EyeWorld Asia-Pacific June 2018 issue

22 EWAP FEATURE June 2018 MFIOL options provide sophisti- cated solutions to individual visual needs, particularly when combined as needed. Blended vision and mini-monovision are IOL combina- tions that have been used success- fully to maximize the visual range through the use of monofocal IOLs of different strengths. Blended vision, or monovision, describes fo- cusing one eye for distance (usually the dominant eye) and the partner eye for near (the non-dominant eye), which allows patients a large degree of spectacle independence. Mini-monovision uses IOLs with a maximal difference of roughly 0.75 D, targeting the patient’s dominant eye for emmetropia while the non- dominant eye is set for –0.5 D or –0.75 D. The idea is that a greater difference between the two eyes may lead to reductions in contrast sensitivity, stereopsis and bin- ocular visual acuity. Both options have the potential to cover the full range of vision and offer spectacle freedom. IOL combinations According to Dr. Raviv, MFIOL combinations can enhance vision and reduce visual side effects. He explained, “For me, every com- bination is on the table. Until recently, the most common com- bination was a pairing of either a ReSTOR [Alcon, Fort Worth, Texas] +2.5 with a ReSTOR +3.0, or toric multifocal [TMF] +3.25 with a TMF +2.75. With EDOF, I frequently start with that IOL and can add a low add TMF in the other eye, if more add is needed. Alternatively, I’ve mixed low add multifocals and EDOF with a monofocal IOL as well. I’ve found that mini-monovi- sion with multifocals doesn’t work out well. The multifocals com- bined with EDOF IOLs have the least glare and halo when plano is achieved. That being said, the EDOF can tolerate micro-monovi- sion of maybe –0.35 D in one eye, which can significantly enhance the binocular near vision. If I think more near is needed on the second eye, I typically will switch to a low add multifocal such as the TMF +3.25.” For Dr. Yeu, not all multifocal combinations are suitable in the monovision or mini-monovision context. “Blended vision depends on a few factors, including near vision needs, height, and prior use of multifocal or monovision soft contact lens,” she said. “I have not used a 4.0 add multifocal IOL since the mid and low add versions be- came available. In order of frequen- cy of presbyopia correcting IOLs, I use the EDOF IOLs bilaterally most frequently (plano dominant eye, –0.25 to –0.50 non-dominant eye). I always aim to place the lowest add possible in the dominant eye, as night vision symptoms are also lower. In the non-dominant eye, I am a fan of the mid add multi- focal for those who have shorter arm spans or prefer to read books/ magazines over e-readers or com- puters. I will do a mini-monovision approach when I use EDOF IOLs in both eyes, particularly for those who have been successful monovi- sion patients in the past. I gener- ally prefer a near emmetropia goal, mixing two add powers with multi- focal IOLs or an EDOF dominant eye/mid add multifocal IOL in the non-dominant eye. I generally do not implement mini-monovision with multifocal IOLs, but I do mix add powers.” When it comes to multifocal toric options, the rules for Dr. Yeu are becoming better understood. For corneal astigmatism that is with-the-rule more than 1.25 D or against-the-rule more than 0.75 D anteriorly, she uses toric MFIOL versions. “This is the best way to proceed in cases of corneal astig- matism,” she said. “I will regularly treat any astigmatism more than 0.2 D, and for lower amounts of corneal astigmatism, by doing femto astigmatic keratotomy at the time of surgery. I correct low levels of postop residual mixed astigma- tism with manual limbal relaxing incisions [LRIs] in the office,” she said. Dr. Raviv opts for toric mul- tifocal IOLs in his patients with corneal astigmatism whenever fea- sible. “The published literature has proven the superiority of toric IOLs over LRIs with regard to accuracy, so I use a toric multifocal or toric EDOF whenever indicated,” he said. “Using what we know about posterior corneal astigmatism and new thinking about using 0.1 D for our surgically induced astigmatism in the Barrett Toric Calculator, I typically use a toric for against-the- rule astigmatism of greater than 0.4 D and for with-the-rule astig- matism greater than 1.5 D. I use femtosecond laser arcuate incisions for the rest.” Models are physicians using The evolution among MFIOLs has been a 20-year process of learning from mistakes and incorporating the latest technologies. Lower add versions of existent MFIOLs and the development of EDOF lenses now provide excellent options for implantation in cataract surgery. “In the U.S., FDA-approved mul- tifocal IOLs include the ReSTOR multifocal IOL [Alcon], Tecnis Multifocal [Johnson & Johnson Vision, Santa Ana, California], and Tecnis Symfony EDOFs [Johnson & Johnson Vision],” Dr. Raviv said. “The AcrySof ReSTOR lens was the first diffractive IOL in the U.S. market in 2005 with a +4.0 add, followed by the ReSTOR +4.0 aspheric in 2007. More recently the ReSTOR +3.0 and +2.5 with ACTIVEFOCUS (also toric) were re- Where we stand – from page 21