REFRACTIVE EWAP JUNE 2023 29 patient. Dr. Waring said all of the above applies, but the cataract patient, “is more easily understood because we know they’ve gotten to the third stage of ocular maturity where internal optics have become so poor that it’s objectively and subjectively affecting quality of life.” He said the role of the anterior surface of the cornea is still important for image quality, and this is where high-resolution tomography comes into play. “If we see irregular astigmatism, for example, we need to understand its root cause, including but not limited to dry eye and EBMD. If we identify EBMD, more times than not we recommend a staged procedure with a superficial keratectomy first … letting the cornea resurface, which often regularizes the previous irregular astigmatism,” Dr. Waring said. Dr. Waring further explained the role of the vitreous on optical dysfunction, crediting the work of Jerry Sebag, MD, on this front. He said that more attention is being paid to this objectively and subjectively so patients can be counseled appropriately. For example, if the patient had vitreous opacities preoperatively but didn’t know about them, they might blame the procedure on poor visual quality when it was an existing condition. Advanced preoperative image quality diagnostics, Dr. Waring continued, can help the surgeon determine where the patient falls in their stage of ocular maturity. We may have a 50-year-old with complaints of glare referred for cataract, Dr. Waring said, but with advanced diagnostics, the source of the glare could be found to be keratoconus, not to be confused with a patient who may only be at the first stage of dysfunctional lens syndrome. “Not only do we get a better understanding of their image quality preop, but we gain a better understanding of their source of optical dysfunction to make better decisions about their care and to educate them better.” Julie Schallhorn, MD, said in an email to EyeWorld that her preop IQ testing includes a combination of standard exam maneuvers, paying particular attention to the ocular surface and eyelids, as well as imaging of the shape of the cornea and of the tear film. “Every preop cataract patient gets a full exam and Placido disc topography and Scheimpflug tomography, and every preop refractive surgery patient also gets an anterior segment OCT with epithelial thickness mapping,” she said. “Refractive patients with any evidence of lens changes on exam or those older than 45 also undergo combined Placido disc/ray tracing imaging (iTrace) to determine the relative impact of lenticular changes on visual quality. In cataract patients with irregular corneas, I will also obtain an iTrace to help determine the relative contribution of the corneal shape abnormalities vs. the lens opacity to visual quality.” If she finds these measurements/images are normal, that’s the entirety of her preop workup. Cataract patients who have an unstable tear film will receive an automated tear continued on page 35 Yao Ke, MD Chief & Professor, Zhejiang University Hospital Eye Center, Second Affiliated Hospital of Zhejiang University School of Medicine 1 Xihu Blvd., Hangzhou, China xlren@zju.edu.cn ASIA-PACIFIC PERSPECTIVES In the development of cataract surgery and IOL design, image quality is getting more attention. Especially with the application of multifocal IOLs and EDOF IOLs, patients are supposed to obtain satisfactory vision quality at all distances. Unlike the simple treatment of lens opacity to improve visual acuity, patients have more expectations about spectacle independence after multifocal IOL implantation. Careful selection of patients, knowledge of IOL design, proper surgical technique and perioperative management are the keys for successful implantation of multifocal IOLs. A stable ocular surface, including tear film, epithelial tissue, and eyelids health, is important to achieve best possible image quality. Besides, dry eye will cause discomfort after cataract surgery. Due to the reduced corneal sensitivity in the elderly population, cataract surgery might aggravate dry eye symptoms. Dry eye treatment before and after cataract surgery is receiving particular attention. The guidelines to treat dry eye include starting with eyelid hygiene and artificial drops. Other options for severe cases are the use of cyclosporine, intense pulsed light (IPL) treatment, and LipiFLow treatment. Positive dysphotopsias such as glare, starbursts, and halos can be common causes of dissatisfaction after multifocal IOL implantation. IOL implant centration, posterior capsule, and refractive error are possible reasons for dysphotopsias. Routinely, halos are the characteristic dysphotopsia caused by multifocal IOL. Thus, perioperative communication of dysphotopsia adaptation might continue to 6 months after surgery. Neuroadaptation is the period during which our brain adapts to and optimizes the new optical system. Coaching patients with rational expectations of dysphotopsias and gradual adaptation are critical during the healing process after multifocal IOL implantation. Combining quality preoperative education with postoperative care, patients would be more likely to obtain satisfactory image quality after multifocal IOL implantation. Editors’ note: Prof. Yao declared no relevant financial interests.
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