EyeWorld Asia-Pacific June 2017 Issue

42 EWAP refractive June 2017 patients are asking for a presbyopic lens solution, they expect to be able to read, but they also demand vision at distance. The new low add lenses have dramatically improved vision at distance, which has made them more popular and has gained patient satisfaction,” he explained. The Symfony IOL is an extended range of focus lens, and it doesn’t have two different focal points. Instead, it has an extended focal point that goes from near out to distance. “There is no point in between where the patient loses vision, so the patient has depth of focus where he or she can see things at different distances. Traditional multifocal IOLs have two distinct focal points, and between those two focal points, there is usually a loss of vision. The Symfony lens is calibrated to provide an extended depth of focus. In my opinion, it gives the highest quality of distance vision of any lenses we have seen in the multifocal category. For this reason, the lens has become extremely popular in a very short period of time in the United States. However, even with the Symfony lens, there is some loss of quality of distance vision,” Dr. Donnenfeld added. “I have seen a tremendous increase in demand. I think patients are looking for these solutions, overwhelmingly. We are doing a much better job of providing them with the outcomes they are looking for. When you are evaluating someone for a multifocal lens preoperatively, you want to make certain that he or she is an optimal candidate, which means good retinal function, good corneas, and no macular degeneration. Postoperatively, if patients complain of loss of quality of vision, the first thing you want to check is whether they have residual refractive error. Unlike with previous generations of lenses, today, most patients can be corrected to a point where they will be happy,” he explained. According to Bryan Lee, MD, JD , Los Altos, California, “the rate of multifocal IOL implantation has been fairly stable for many years, in the 7% to 9% range (actual number is 5–6%). There are definite advantages in convenience, but these lenses necessarily require some optical compromises. Of course, there are also some patients for whom the cost is a barrier.” He noted that the future for presbyopia-correcting IOLs looks promising as the number of Baby Boomer patients needing cataract surgery increases. “The new category of extended depth of focus IOLs should also drive growth in this segment,” he explained. He added that there is always a sacrifice of some quality of vision with multifocal IOLs. “Patients are trading some sharpness for convenience. Contrast sensitivity decreases because incoming light is being split between the distance and near images, and some of the light is lost because of the optics. I also tell all of my patients to expect halos and night symptoms, but I explain that most patients do not find them very bothersome,” he said. “Ultimately, I think the key is to have a well-informed patient with realistic expectations. If the patient is unhappy, I have a low threshold for IOL exchange because unhappiness with a multifocal is a reversible condition,” he added. EWAP Editors’ note: Dr. Donnenfeld has financial interests with AMO, Alcon, and Bausch + Lomb (Bridgewater, New Jersey). Dr. Foster has financial interests with Alcon, Bausch + Lomb, AcuFocus (Irvine, California), and Ivantis (Irvine, California). Dr. Lee has no financial interests related to his comments. Contact information Donnenfeld: ericdonnenfeld@gmail.com Foster: gjlfos@gmail.com Lee: bryan@bryanlee.pro phacoemulsification surgery. They had a shorter dry macula period before and after phaco and needed more injections after surgery for visual recovery,” Dr. Vassileva explained. Fluorescein angiography revealed a predominance of classic choroidal neovascularization in Group IA (66.6%) and a predominance of occult choroidal neovascularization in Group IB. Group II demonstrated a predominance of classic choroidal neovascularization (63.5%). Dr. Vassileva observed better BCVA outcomes in patients who were treated for wet AMD prior to cataract surgery and who experienced longer dry macula periods both before and after surgery. The patients from Group IB and Group II needed a longer time to improve BCVA. Dr. Vassileva’s observations concur with previous studies that demonstrated risk factors associated with exudation recurrence in wet AMD patients undergoing cataract surgery. One such study was a retrospective review of medical records in which 39 patients were identified as having had cataract surgery after being treated with anti- VEGF drugs for exudative AMD. 1 It showed that the diagnosis to surgery period (P=0.001) and the preoperative exudation- free period (P<0.001) were both significantly longer in patients without recurrence than in patients with recurrence. The study authors recommended that cataract surgery be performed after a sufficiently long exudation-free period to minimize exudation recurrence. Performing cataract surgery at the right time for each patient is of the essence. Dr. Vassileva noted, “Many studies show evidence of increased risk associated with cataract surgery for AMD progression, especially in patients with wet AMD. But, when patients have both wet AMD and cataract and visual acuity is declined, monitoring macular changes is more difficult, and it is hard to define the cause for vision loss. Our decision to perform cataract surgery in our wet AMD patients is really a personalized timing approach. We have to perform surgery when visual acuity decreases but must take into consideration all the risk factors and make sure to always explain the process to patients along the way. Cataract surgery is beneficial for all patients who have the comorbidities wet AMD and cataract. Surgery provides them with a better quality of life and should not be delayed to ensure optimal monitoring and treatment of wet AMD. Patients with wet AMD should receive blue light filtering IOLs, and they need to be followed very closely after phacoemulsification, especially macula monitoring using OCT and fluorescein angiography to identify fluid recurrence.” EWAP Reference 1. Lee G, et al. Factors influencing the exudation recurrence after cataract sur- gery in patients previously treated with anti-vascular endothelial growth factor for exudative age-related macular degen- eration. Graefes Arch Clin Exp Ophthalmol . 2014;252:1573–9. Editors’ note: Dr. Vassileva has no financial interests related to her comments. Contact information Vassileva: centersight@sobalpashev.com Timing – from page 39 Era – from page 41