Dr Mahipal Sachdev explained that he would follow a stepwise approach of preoperative assessment (Figure 2). “Preoperative exclusion criteria such as preoperative dry eye, corneal scarring, pupil size of <2.5 mm and monofocal implant in the rst eye are important in managing postoperative challenges,” he clari ed. Accurate and reliable ocular biometry is essential for IOL power calculation.3,12 Dr Sachdev advised surgeons to analyze the posterior cornea using IOLMaster® 700 (ZEISS) and consider matching the residual cylinder with total keratometry and corneal topography. “Residual cylinder is detrimental to the patient and compromises the outcome any IOL implantations,” added Dr Ramamurthy. “Make sure you have accurate biometry and exclude all contraindications to any multifocals,” advised Dr Paul. Dr Fam shared that the target refraction for TECNIS SynergyTM should be emmetropia- or hyperopia-targeted and not myopia-targeted since TECNIS SynergyTM delivers good near vision. “By targeting myopia, the dysphotopsia will worsen and make the patient more unhappy,” cautioned Dr Fam. Dr Kim Myoung Joon shared that he uses an easy to remember ABC stepwise approach of preoperative assessments for all his PCIOL cases - Astigmatism control, Biometry, and, Corneal status. Large angle kappa plays a role in the decentration of multifocal IOLs and may result in glare and halos, although angle alpha better predicts photic phenomena with multifocal IOLs.3 As such, extremely large angle kappa and angle alpha should be avoided. Patients’ postoperative expectations should be adequately managed and be informed of the need to wear glasses for some activities as well as the possibility of visual disturbances such as glare and halos, especially at night.12 Clear communication such as showing patients various photic phenomena images during preoperative counselling is helpful in managing patient expectations. However, with neuroadaptation, photic phenomena will be tolerated and will not be too bothersome for patients. Furthermore, while glares and halos are common across all trifocals, patients receiving TECNIS SynergyTM who have been counselled can generally accommodate and tolerate them well. Clinical pearls for TECNIS SynergyTM: Postoperative management and neuroadaptation Visual neuroadaptation plays an important role in determining the nal visual outcomes after IOL implantation.13 PCIOLs may require 4–8 weeks for visual adaptation to attain excellent outcomes.12 Early postoperative neuroadaptation has been observed in patients with multifocal IOL implantation. In patients receiving multifocal IOL implantation, adaptation suppression was observed in the early postoperative stage, resulting in visual disturbances. However, these visual disturbances greatly improved following visual neuroadaptation by 3 months postoperation.13 “Neuroadaptation is very important, can be multifactorial, and may be attributable to personality,” said Dr Fam. All other factors such as dry eye and refractive error should be addressed before neuroadaptation. It is also helpful to consider patients’ age and ocular history. “I believe younger patients neuroadapt quicker than older patients,” noted Dr Ramamurthy. To speed up neuroadaptation, Dr Boonchai Wangsupadilok would give his patients some visual tasks to perform at home postoperatively. “I would get my patients to watch television for an hour a day and have them explain how they feel during the rst week follow-up. Generally, my patients can adjust within 2–4 weeks,” said Dr Wangsupadilok. For Dr Rojanapongpun, he would consider intervening if neuroadaptation failed 3–6 months postoperatively in patients with dysphotopsia. “Personally, I have had no issues with lens exchange within 6–12 months, if the surgery was performed well,” he noted. Glare and halos are more common among patients with large pupils.3 Before going to neuroadaptation, Dr Noguchi pointed out that it is important to focus on factors such as patient’s age and pupil size or position. Posterior vitreous detachment (PVD) is common after cataract surgery with IOL implantation.14 Although it is considered a complication of low clinical relevance, its occurrence suggests the impact of cataract surgery on the architecture of the ocular globe. However, PVD does not directly threaten vision. Dr Robert Paul explained that when patients complain of blurring or waxy vision, surgeons should not attribute all complaints to the optics of the lenses, but to rule out other factors. Clinical pearls on achieving high patient satisfactionwith TECNIS SynergyTM Continuous-Range-of-Vision IOL “Neuroadaptation is very important, can be multifactorial, and may be attributable to personality.”
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