EyeWorld Asia-Pacific June 2014 Issue

39 EWAP CAtArACt/IOL Pseudophakic dysphotopsia June 2014 is any dry eye,” she said. “Make sure that the ocular surface is healthy because the first thing that we get to is the tear layer when we’re looking at how light is refracted by the eye, so any ocular surface disease can certainly be problematic for the patient. If there is ocular surface disease, that needs to be adequately treated because it can either change the refraction and/or cause some dysphotopsia.” Counseling patients Dr. Berdahl explains to his patients that multifocal IOLs are the best technology to make them spectacle independent, but he never promises this as a certainty. He explains that multifocal IOLs also have tradeoffs to consider. “One of those tradeoffs is that vision in low light might not be as good,” he said. “Another tradeoff is that there’s a decent chance that the patient will have rings or halos around some light.” If a patient is willing to put up with these possibilities to be more spectacle independent, he or she would probably be a good candidate for this type of lens. Dr. Talley Rostov said it’s important to determine if the glare/halo was present immediately postoperatively or occurred gradually. “If it’s something that was present immediately postoperatively and hasn’t gotten any better, that may be someone who needs an IOL exchange,” she said. However, if the patient was seeing great for the first several weeks after surgery, it could be a posterior capsule problem. Different IOL types and designs Sometimes the design of the IOL matters with this problem, Dr. Talley Rostov said. However, she noted that glare and halos can occur with any of the multifocal IOLs. She said there are complaints of waxy or diminished vision, especially a little more with the ReSTOR IOL (Alcon, Fort Worth, Texas, U.S.). She stressed the importance of paying attention to details with multifocal IOLs. “Multifocal IOLs are especially sensitive to any sort of refractive error, decentration, so it’s important to make sure all of those things are spot on.” Dr. Katsev said he sometimes finds that both diffractive lenses, the Tecnis Multifocal (Abbott Medical Optics, Santa Ana, Calif., U.S.) and the ReSTOR, can have issues, but these can usually be overcome. “Correcting any little refractive error helps to solve the problem,” he said. You can’t be 100% sure that the dysphotopsias of multifocal lenses won’t be a problem, but you can eliminate the patients who might have more of a problem, he said, like those with irregular astigmatism and engineer-type personalities. “When you have an accommodating IOL like the Crystalens [Bausch + Lomb, Rochester, NY, U.S.], you only need to worry about edge glare and uncorrected refractive error,” Dr. Katsev said. EWAP Editors’ note: Dr. Tipperman has financial interests with Alcon. Dr. Talley Rostov has no financial interests related to her comments. Dr. Berdahl has financial interests with Alcon and Bausch + Lomb. Dr. Katsev has financial interests with Bausch + Lomb, Alcon, Abbott Medical Optics, and Allergan (Irvine, Calif., U.S.). Contact information Berdahl: john.berdahl@vancethompsonvision.com Katsev: katsev@aol.com talley rostov: atalleyrostov@nweyes.com tipperman: rtipperman@mindspring.com dislocating the entire lens,” he said. “In order to solve this problem, I ended up incising the capsule with the keratome, grasping the incised edge under viscoelastic with a tying forceps, enlarging the tear further, and leading this tear into a circular pattern.” This was the first continuous tear capsulorhexis. After discovering this technique, Dr. Neuhann began to work on it as a reproducible technique. However, it was a challenge because viscoelastic was not readily available; he had some of the few samples of this where he was working in Germany. “Having heard of Howard Gimbel’s technique presented in 1985, which joined several capsular punctures by tears with the capsulotome, I developed a technique to perform a continuous circular tear under irrigation with a needle-capsulotome starting from a single puncture and including this puncture in the tear-out to create a 360-degree continuous tear contour,” Dr. Neuhann said. The technique can be performed under all circumstances. It was then that Dr. Neuhann changed the name of the technique to capsulorhexis because it was more of a tear than a cut like a capsulotomy. “We first named it continuous circular capsulotomy but because it did not have to be a perfect circle to resist tears, we changed the name to continuous curvilinear capsulorhexis,” Dr. Gimbel said. What has changed? Dr. Neuhann said there hasn’t been much change since he first started using the continuous curvilinear capsulorhexis (CCC) technique. “The unlimited availability of viscoelastic substances has made the technical performance easier and has made technical variations possible, such as the use of forceps through the main incision or tube guided through a paracentesis,” he said. Additionally, the advent of capsule dyes has made the visibility with white cataracts easier. He added that with the increased popularity of femtosecond laser- assisted cataract surgery, there has been a return to the can opener technique. “We have better viscoelastic for challenging cases,” Dr. Gimbel said. He added that trypan blue can help stain white capsules, which were previously frustrating to deal with. There have been many mechanical devices and means like the Fugo blade (Medisurg, Norristown, Pa., U.S.) to cut through a very fibrotic capsule, he said. “Of course now we have the femtosecond laser to make it perfectly round and centered,” Dr. Gimbel said. “But the name of the game is continuous. It doesn’t have to be circular. Some argue that it has some effect on lens tilt if it’s perfectly centered and round.” He added that the CCC technique has allowed him to develop the divide and conquer technique because with an intact opening, there is no risk of splitting out. The CCC demanded dividing the lens because a very brunescent lens can’t be brought out of the capsule unless you have a large opening, Dr. Gimbel said EWAP Editors’ note: Drs. Neuhann and Gimbel have no financial interests related to this article. Contact information Gimbel: hvgimbel@gimbel.comN euhann: prof@neuhann.de Managing - from page 37