EyeWorld Asia-Pacific September 2013 Issue

41 EWAP CAtArACt/IOL September 2013 An eye exhibiting epithelial basement membrane dystrophy (EBMD). This cor- neal condition, like corneal guttata and other comorbidities, should be identi- fied and dealt with before implanting a multifocal IOL in a patient. Source: Richard J. Mackool, Sr., MD better candidate. For example, if a patient has dry eye, compliancy with treatment plays a major role in determining how successful a multifocal IOL would be for that individual. “The motivated patients can overcome almost anything,” he said. Corneal guttata Dr. Berdahl said a few scattered corneal guttata does not automatically rule out a candidate for a multifocal IOL, but a patient’s motivation and severity of the guttata also need to be considered. It would probably be better to put the multifocal IOL in a patient who is a bit older because it could be challenging to deal with if the condition worsens over time. Dr. Mackool Jr. said it’s important to get a cell count with corneal guttata to determine how significant it is. “You need to evaluate the possibility that these guttata will advance to the point that they’re visually significant,” he said. Determining if a patient with some corneal guttata is still a candidate for a multifocal IOL centers around if contrast sensitivity is affected. “The more contrast sensitivity they have, the less likely the operation will be successful.” Dr. Mackool Jr. said just a few guttata should be fine. Dr. Wolfe said if a patient has a few guttata with a normal endothelial cell count, then that is not a problem for a multifocal IOL. “I think the severely undulating endothelium of cornea guttata compromises vision even before detectable edema occurs,” he said. “As the condition progresses it will only further compromise the visual function with a multifocal IOL.” He said he would not use a multifocal IOL in these patients. Macular rPE changes or drusen Dr. Wolfe said when considering a multifocal IOL in a patient with macular retinal pigment epithelium (RPE) changes or drusen, you must first consider what the patient’s current visual function is. Someone with good visual function could do well with a multifocal IOL. With progression of macular degeneration, the benefit of this type of lens could be lost, so it’s important to look at the pattern of a patient’s macular pathology. Dr. Mackool Sr. said it is usually advised that someone with macular degeneration should not get a multifocal IOL, but there is no definite yes or no answer. However, he said that most people with macular degeneration will not use multifocal IOLs. Especially with mild cases, he would be concerned with putting in a multifocal IOL and then having more severe macular degeneration affect the lens later on. “If there’s any drusen at or near the fovea, then I don’t do the multifocal IOL,” Dr. Berdahl said. In that case, he said an accommodating option or monovision is likely the solution. Diabetes with no BDr or mild BDr with no macular edema Dr. Berdahl said considering someone for a multifocal IOL who has diabetes with no background diabetic retinopathy (BDR) would be no problem. He also said that mild BDR with no macular edema should generally not rule someone out for a multifocal IOL. However, the patient would have to show that he or she is trying to control the diabetes. Both Dr. Mackool Sr. and Dr. Mackool Jr. agreed that patients with diabetes and no sign of retinopathy or who have the condition under control could still be candidates for multifocal IOLs. “If they have signs of background diabetic retinopathy, I think that’s something that you should consider strongly as a contraindication to doing a lens,” Dr. Mackool Jr. said. “Diabetes with no retinopathy is no problem, if the risk of developing sight-threatening retinopathy is low,” Dr. Wolfe said. Patients with diabetic retinopathy should be considered on an individual basis. He said presence of macular edema is a bad condition to pair with a multifocal IOL. Following up with the multifocal IOL If you’re considering implanting these lenses in patients who aren’t ideal candidates, they need to indicate that they understand this and the surgeon needs to be comfortable with that fact, Dr. Mackool Sr. said. “The patient should know from the outset that it’s not an exact science trying to decide which implant and which implant strength is best for any given patient.” He said regardless of the number of measurements and amount of preparation, patients need to know that they may not get a perfect result. “Sometimes people are disappointed if I won’t do a multifocal for them,” Dr. Berdahl said. He said it’s common to see patients with comorbidities when screening for a multifocal IOL. Three critically important keys to consider with multifocal IOLs are patient psychology, patient anatomy, and finishing the job to make sure there is no residual refractive error, he said. Most of his patients have been satisfied with the multifocal IOLs he has implanted because he is conservative in choosing those who receive them. EWAP Editors’ note: Dr. Berdahl has financial interests with Alcon (Fort Worth, Texas, USA/Hünenberg, Switzerland) and Bausch + Lomb (Rochester, NY, USA). Dr. Mackool Sr. has no financial interests related to the article. Dr. Mackool Jr. has no financial interests related to the article. Dr. Wolfe has financial interests with Alcon and AcuFocus (Irvine, Calif., USA). Contact information Berdahl: johnberdahl@gmail.com Mackool: mackooleye@aol.com