EyeWorld Asia-Pacific March 2020 Issue

EWAP MARCH 2020 9 FEATURE Cheong Fook Meng, MD Head of Ophthalmology Department, Gleneagles Kuala Lumpur Suite 312 MOB, 282 Jalan Ampang, 50450 Kuala Lumpur fmcheong@gmail.com ASIA-PACIFIC PERSPECTIVES T he overwhelmingly positive initial feedback from the U.S. ophthalmologists replicates our own trifocal intraocular lens experience in the Asia-Pacific region. The trifocal IOLs provide the greatest range of presbyopia correction combined with good quality distance vision, compared to the limited bifocality of bifocal or EDOF IOLs. They also have increased utilization of transmitted light energy and reduction in scattered light loss. Consequently, I find that patients are happier with the quality of vision attained and they seem to suffer less from bothersome dysphotopsias. Reading ability under dim light conditions is improved. In addition, the PanOptix trifocal IOLs have an intermediate focal distance of 60 cm, which is ideally suited for most patients in Asia with our shorter arm lengths. For consistent clinical success, I concur with the observations made in the article. I would reiterate the following: (1) Perioperative dry eye management is essential for reliable biometry measurements and good postoperative visual acuity and quality. (2) Apart from hitting the spherical refractive target, astigmatism control is equally important. In my experience, patients are happiest when postop astigmatism is 0.50 D or less. Nearly 70% of my trifocal implantations are toric IOLs. (3) I take at least three keratometry readings from different devices, which I input into the Barrett Toric Calculator to obtain the median values, to refine the toric power selection and alignment for more predictable astigmatism correction. (4) I perform OCT scans in every case and corneal topography in most, to exclude conditions that can compromise outcomes. I would exclude eyes with established maculopathies, glaucoma with central field defects, and corneal pathology with irregular astigmatism. Setting expectations is an important element in ensuring satisfactory outcomes. For patients with high near and intermediate visual demands, such as professional photographers, I would forewarn these patients that spectacles may be required for visualization of the fine details of low contrast color variations and color shades when examining their images close up. Previous LASIK is no longer an absolute contraindication in my practice as the PanOptix IOLs have good contrast sensitivities. These IOLs are also versatile enough to be combined with a preexisting monofocal or bifocal IOL in the contralateral eye without inducing much adaptation difficulties to the patients. Currently, my preference for presbyopia correction is still bilateral trifocal implantations because of the synergistic effect of binocular summation, giving rise to a fuller range of vision clinically and superior defocus curves when tested objectively. Editors’ note: Dr. Cheong is a consultant with Alcon Laboratories. to our international colleagues, really provides a nice range of vision where people are able to see their computers and read without needing to be dependent on glasses,” Dr. Solomon said. Dr. Cionni offered a similar point, saying that the same IOL model can be implanted in both eyes, improving results and making the preop discussion easier for the surgeon and more understandable for the patient. Dysphotopsias, Dr. Yeu said, seem to be a lesser concern with the PanOptix trifocal technology, particularly because the overall range and quality of vision are excellent. She said it’s more of a ring-like halo, rather than streaking or starbursts, so it’s easier to describe to patients. Considering candidates A healthy macula and ocular surface are key for success with these lenses, the sources said. Dr. Yeu said she is still relatively stringent in selecting patients for PanOptix. She is not currently offering this lens to patients who have had prior refractive surgery because, she said, she’s in an early phase of using the technology. Dr. Solomon had used PanOptix in one post-LASIK patient who was 2-weeks postop and doing well when EyeWorld spoke with him. While patients with prior refractive surgery were excluded from the FDA clinical trial and historically many U.S. surgeons have shied away from using multifocal lenses in these patients, he said the clinical experience in the U.S. with EDOF lenses and trifocals overseas in post-refractive patients is such that he felt confident doing so in a patient who didn’t have irregularities with their vision. PanOptix is available as a toric, correcting up to 3 D of astigmatism (T3–T6 available). Dr. Solomon said he’ll pair a nontoric version with femtosecond arcuate incisions for lower amounts of astigmatism, and Dr. Yeu said she’ll do the same with a toric version for higher amounts of astigmatism. In terms of setting expectations, Dr. Yeu said she feels looking at patient- specific considerations are less of an issue with these lenses. She still sets the expectation that patients will need extra magnification for extremely fine print or in poor lighting conditions, but Dr. Yeu said this conversation is more to cover her bases. Dr. Solomon said he also tells patients preoperatively that a presbyopia-correcting cataract surgery could be a two-part procedure: First to address the cataract and implant the lens and second to perform enhancements that might be necessary. He said enhancements occur in about 15% of premium IOL patients. When to avoid trifocals Dr. Cionni said that although it hasn’t been studied, it’s likely that patients with significant corneal aberrations would not be happy with multifocal, EDOF, or trifocal IOLs. Patients with RK and keratoconus, for example,