Eyeworld Daily News

MAY 17, 2020 | EYEWORLD DAILY NEWS | 3 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING Dr. Jackson said, is to attain clear vision at distance, inter- mediate, and near. You must maintain optical quality and maintain binocularity with short adaptation time. To obtain natural vision with multifocality, Dr. Jack- son said there are good, but not perfect, options available, like EDOF lenses, trifocals, and low-add bifocals. Perfect, but not good, candidates are needed with these options for successful outcomes, he said. Perfect candidate criteria include: • Pristine ocular surface • No macular pathology • A plan to correct corneal astigmatism • Realistic expectations • Corneal topography/tomog- raphy/epithelial mapping that shows ability to treat re- sidual refractive error postop • Angle alpha/kappa less than 0.7 • Utilization of fourth-genera- tion IOL formulas • Corneal quality Dr. Jackson said it's import- ant to know your refractive end target for the multifocal IOL you select for your patient. It changes for each lens. In conclusion, Dr. Jackson stressed the importance of not referring to "monovision" or "multifocality," but rather "blended" or "natural vision" when talking with the patient. For blended vision, he stressed the importance of de- termining eye dominance. For natural vision, Dr. Jackson again emphasized determining the "perfect can- didate" for imperfect options. Re-enforce realistic expecta- tions with the patient. Editors' note: Dr. Koch has no financial interests related to his comments. Dr. Vasavada has financial interests with Alcon. Dr. Jackson has financial interests with Alcon, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision, LENSAR, and Marco. and Hill proposed simple terminology and described the figures needed to best display astigmatic outcomes, as well as provided a downloadable spreadsheet. Dr. Koch went on to discuss the terminology, first noting surgically induced astigmatism (SIA). There is predicted SIA, actual SIA, and SIA prediction error (the difference between actual and predicted). You can calculate this separately for corneal values, for the IOL, and for the eye as a whole. For IOL surgery, there's predicted postoperative re- fractive astigmatism, actual postoperative refractive astig- matism, and the postoperative refractive astigmatism predic- tion error (vector difference between actual and predicted), Dr. Koch said. To display astigmatism clearly and accurately, combin- ing magnitude and meridian, you can use single-angle plots or double-angle plots, Dr. Koch said, adding that he thinks double-angle plots are a better way. The single-angle plot looks like a phoropter. To con- vert this into a double-angle plot, double the angles. With a single-angle plot, though it looks like a phorop- ter, it's hard to know what the data shows, Dr. Koch said. But if you make a double-an- gle plot with the exact data points, all of the data points are collected or gathered more clearly. Dr. Koch thinks that dou- ble-angle plots are highly informative both visually and numerically. They're easy to understand once you grasp the concept of the doubled angle, with the with-the-rule (WTR) eyes to the left and the against-the-rule (ATR) eyes to the right. Abhay Vasavada, MD, Ahmedabad, India, shared his five pearls for managing the very small eye. He began by discussing microphthalmos, nanophthalmos, and relative anterior microphthalmos. His first pearl in dealing with very small eyes was the preoperative assessment, which is vital, he said. Short axial lengths, scleral thickening, and increased lens volume are the features of nanophthalmos. A narrow anterior segment in advanced angle closure glauco- ma causes similar problems for the cataract surgeon as a very small eye. Therefore, it's im- portant to look for glaucoma. His second pearl related to counseling. It's important to counsel the patient and the family regarding the chal- lenging nature of the surgery and the possibility of serious complications, he said. Possible complications include uveal in- flammation, glaucoma, corneal edema, choroidal effusion, or losing the eye. His third pearl was to pay attention to intraoperative de- tails. He mentioned anesthesia, OVD, and other techniques. Dr. Vasavada's fourth pearl was about IOL implantation, which he said remains a chal- lenge. He prefers to implant an available high-power IOL and correct residual ametropia postoperatively. But customized IOLs and piggyback IOLs re- main valuable options as well, Dr. Vasavada said. His final pearl was about postoperative considerations. It's important to continue mon- itoring in the postoperative period for glaucoma, corneal health, retinal evaluation, and correcting refractive error with glasses or contact lenses, Dr. Vasavada said. Mitchell Jackson, MD, Lake Villa, Illinois, presented on when to offer monovision and when to offer multifocality to patients. When talking to patients, we have to change the way we're thinking, he said. Instead of using terms like monovision or micro/mini-monovision, he suggested using blended vision. Instead of using the term "mul- tifocality," he suggested the term "natural vision." For blended vision, Dr. Jackson mentioned several preoperative considerations including the patient's oc- cupation and personality. Blended vision may work best for those in an occupation where he or she is changing viewing distances constantly, but it might not be ideal in an occupation with prolonged distance or near vision tasks or if the patient is in need of good stereoacuity. In terms of personality, he said that per- severance is more important than motivation. Prior contact lens wearers adapt most easily to this, and if blended vision is not achieved for these patients, the patient will likely be very unhappy. Dr. Jackson also discussed the importance of eye domi- nance in blended vision, saying that 75–80% have success with the dominant eye for distance, while up to 25% prefer the dominant eye for near. It's also more successful in patients with alternating dominance. Dr. Jackson suggested a preoperative contact lens trial for blended vision, which could be as long as 6 weeks. If the trial is unsuccessful, consider switching eyes. In terms of IOL options, Dr. Jackson said you must correct astigmatism with a monofocal toric. He said the Crystalens and Trulign (Bausch + Lomb) should be considered for blended vision, and he found the enVista and enVista toric (Bausch + Lomb) have shown limited but beneficial effect in many patients. To adapt to blended vision, Dr. Jackson suggested limiting night driving at first and hav- ing driving glasses. Make sure to have options for distance correction (contact lenses, laser vision correction, or SMILE). Is multifocality really natural vision? The challenge, continued from page 1

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