EyeWorld Asia-Pacific March 2019 Issue

48 March 2019 EWAP REFRACTIVE quality of vision at distance, which led him to, at the time, place the lens in the nondominant eye first to see how the patient might tolerate the optics. Newer low-add multifocals and the Symfony EDOF provide such quality of vision at distance that this is less of an issue, he said. “I’ve changed my mindset, and now I place the EDOF lenses in the dominant eye first, and what I want to know is how happy they are with their reading,” Dr. Donnenfeld said. “If they come back and say they’re happy with their distance and their reading is good, I put the same lens in their nondominant eye. If they come back and they say they like the distance but they don’t think they have enough reading, I can either do nanovision with the Symfony lens or I can place a Tecnis 3.25 D lens that will give more reading.” Dr. Solomon said he discusses nanovision all the time with his patients who are seeking spectacle independence. “What I tell them is their distance vision will be a little worse, but it’s in an effort to give them a better range of vision at intermediate and near. They’re going to have a little more haloing of lights with nanovision because you get that with a little bit of distance blur, but as long as they know that on the front end, they won’t be as bothered by it. A lot of patients choose it,” he said. Dr. Solomon said he also has positive outcomes with patients who have an EDOF lens in one eye and a multifocal, like the Tecnis 3.25 D, in the nondominant eye, allowing both eyes to be set to plano but the nondominant eye functioning at a slightly higher add for reading. Dr. Donnenfeld has taken this approach as well, but his preference is to use the same platform in both eyes. Like anyone being considered for a multifocal or EDOF lens, Dr. Solomon said he assesses the patient’s personality, among other factors. “I don’t do [nanovision] in type A patients or patients who are constantly going to compare one eye to the next, or anyone who is not an EDOF or multifocal candidate (those with irregular astigmatism, macular degeneration, diabetic retinopathy),” he said, adding that it is important to optimize the ocular surface, obtain accurate preoperative measurements, and optimize surgeon factors. “It’s going to be even more critical for the dominant eye that you hit plano because if both eyes are off target, patients aren’t going to be as happy. In nanovision and monovision patients, it’s critical to get the dominant eye on target for distance.” EWAP References 1. Donnenfeld ED, et al. Visual acuity outcomes post-implantation of an extended depth of focus toric IOL targeted for emmetropia or nanovision. Paper presented at the 2018 ASCRS•ASOA Annual Meeting. 2. Slade SG, et al. Extended depth of focus (EDOF) toric IOL targeted for emmetropia in both eyes or nanovision: defocus curve and reading speed results. Paper presented at the 2018 ASCRS•ASOA Annual Meeting. 3. Sandoval H, et al. Visual and refractive clinical outcomes with a new extended depth of focus toric intraocular lens targeted for binocular emmetropia or slight myopia in the nondominant eye. Paper presented at the 2018 ASCRS•ASOA Annual Meeting. Editors’ note: Dr. Donnenfeld has financial interests with Johnson & Johnson Vision and Alcon (Fort Worth, Texas). Dr. Solomon has no financial interests related to his comments. Contact information Donnenfeld: ericdonnenfeld@gmail.com Solomon: kds@cepmd.com Recovering from a posterior capsule hole - from page 46 posterior capsule break, you can’t put the lens in a bag so you have to fixate it in some other way. But here, the break ended up being so small that it did not extend so we could still put our lens right in the capsular bag, and that even helped cover the hole more.” Dr. Devgan also oriented the lens haptics 90 degrees away from the posterior capsular hole to ensure that they would not intersect it. Another change in such cases is that the hydration of the corneal incision should be done before removal of the viscoelastic to prevent collapse of the anterior chamber. Then, use low pressure and lower bottle height during irrigation/aspiration to remove the viscoelastic. Small shallowing can be quickly addressed by increased hydration. When a hole is manageable Dr. Devgan’s delineation between when a hole is manageable and when it’s unmanageable is if the defect is one-third the size of the optic diameter. Any hole that size or smaller still allows lens placement in the capsular bag. “If I have a huge hole, I can’t put the lens in,” Dr. Devgan said. “But when the lens is 6 mm in diameter and the hole is 2 or 3 mm in diameter, I can certainly put that lens in the capsular bag.” At the end of the case it’s important not to let the anterior hyaloid face collapse and allow vitreous to come through. In the postop period, the surgeon needs to look to ensure there’s no vitreous prolapse, as he or she would as part of any routine postop care. “I fumbled the ball, but I recovered and everything was fine,” Dr. Devgan said. “The capsular defect had no effect on the patient’s visual outcome because it was caught quickly. When you catch a complication like this early, you can still have problems but you can recover the ball. “ The case illustrates that every surgeon will face a complication sooner or later, and the key is knowing how to minimize and recover from it. The full case including video can be seen at www. CataractCoach.com. EWAP Editors’ note: Dr. Devgan has no financial interests related to his comments. Contact information Devgan: devgan@gmail.com Getting better - from page 47