EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/153099
48 EW International August 2013 International outlook "Premium" IOLs critical in certain cases by Matt Young EyeWorld Contributing Writer T he role of premium IOLs is expanding in our practice as we understand how to use them to their full potential. In this article we are introduced to another indication for multifocal IOLs in patients with cataracts related to a genetic disorder. This raises the broader issue of which individuals are ideal candidates for premium IOLs. At the heart of the matter is the fact that these lenses provide better functional vision. Beyond Alport syndrome, this article reminds us that younger patients in particular benefit from multifocal IOLs regardless of the etiology of the cataract. While many surgeons may not have treated a patient with Alport syndrome, most have encountered cataracts in younger patients. Keeping the option of using premium IOLs in mind for these patients is the take-home point. John A. Vukich, MD, international editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) M ultifocal IOLs are usually considered for that premium perfection-demanding crowd among cataract patients. But sometimes, multifocal IOLs aren't for the privileged, but rather, the needy. Anterior lenticonus—part of Alport syndrome— recently was treated successfully with multifocal IOL implants, demonstrating the impact these IOLs can have for the seriously visually impaired around the world, and not just for a privileged few. Multifocals for lenticonus Alport syndrome is a genetically transmitted disease that tends to affect the basement membranes of the kidney, the cochlea and the eye. Two recent cases observed by Sonu Goel, DNB, phaco refractive surgeon and director, Anand Eye Hospital, Jaipur, India, were anything but typical. "Lenticonus was the only symptom," Dr. Goel said. "The patients did not have other issues." Anterior lenticonus is by definition associated with Alport syndrome. Two patients—a 22-year-old female and a 25-year-old male—had presented for refractive surgery. "They were using glasses and they wanted their glasses off," Dr. Goel said. "They were never diagnosed with Alport syndrome." In the female patient, Dr. Goel observed bilateral bulging of the anterior lens capsule. Her myopia was severe at –17.5 D in the right eye and –18.5 D in the left. "Oil droplet appearance was prominent in both eyes suggestive of anterior lenticonus," Dr. Goel said. "The patient had no signs of hearing loss. Serologic or urine examination was normal." In the male patient, bilateral anterior and posterior lenticonus were observed. Vision had progressively decreased over the past 5-7 years to where UCVA in the right eye was 6/60 and in the left eye was 6/36. Again, Dr. Goel found no systemic abnormality. In both patients, phacoemulsification was performed with multifocal implantation. In the female patient, UCVA was 20/50, improving to 20/20 with a minor subsequent astigmatic correc- Preoperative state showing anterior and posterior lenticonus Postoperative status after multifocal IOL implantation Source (all): Sonu Goel, DNB tion. In the male patient, UDVA was 6/12 and CDVA was 6/6 in both eyes. "Successful results were gained in postoperative visual acuity and patient satisfaction by implanting multifocal IOLs for bilateral anterior lenticonus and posterior lenticonus," Dr. Goel said. In these patients, the capsulorhexis is challenging, Dr. Goel noted. "The capsulorhexis should not start from the center but from the mid-periphery, using microcapsulorhexis forceps," he said. "It is an elastic capsule like in pediatric patients." Initially, Dr. Goel said, when the patients presented for refractive surgery, they were considered for LASIK and for phakic lenses. "Then to our surprise the lenses were defective and the refractive error was because of lenticonus (axial length being normal with standard IOL power)," Dr. Goel said. "When photographs were taken at the slit lamp, that classic oil droplet sign characteristic of lenticonus appeared."