REFRACTIVE 40 EWAP SEPTEMBER 2022 would argue that each of these lenses has distinct advantages. You have to figure out what works best in your hands; for example, a lens that works best in my practice may not work as well in someone else’s. … If you get great results with one, offer one. But if you can identify the advantages of certain lenses, you’ll find patients who fall into certain categories and line up better with certain lenses,” he said. Dr. Braga-Mele said there are patients who choose to go with the standard lens because it’s what they want and/or what they can afford, “but they deserve to know about all the choices so they can make an informed decision.” “There are those who want the monofocal aspheric, and whether it is distance vision that they want, monovision that they want, or they are low myopes and want to be low myopes again because that’s what they’ve been all their life, you have to give them that choice,” Dr. Braga-Mele said. “If they have astigmatism, it can be unmasked by cataract surgery, too, and patients may be unhappy if you don’t offer them an astigmatic choice. Moving forward from that refractive challenge is the challenge of presbyopia-mitigating IOLs. ... We’re trying to minimize the need for glasses but not get rid of glasses completely; that’s how I tend to explain it to my patients. We can get rid of glasses for 85–90% of their tasks but we’re not getting rid of glasses completely.” Dr. Braga-Mele said she started with Alcon presbyopiamitigating IOLs because she liked the consistency she experienced with their other IOLs. She said that when getting into these technologies to choose brands that you’re familiar and comfortable with. Even if patients are not a candidate for a presbyopia- mitigating IOL, Dr. Davidson said that it’s important to discuss with them and share why you’re recommending a specific IOL. “I say it with every patient because I don’t want them going home thinking, ‘Why didn’t he mention it to me?’ We had that situation in our practice when ReSTOR [Alcon] first came out. We had a couple of physicians who didn’t offer it. We had patients in the waiting room hearing stories, and we had some upset patients because we didn’t offer it to them. We now have a policy in our practice … that if you don’t feel comfortable doing a refractive IOL, you need to at least mention it to the patient, and if the patient wants it, you need to refer to another surgeon in the practice who offers this technology.” Dr. Davidson further clarified that just because there are several lens options offered at a practice, it still important to come up with a single “best” recommendation because too many choices can be confusing for patients and they look to us as their surgeons for guidance. “It’s still my job to recommend a single lens to the patient,” he said. Dr. Braga-Mele also said that she educates patients about all the choices that are available, Presbyopia eye drops in development Multifocal and trifocals: Dr. Braga-Mele said it’s important to have a pristine eye for these lenses. Patients cannot have corneal issues like dry eye or EBMD, visual field defects, or retinal pathology or potential for progression of retinal pathology. She will consider a patient who has had a very mild refractive ablation for these lenses. Dr. Davidson said he’ll use these lenses in otherwise healthy eyes. He’s also willing to do them on patients who are post-refractive, provided they have good-looking topography. Astigmatism should be minimal and regular, he said. Ideal patients in Dr. Vendal’s practice for trifocals or multifocal lenses are those with healthy retinas and optic nerves who want as much independence from glasses as possible and who can tolerate some nighttime artifact. Extended depth of focus (EDOF): These IOLs, Dr. Braga-Mele said, can be offered to patients with mild dry eye, but she veers away from other corneal pathology. She said these lenses can also be offered to patients with mild to moderate glaucoma and those with mild macular degeneration or small epiretinal membrane because contrast sensitivity is not reduced. “The patient [should be] informed that they will get a range of vision that may not be 20/20 because of their ERM but they won’t lose contrast sensitivity, and that’s the key with these lenses,” Dr. Braga-Mele said. Dr. Davidson said if a patient is concerned with glare or halo, these lenses are a better option for them. Dr. Vendal also noted the benefit of good contrast sensitivity at distance and said ideal candidates are those who spend most of their time looking at an intermediate/ computer distance and who can tolerate some nighttime artifact. There is a non-diffractive EDOF option now that doesn’t have any nighttime glare/artifact, she said. “As a cataract/refractive surgeon who also practices glaucoma, it has been exciting to have a non-diffractive option for my subset of glaucoma patients who previously could only choose monofocal implants at the time of cataract surgery,” she said. “I think it’s very important that when you’re starting to venture into the presbyopia-mitigating IOL portfolio, even with the EDOF lenses, you should start with pristine eyes so you can optimize your outcomes,” Dr. Braga-Mele said. Id al candidat s for resbyopia-mitigating IOLs A holistic - from page 35
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