EyeWorld Asia-Pacific September 2015 Issue

September 2015 25 EWAP FEATURE out with very good quality vision. I have found that the key to success in implementing this new technology is to quickly and accurately ascertain what the patient really wants to see without correction and match it to the best IOL to achieve that goal. I accomplish this by requiring each patient to complete a simple, 1-page questionnaire to determine what the patient’s desired outcome is. The questionnaire helps patients pinpoint what they really want, while also shaping expectations before they even meet with me; patients begin to realize that there are certain optical compromises that they may be required to make. I utilize the information garnered from the questionnaire, in conjunction with my discussion with the patient, to customize a solution to help them to meet their visual target or to help them understand that they may have unrealistic goals. Managing patient expectations is an important step in determining successful outcomes. Developing the surgical plan Developing the surgical plan begins by determining the best level of add power, or combination of add powers, to achieve the patient’s desired outcome. This decision should never be left in the hands of the patient; this is the surgeon’s responsibility. Finding the best solution is dependent upon ensuring that the surgeon and patient are working within the same confines of context and that the patient has a complete understanding of the advantages and disadvantages associated with each lens. This is an area where the questionnaire proves valuable. I use the Tecnis Multifocal family of IOLs, which are currently available in 3 add powers, offering enhanced vision at one of three focal points: +2.75 D, +3.25 D, and +4.0 D. In my experience, as well as in published studies, the Tecnis Multifocal lenses provide a quality of vision advantage over earlier multifocal lenses, particularly in multiple lighting conditions, with patients reporting lower incidences of halos and night glare. 1 Additionally, Tecnis lenses are shown to reduce chromatic aberration for improved optical quality, 2 have a wavefront- designed aspheric surface that corrects spherical aberration to essentially zero, 3 and are made of a lens material not associated with glistenings. 4 Other benefits include a UV-blocking and glare-reducing design. 5,6 Patients surveyed for FDA approval reported extraordinary satisfaction rates. Up to 98% reported the ability to function comfortably without glasses at intermediate and far distances, and up to 97% stated that they would implant the same IOL again. 1 This level of satisfaction is extraordinary. Intermediate to distance vision (~50 cm theoretical reading distance): For the patient who requests good distance and intermediate vision, I will typically select the +2.75 D IOL for bilateral implantation. This lens provides patients superior distance quality and favors longer intermediate vision activities such as working at the computer and reading labels while grocery shopping. However, for the finest print the patient may need to utilize reading glasses. The highest levels of satisfaction in the FDA study as well as from my patients are with this particular lens. Intermediate to near vision (~42 cm theoretical reading distance): I will select the +3.25 D lenses for patients who prefer enhanced performance for closer intermediate activities. This might include reading a handheld device, such as a tablet or phone. Near vision (~33 cm theoretical reading distance): Patients who prefer engaging in near vision activities such as reading, sewing, or knitting benefit most from the traditional +4.0 high add-power lenses. Mix and match: This is the most common approach I utilize in my practice for implanting bilateral multifocal lenses. For a typical case, I will implant the +2.75 D in the nondominant eye, and then the +4.0 add in the contralateral eye. By combining the 2, we achieve all 3 ranges of vision. While there is overlap with these lenses, my patients report a clear improvement in close vision with the +4.0 D compared to the +2.75 D. My surgical protocol is to operate on the nondominant eye first and implant the +4.0 D lens. I explain to the patient that midrange vision will be a point of relative weakness compared to distance and near vision; however, we will fill in the gap when we implant the +2.75 D lens in the dominant eye approximately a week later. This protocol works well in situations where both cataracts are about the same size. If there is significant asymmetry between the cataracts, I will operate on the worst eye first. Getting started To conquer any trepidation of implementing the new multifocal add power lenses into a surgical practice, I recommend selecting patients with low hyperopia. Due to their tendency toward overall poor uncorrected vision, these patients are more likely to be accepting of almost any result. Additionally, I suggest starting with the +2.75 D lens due to the 97% satisfaction rate. 1 Incorporating the low add power IOL options allows for unique patient customization, resulting in high patient satisfaction rates—an outcome everyone will be happy about. EWAP References 1. DFU, Tecnis Multifocal 1-Piece IOL, Models ZKB00 and ZLB00, and DFU, Tecnis Multifocal 1-Piece IOL, Model ZMB00. 2. Zhao H, Mainster MA. The effect of chromatic dispersion on pseudophakic optical performance. Br J Ophthalmol. 2007;91(9):1225–1229. 3. Tecnis Foldable Posterior Chamber Intraocular Lenses (package insert). Abbott Medical Optics Inc. 4. Mainster MA. Violet and blue light blocking intraocular lenses: photoprotection versus photoreception. Br J Ophthalmol. 2006;90:784–792. 5. Nixon DR. New technologies for premium outcomes: next generation phaco and Tecnis 1-Piece IOL. Presented at the 25th Congress of the ESCRS, 2007, Stockholm, Sweden. 6. Calculated based on Holladay I formula. Holladay JT, Prager TC, Chandler TY, Musgrove KH, Lewis JW, Ruiz RS. A three-part system for refining intraocular lens power calculations. J Cataract Refract Surg. 1988;14(1): 17–24. Editors’ note: Dr. Dell is in private practice at Dell Laser Consultants in Austin, Texas. He has financial interests with Abbott Medical Optics. Contact information Dell : steven@dellmd.com