In case of dense cataract with poor OCT view, the patient should be informed about this potential cause of a poor outcome. • In dense cataract with poor fundus view, patient should be informed about potential causes of poor outcome such as macular degeneration or dystrophy, normal tension glaucoma. • 1% of cataract patients may have amblyopia. Editors’ note: Dr. Pangputhipong has no financial interests related to his comments. Views from Asia-Pacific how good I can rehab the ocular surface before deciding which lens to use.” If he can improve the ocular surface and tear film quality before implanting the lens, he would be happy to use a multifocal IOL. However, he said it is important to address the problem beforehand because it may pose a problem if the multifocal IOL is implanted and then attempts were made later to address the tear film. Dr. Mackool Sr. said dealing with ocular surface disease for potential multifocal IOL candidates can be challenging. “Not only is it a very complex subject, it comes in all different degrees, creates all different degrees of disability, and there are a number of different ways that you can deal with it preoperatively and postoperatively.” With ocular surface disease, Dr. Mackool Jr. said motivation is crucial. It’s important to look at how far a patient is willing to go in certain measures to become a Abhay VASAVADA, MD Director, Iladevi Cataract & IOL Research Centre Raghudeep Eye Clinic, Gurukul Road, Memnagar, Ahmedabad – 380 052, India Tel. no. +91-79-27492303, 27490909 Fax no. +91-79-27411200 icirc@abhayvasavada.com Vaishali VASAVADA, MD Consultant, Iladevi Cataract & IOL Research Centre info@raghudeepeyeclinic.com P atient selection is one of the most crucial aspects of ensuring successful outcomes following multifocal IOL implantation. Screening out those candidates who are not good candidates for multifocal IOL is key to avoid postoperative embarrassment and unhappy patients. Wheareas it is true that those patients who are primarily motivated for spectacle independence are the best candidates for multifocal IOL implantation, every patient should be made aware of the variety of IOL options available, including multifocal, toric, toric-multifocal, and aspheric IOLs. More often, it is the lack of awareness that precludes patients from choosing multifocal IOLs and other advanced technology IOLs. However, I discuss the suitability of multifocal IOLs with patients only after performing a detailed preoperative evaluation, which includes corneal topography for assessment of astigmatism, dry eye assessment, aberrometry, specular microscopy, and retinal evaluation along with spectral domain OCT of the posterior segment. In case a patient is not a suitable candidate for multifocal IOL implantation, the patient and their caregivers should be informed about why it is not a good idea to implant multifocal IOLs in his/her eye. Presence of any ocular comorbidity is a red signal for me, and we would usually avoid implanting a multifocal IOL in these patients. Drusen at or around the macula, epiretinal membranes and evidence of nonproliferative diabetic retinopathy are contraindications for us to implant multifocal IOLs. However, in well controlled diabetics without any changes of diabetic retinopathy, we would not hesitate in implanting a multifocal IOL. Similarly, presence of or high degree of suspicion of glaucoma, Fuchs’ dystrophy or zonular weakness due to pseudoexfoliation are all situations where we would not implant a multifocal IOL. An important yet often neglected aspect in preoperative evaluation is the assessment of ocular surface disease (OSD). Ocular surface symptoms are often the cause for patient dissatisfaction following an otherwise perfect surgical outcome. In case any form of OSD is detected, it should be treated aggressively prior to performing cataract surgery. More importantly, treatment for the OSD should continue even after surgery, to ensure a smooth postoperative course. To summarize, ensuring proper patient selection will ensure satisfied multifocal patients which will in turn add the wow factor in your practice and enhance your multifocal IOL practice. Editors’ note: Dr. Abhay Vasavada and Dr. Vaishali Vasavada have no financial interests related to their comments. Comorbidities - from page 39