EyeWorld India March 2019 Issue

18 EWAP FEATURE March 2019 desires to pay for it. But after you get past that, how do you know what lens? If a patient has macular disease, epiretinal membrane, a small set of drusen, I tend to tell them you don’t need a multifocal lens, you either need a Symfony or a Crystalens. If that patient says I can’t handle any side effects, the purest vision they’re going to get is with the Crystalens, but they won’t get as much reading vision. If the patient says, “I want a little more reading,” and they’ve got a small amount of microaneurysms in the macula from diabetes, I’m not opposed to putting in a Symfony lens in those patients. … If a patient desires close reading vision, I’m not going to use an EDOF or an accommodating lens, I’m going to use a multifocal lens. Dr. Raviv: Today, in the United States, the ReSTOR ACTIVEFOCUS toric, Tecnis Symfony toric, and Trulign toric are available. The cylinder powers available with the toric multifocal IOL/EDOF IOLs are 1.5–3.75 D at the IOL plane, treating up to approximately 2.5 D of astigmatism at the corneal plane. The Trulign toric ranges from 1.25–2.75 D at the IOL plane. Due to the increased incidence of ATR with aging, it is common to have significant cylinder to treat in the cataract age population. I would estimate that more of my EDOF patients get the toric version over the spherical one. Reducing astigmatism is so important in refractive cataract surgery that I will frequently choose the type of presbyopia- correcting IOL based on the astigmatism present. For example, anyone with 1.25 D of ATR cylinder or greater would do best with a toric IOL, which rules out the low-add multifocal Tecnis ZLB00 and ZKB00, which are only available in spherical powers. Dr. Lindstrom: I mostly use Symfony toric with good experience. There is a small incidence of rotation, less than 5%. EyeWorld: Are there patients with corneal cylinder in whom you would not put a multifocal or EDOF IOL? What about cases with irregular astigmatism or keratoconus? Dr. Patterson: I’m not going to put a premium lens in someone with corneal pathology because, in my opinion, that means the cornea will not tolerate a premium technology in the first place. ... If you use a premium lens and you can’t use an LRI or toric option, to me there is something wrong with the cornea and you shouldn’t be doing it. Irregular astigmatism, astigmatism that is a pellucid marginal degeneration, some sort of keratoconus patient, I won’t use it on. Any patient who has severe keratopathy, such as map- dot-fingerprint that has not been treated, Salzmann’s nodule, a herpetic eye patient, I would not use a lot of multifocal lenses in people who have corneal pathology because we know without question their side effects are greater. They have more glare, more halo, and you’re not as accurate in treating their astigmatism. Dr. Raviv: If their corneal cylinder is irregular, they may not be great multifocal/EDOF IOL candidates but also not toric. Also, patients with cylinder above 3 D will do best with the higher toric power IOLs, which are only currently available with the monofocals. If consistent repeatable Ks are achieved on multiple devices, I’m inclined to offer toric IOLs for keratoconus. For irregular astigmatism from pterygium, epithelial basement membrane dystrophy, Salzmann’s, I generally recommend treating the pathology before proceeding with a presbyopia-correcting IOL. Dr. Lindstrom: I wouldn’t implant diffractive multifocal IOLs in anyone with over 0.5 root mean square of higher order aberration. I also am sure to look for dry eye, which is treatable. EyeWorld: What about IOLs in the pipeline, which could be used for both presbyopia and astigmatism correction? Dr. Patterson: The IC-8 (AcuFocus, Irvine, California) is going to be a game changer. It has distance and near correction, and regardless of the axis that it falls on, the toricity is still going to be corrected. I’m excited about the AT LISA, which is the trifocal from Carl Zeiss Meditec (Jena, Germany). I’m more excited about the AT LARA (Carl Zeiss Meditec). … The ability to have some sort of accommodative/ enhanced depth of focus lens over a multifocal is always going to be a little better because it’s a blended vision. If we can get that a little more optimized, that would be good. I know Symfony 2 is on the way out at some point, and that is exciting. PanOptix (Alcon) should be a great lens. … Juvene (LensGen, Irvine, Marking the axis for an LRI. LRI being placed at the limbus. Source (all): Michael Patterson, DO Astigmatism and presbyopia-correcting – from page 17