REFRACTIVE EWAP SEPTEMBER 2022 41 Yoshihiko NINOMIYA, MD Vice President & Director of Department of Ophthalmology, Yukioka Hospital Clinical Professor, Department of Ophthalmology, Osaka University Graduate School of Medicine 2-2-3 Ukita Kita-ku, Osaka, Japan 530-0021 yoshihikoninomiya@gmail.com ASIA-PACIFIC PERSPECTIVES Choosing the best intraocular lenses (IOLs) is important to meet the expectations of patients who are seeking spectacle independence. The patients determine the success or failure of cataract surgery based on their uncorrected visual acuity. Getting to know the patient is the first key step in choosing the best IOLs. Learning about a patient includes diagnosing the patient’s eye condition and understanding his/her lifestyle and vision preference through interviews and questionnaires. To enhance the patient’s understanding of IOLs, it is important to gauge the patient’s level of understanding and explain the concept of monofocal IOLs. Then, if they are interested in multifocal IOLs, the associated cost should be explained before explaining multifocal IOLs. In Japan, multifocal and EDOF IOLs are covered by neither national health insurance nor private medical insurance (except for the Lentis Comfort LS-313 MF15 and its toric model (T1-3)). For patients who are uncomfortable paying out-of-pocket or are concerned about glare and halo, I have recommended monovision or the Düsseldorf Formula (monovision with Lentis Comfort). Compared to the aforementioned monofocal and multifocal IOLs, I found that my patients have a harder time understanding toric IOLs. However, simply saying that toric IOLs cure blurry vision can be misleading. Blurry vision can occur after surgery due to minor refractive errors or reduced contrast sensitivity from ocular surface, corneal, or retinal disease. So, rather than explaining astigmatism to my patients in terms of how they see, I have defined astigmatism conceptually using keratometric values and topographic maps. I always follow up with the patients and check their astigmatism after their surgery, too. While multifocal IOLs are important, my reading of research confirms that astigmatism must be alleviated for those lenses to have their effects. I use an astigmatism map from the wavefront sensor (KR-1W, Topcon) or the “toric check” feature of iTrace (Tracey Technologies) to check the reduction of ocular astigmatism attained by the orthogonality between corneal astigmatism and internal astigmatism. While some may believe that preoperative explanation is important, I suggest that postoperative explanation with special attention to astigmatism is also required for a holistic approach to refractive IOL offerings. Editors’ note: Dr. Ninomiya disclosed no relevant financial interests. not focusing on brand names but rather helping them choose the best visual range for their needs. “Look at the patient, look at their needs and personality, look at their eye anatomy and what’s a fit, then offer what’s available,” she said. Dr. Braga-Mele said that in order to successfully offer the full range of IOLs, there are certain diagnostic tools that will help ensure success. You need to have a good biometer, good formulas (she prefers the Barrett Universal or the Barrett True K), good refractive outcomes from your monofocal IOLs, and a good topography with multiple sources of corneal astigmatism measurements. For efficiency, in some practices it might make sense to have a tech, she said. Dr. Vendal said the learning curve among the different advanced technology IOLs is similar. “We are not reinventing the wheel but rather improving our already existing options for patients, so new users should not be hesitant about trying the new advanced technology models. There are pearls that I think can help set us up for success,” she said, offering the following: 1. Extra chair time is needed to learn the patient’s needs. 2. Preoperative testing is required to uncover subtle retinal disease that could make a difference in lens choice. 3. Extra attention should be paid to dry eye and improvement prior to biometry. 4. Use multiple measurement modalities to calculate the most accurate IOL power possible. 5. Manage astigmatism aggressively. 6. Use intraoperative biometry, if available, to add additional data for decision making. Dr. Braga-Mele said that some physicians, like those in their last 5 years of practice, might not want to get into offering a whole range of relatively new IOLs. However, she thinks they should still let patients know what’s available, and if the patient wants that technology, refer them to a surgeon who offers it. “Even if you don’t do trifocal or multifocal IOLs because you don’t think it’s worth the visual aberration that could occur, you should at least let them know that there is this availability and why you don’t like that technology and let them make that decision,” she said. EWAP Editors’ note: Dr. Braga-Mele, MD is Professor of Ophthalmology, University of Toronto, Toronto, Canada, and has interests with Alcon. Dr. Davidson is Professor and Vice Chair for Quality and Clinical Affairs, UCHealth Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, Colorado. Dr. Vendal is Founder and Medical Director, Westlake Eye Specialists, Austin, Texas. Drs. Davidson and Vendal have interests with Alcon and Johnson & Johnson Vision.
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