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4 EW San Francisco 2013 Monday, April 22, 2013 Attention continued from page 3 way of thinking, that means we tell patients we're confident the lens will allow for their best chance of spectacle freedom. We explain that if the lighting is not adequate, the print is very small, or the contrast is inadequate for what they're reading, they might require some help with magnifiers. While those scenarios are a rare occurrence, patients need to know that this is a possibility. We also want them to anticipate a distinct ring around lights at night. We tell patients that this isn't a matter of "if it happens," but "when it happens," and that it means "the implant is working." Explain that these "rings," which may seem particularly bothersome prior to the adaptation process, become almost unnoticeable over time; that is very reassuring to patients. Identifying contraindications As opposed to looking for things that might "qualify" a patient for a multifocal IOL, we suggest the surgeon look at every patient as a potential candidate for a multifocal lens, and then determine if there any contraindications to the lens. I recommend surgeons start at the back of the eye and work forward when evaluating the clinical qualifications of a potential multifocal patient. We look for retinal issues— such as diabetic retinopathy, macular degeneration, or epiretinal membranes—that might reduce contrast sensitivity. We look at the optic nerve, assessing it for glaucoma damage, neuropathy, or optic atrophy. We evaluate the lens for loose zonules or traumatic subluxation. Finally, we look for anything problematic on the cornea, such as ectasia, ocular surface disease, high degrees of astigmatism (which are better treated with toric IOLs), or even previous refractive surgery. Patients with expected postoperative astigmatism >1.0 D may not achieve optimal visual outcomes. It's been my experience that, even if treated, there is enough reduction in contrast sensitivity to interfere with the patient's quality of vision. Pearls for multifocal lenses It is generally felt that reducing incision size will lessen surgically induced astigmatism (SIA). In converting to a 2.2- or 2.4-mm incision, the surgeon may simply use the same technique, instrumentation (except for a smaller phaco tip and sleeve), and even fluidic parameters as used with a larger incision. In my experience, the smaller incision has resulted in more predictable outcomes by reducing SIA. Orienting a multifocal lens vertically (with the footplate at the 12 and 6 o'clock positions) allows for better consistency in maneuvering the lens to the visual axis. With a vertically oriented lens, it's much easier to "nudge" the IOL nasally when needed. I ask the patient to look directly at the microscope light. Because of the central diffractive zone the lens has a "bull's eye" that allows for easy alignment. My advice to those without a great deal of multifocal IOL experience: Don't be afraid to rotate the lens away from the vertical axis. Orient the lens however necessary to ensure the light reflex is directly centered on the lens. Another pearl: Avoid touching the optic of the implant at all times. I recommend maneuvering the implant with a soft tip I/A instrument rather than forceps or hooks. It is very important that the anterior capsule overlap the optic for 360 degrees. Some excessive overlap or even a slightly smaller capsulotomy is preferable to a larger capsulotomy that might not ensure overlap. Without this anterior capsule overlap, centration and effective lens position may be significantly affected. spaced weeks apart allow the patient to determine whether or not the multifocal lens was a good choice and if not, convert the contralateral eye to a monofocal lens. In my opinion, maybe these patients (similar to those who require an hour-long discussion about the multifocal IOL) are not good candidates for the implant in the first place. I would agree, however, that unilateral multifocal IOLs can, at times, be very well tolerated with an opposite eye that is either phakic or pseudophakic with a monofocal IOL. mises you—and your patients—will need to accept. What we're trying to do is minimize compromises and find those that patients can adapt to most readily. That's why I'm a strong believer in multifocal lenses. Cataract surgeons who are not yet embracing these lenses are missing a big opportunity. Minimizing compromise Dr. Black is founder of Eye Associates, Jeffersonville, Ind. He can be contacted at drbradblack@aol.com. No matter which method of correcting "surgically induced, pseudophakic presbyopia" we are choosing right now, there are some compro- *AcrySof, ReSTOR, and IQ ReSTOR are trademarks of Novartis. Reference 1. AcrySof ReSTOR IOL +3 Directions For Use ReSTOR +3: A "quantum leap" forward In my experience, the aspheric ReSTOR +3 multifocal IOL is a significant improvement over earlier versions. The range of vision the +3 provides is much more in line with the needs of today's patient—vision that is not only excellent at near but also at intermediate distances.1 The +4 simply didn't provide adequate intermediate vision for our premium lens patients. In Figure 1, the defocus curve of the +3 clearly provides patients a much better range of vision than the +4, with intermediate vision "only" dropping to the 20/2530 level. The +3 is a quantum leap forward, a significant improvement over previous lenses, and certainly worth trying for any surgeon previously disenchanted with the earlier multifocal IOLs. Figure 1: The best case mean defocus curves in cataract patients at six months postop who had received either the AcrySof IQ ReSTOR IOL +3.0 D or +4.0 D Source: AcrySof IQ ReSTOR Directions For Use Surgical timing With multifocal IOLs, I prefer performing bilateral surgery a bit closer together. It's been my experience that patients adapt better to the technology if the implants are done a week or two apart, even sooner when schedules permit. The closer together the surgeries, the faster the patient seemingly adapts to the technology. There are some surgeons who argue that bilateral surgeries Figure 2: The ranges of visual acuity achievable with the AcrySof IQ ReSTOR IOL +3.0 D and +4.0 D models Source: AcrySof IQ ReSTOR Directions For Use Please refer to page 8 for important safety information about the Alcon products described in this supplement.