EyeWorld Asia-Pacific June 2017 Issue

65 EWAP DEVICES June 2017 Dr. Garg said EDOF recipients can still have some unwanted visual side effects but, so far, patients he has implanted tend to not complain as much about nighttime halo and glare compared to some multifocal recipients. “Therefore, I feel more comfortable putting them in younger patients who lead active lifestyles,” Dr. Garg said. “However, if I have an elderly patient who wants some independence from spectacles and really does not drive much at night, I may favor a low-add multifocal lens.” EDOF targets The broader defocus curve on an EDOF IOL can be used in a few ways, Dr. Walton said. “Typically, I’ll recommend the dominant eye first with an EDOF if the cornea is consistent across our four devices and we get good optical biometry data,” Dr. Walton said. “This is in contrast with monofocals for which I tend to recommend non-dominant first at a slightly myopic target to increase the chance of hitting distance in the dominant without erring toward hyperopia.” After the first eye, Dr. Walton re-evaluates the patient’s functional status and if they are happy at all distances, he aims to replicate it in the second eye to preserve optimal depth perception. “If they want more near, we can use loose lenses over the first eye to simulate what the second will look like,” Dr. Walton said. “Most patients will not need more than –0.5 D of myopia in the non-dominant eye to achieve an excellent result, and I typically aim closer to –0.35 D.” Compared to options Because of their optical advantages, Dr. Chang uses EDOF IOLs as his primary lens for correcting presbyopia. He makes it clear to patients that they will have reduced dependence on glasses for intermediate and near vision but may still need glasses for very small print. He occasionally uses monofocoal IOLs for monovision in patients who prefer not to pay out of pocket but is careful to limit it to patients who have previously experienced monovision—either with contact lenses or naturally—and enjoy it. In patients with long- standing monovision, Dr. Garg often keeps them with monovision after cataract surgery, but he has had success switching some to EDOF IOLs. “There is some data to suggest that EDOF IOLs can be used in patients with subtle macular/optic nerve dysfunction,” Dr. Garg said. “I still counsel these patients extensively about the pros and cons of this.” Dr. Dell has found accommodating IOLs offer a greater margin of safety in some patients. “While many patients with less-than-perfect eyes can receive an EDOF lens safely, the image quality with an accommodating IOL will always be better,” Dr. Dell said. “Accommodating IOLs are associated with a different constellation of challenges, such as slightly reduced refractive predictability, susceptibility to capsular contraction, and greater PCO formation. Accommodating IOLs work extremely well when carefully utilized, but the near vision effect is sometimes variable from patient to patient.” Mix and match? Dr. Dell said his practice has extensively mixed EDOF IOLs with multifocal IOLs, which he describes as “an extremely good and underutilized strategy.” Dr. Chang agreed on good results from mixing lenses, particularly in low myopes who received an EDOF lens in the dominant eye and feel like they want more near vision. “I typically use a 3.25 D multifocal in the other eye, and they’ve been quite happy with that,” Dr. Chang said. “Their perception of intermediate and near blends together—it’s not like a monovision situation where the difference throws them off. Even though their night vision symptoms are slightly different, patients tolerate it well.” Previous corneal surgery In patients with previous refractive surgery, the degree of corneal irregularity and the type of prior refractive surgery are the primary drivers of which type of IOL to use, said Dr. Dell. For example, EDOF or multifocal IOLs can be very successful in patients who have undergone prior myopic wavefront-guided or wavefront- optimized LASIK. Prior hyperopic LASIK is more problematic owing to the negative spherical aberration these patients typically demonstrate. All multifocal IOLs and EDOF IOLs available in the U.S. will add to this negative spherical aberration. Additionally, hyperopic LASIK patients also demonstrate more challenging ocular surface disease presentations, which can further complicate the situation. “Patients with prior refractive surgery must be cautioned that hitting the refractive target will be more difficult, but these patients understand they have complex cases,” Dr. Dell said. “They can often be very grateful, even with a refractive miss postop, so long as there is a plan in place preop to address that potential outcome.” EWAP Editors’ note: Drs. Chang and Garg are consultants for AMO. Dr. Dell is a consultant for AMO and Bausch + Lomb (Bridgewater, New Jersey). Dr. Walton has financial interests with Alcon (Fort Worth, Texas). Contact information Chang: dchang@empireeyeandlaser.com Dell: steven@dellmd.com Garg: samgarg@gmail.com Walton: drwalton@visiontexas.com