EyeWorld India June 2015 Issue

June 2015 12 EWAP FEATURE Multifocal IOLs by Lauren Lipuma EyeWorld Staff Writer With new multifocal IOL technology poised to enter the U.S. market, experienced surgeons discuss best practices for implantation M ultifocal IOLs have the potential to give patients spectacle independence after cataract surgery, but the difficulty in adapting to multifocality makes the lenses a good surgical option for a small percentage of patients. “Multifocality is almost like a learned behavior—there’s an adjustment phase that patients have to go through,” said Robert Weinstock, MD, The Eye Institute of West Florida, Largo, Fla. “Even with that, there are some patients who cannot get used to it and have some debilitating glare at night or an overall decreased quality of vision.” New IOL technology poised to enter the U.S. market this year and new implantation techniques, however, will expand the multifocal options available to patients, offering the potential of increased range of vision, fewer unwanted visual effects, and astigmatism management options. With these new technologies and methods, surgeons may be able to offer multifocal IOLs to a wider array of patients. Dr. Weinstock, Douglas Koch, MD, professor and the Allen, Mosbacher, and Law chair in ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, and Bonnie An Henderson, MD, partner at Ophthalmic Consultants of Boston and clinical professor of ophthalmology at Tufts University School of Medicine, Boston, discussed the best practices for multifocal IOL implantation, techniques for mixing and matching multifocal and monofocal IOLs, and the new lens technologies that they are most excited about. AT A GLANCE • Multifocal IOLs—and presbyopia-correcting lenses in general—make up less than 10% of cataract surgeons’ annual volume. • Personality is a major factor in determining who is a good candidate for multifocal IOLs. • New technologies such as toric multifocal and extended range of vision IOLs will expand the pool of patients who are candidates and provide better options for spectacle independence. Who are the best candidates? The physicians agreed that multifocal IOL candidates should have healthy eyes free of sight- threatening pathology, such as corneal scars or irregularities, significant dry eye, or macular pathology. “Any type of epiretinal membrane, significant macular degeneration, or moderate end- stage glaucoma makes someone a poor candidate for a multifocal IOL,” Dr. Weinstock said. Because some patients with healthy retinas may go on to develop retinal pathology following surgery, it is vital to assess risk for retinal disease preoperatively, he added. Take a family history and look for risk factors such as diabetes and smoking, he said. Personality is another major factor in determining who is a good candidate for a multifocal IOL. According to Dr. Weinstock, the best candidates are those who have dense cataracts and have not been bothered by them. “That lets you know that they have somewhat of an easygoing personality—the fact that they haven’t rushed into cataract surgery,” he said. “In addition, a dense cataract causes a lot of glare at night, so these patients are already used to glare. If it’s not bothering them that much, there’s a good chance that the glare from the multifocal won’t bother them.” Although surgeons have historically avoided implanting multifocal IOLs in “type A” personalities, do not exclude these patients as candidates, Dr. Henderson said—they might have the most realistic expectations. “I find that those ‘type A’ patients have already done their homework and read about the difficulties of multifocal IOLs,” she said. “They understand the limitations but are willing to accept them in return for less spectacle dependence.” Astigmatism management Another important criterion for multifocal IOL implantation is that the patient has manageable astigmatism that requires no treatment or can be treated reasonably with limbal relaxing incisions (LRIs) or other corneal incisions, Dr. Koch said. “Addressing the astigmatism upfront is critical,” Dr. Weinstock said. “It’s a process of preop, intraop, and even postop management.” Astigmatism management Tecnis Symfony lens Source: Abbott Medical Optics continued on page 14