EyeWorld Asia-Pacific September 2017 Issue

Views from Asia-Pacific Chandra BALA, MD Clinical Associate Professor PersonalEyes Level 2, 33 York Street, Sydney, Australia Tel. no. +88337111 chandrabala.eye@gmail.com T he ability to be successful with multifocal IOLs has never been easier with so many optical designs now available to surgeons and patients. The basic key to success with multifocal IOLs has not changed…“give the patient more than you take away.” Establishing if MF-IOLs will give the patient a better quality of life than they currently have is an important starting point and can exclude patients early in the vetting process. Asking a simple question such as “Out of 10, how much does relying on glasses currently impact your quality of life?” followed by “Out of 10, how much would not relying on glasses to see improve your quality of life?” is an easy way to get an initial feel for patient motivation. You can follow this up with “Out of 10, how much would seeing rings around lights and glare from street lights and car headlights at night bother you?” The second step to success is to understand if, visually, are you going to give the patient more than you are taking away? Patients with moderate to advanced cataracts are always going to be easier than those who still have good vision. Hyperopes who have blurred unaided vision at distance, intermediate, and near are always considered the “easy” patients as you are giving them more vision at all distances without really taking much away from them at all. With emmetropes, you must consider if the improvement at near outweighs the changes to their distance vision. Beware of the patient who is uncompromising. With myopes, will what you are giving them at distance outweigh what you are taking away from near? Beware of the –2.0 to –3.0 myope who can do their make up without glasses or who read by just lifting up their glasses. The third step is knowing what lens selection will best match the patient’s tasks. Refractive lenses are good for photopsia-averse patients. Many will still need glasses for intermediate. Without spectacle independence, consider the value proposition being offered to these patients. Trifocals are most likely to provide spectacle independence and lens selection is usually based on patient-preferred working distances (which may be affected by their height). Patients don’t think in cm so discuss working distances in terms they can relate to and remember postop when adapting to their new vision. The defocus curves show that PanOptix (Alcon, Fort Worth, Texas) will give patients better vision at arm’s length than the AT-LISA (Carl Zeiss Meditec, Jena, Germany) and FineVision (PhysIOL SA, Liège, Belgium), which dip here. An easy rule of thumb for making a trifocal lens decision is if patients need to have a high level of intermediate acuity beyond their outstretched fingertips then consider AT-LISA or FineVision. If the patient can comfortably position all their near and intermediate tasks at the distance of their outstretched finger tips or closer then PanOptix may be your best lens choice. Also consider the anatomy of extremes. If they are high myopes or hyperopes the IOL dimensions are an important consideration as it may rotate or vault, respectively. High myopes may need retinal detachment surgery in the future and perhaps a hydrophobic IOL would be a better choice as it will not opacify with gas during vitrectomy. Lastly, if the outcome is a refractive surprise, then be willing and ready to do excimer laser. This is especially important in the dominant eye. Editors’ note: Dr. Bala declared no relevant financial interests. Shin YAMANE, MD Assistant professor, Yokohama City University Medical Center 4-57 Urafune-cho, Minami-ku, Yokohama, Kanagawa 232-0024, Japan Tel. no. +81-45-261-5656 Fax no. +81-45-253-8490 shinyama@yokohama-cu.ac.jp D r. Dell’s questionnaire is well constructed and very useful for IOL selection. Even if surgeons teach patients the characteristics of all IOLs, it will be difficult for them to choose the best IOL themselves. It is difficult to choose from many choices. By choosing two or three choices in this questionnaire, patients can get closer to choosing the best IOL. It is also a good idea to use the length of the paper for judging the reading distance. Analysis of this questionnaire and the satisfaction after surgery may make it possible to predict the degree of satisfaction after surgery. Supplementary images may help patients understand. It is difficult to understand halo and dysphotopsia without images. Photos and videos are easily added in the digital version. There are some things that I will definitely check on when choosing patient IOL that are not included in this questionnaire. History of refractive surgery, glasses and/or contact lens use, etc. Satisfaction level and problems on current appearance also help to predict postoperative satisfaction. It is important to determine which eye is dominant. However, this may be difficult for patients to answer themselves. Patient personality is also important for choice of IOL. Dr. Dell said, “The least happy people postoperatively were those who rated their personality exactly in the middle of the scale.” This is a very interesting fact. I think that it was kindness to show how to approach patients who have made such a choice. There is a tendency for Japanese to choose the middle, and many people may be included in this category. I strongly agree with the opinion of Dr. Braga-Mele. Questionnaires are useful, but it is not possible to omit discussions between surgeon and patient. The choice of IOL is complicated and there is no single answer. Most patients hope to see all ranges (distant, intermediate and near) without glasses and also want to drive at night. Questionnaires help patients to get their priorities right but it is also important for patients and surgeons to think together. Editors’ note: Dr. Yamane declared no relevant financial interests. One way – from page 35 continued on page 38 “ The basic key to success with multifocal IOLs has not changed... ‘ give the patient more than you take away. ’ ” - Chandra Bala, MD 36 EWAP CATARACT/IOL September 2017