Eyeworld

EW REFRACTIVE 60 December 2018 Presentation spotlight by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer a patient with perfect results may have complaints of foreign body sensation, burning, and fluctuating vision. Diagnose and treat dry eye and MGD before surgery and con- tinue treatment after surgery," Dr. Kaskaloglu said. Specular microscopy: Dr. Kaska- loglu examines the eye for corneal guttata, noting that the severity of guttata is the key point. "A few scattered corneal guttata do not rule out a candidate for MFIOL implan- tation. Determine the severity of the guttata, especially in older patients. If they have only a few guttata you can overlook them and use multifo- cal IOLs," he said. Pupil shape and size: Surgical complications can arise in eyes with both large and small pupils. Small pupils can present surgical challeng- es during IOL implantation because of the need to stretch the pupil, which could encumber the central- ized positioning of the IOL. Con- traindications for MFIOLs include few days. If feasible, he schedules LASIK and in the case of a refractive surprise, he will generally exchange the IOL. In cases of persistent glare and halos, he exchanges the MFIOL for a monofocal implant, howev- er, if dysphotopsia is limited, he may choose to wait. With reduced contrast sensitivity, he recommends watchful vigilance, and before making the decision to exchange the MFIOL, he tries to find the real cause of the complaint. Preop pearls Ocular surface disorders: The tear film is the first refracting surface of the eye. The challenge is identifying ocular surface disease, as 40% of dry eye patients are asymptomatic, as are many of those with meibomian gland dysfunction (MGD). Corneal surface: This can strongly influence postoperative comfort and vision. Note that preoperative keratometry and topography are affected by ocular surface disorders and cause IOL power errors. "Even a small error will not cause signifi- cant spherical aberrations or HOAs," Dr. Kaskaloglu said. "The question always seems to be whether to implant MFIOLs after LASIK. My answer is that LASIK is the treatment of choice for a small refractive error after MFIOL implantation, there- fore, it is logical for us to be able to implant MFIOLs after LASIK for small refractive errors. Note that myopic LASIK induces increased postoperative spherical aberrations, therefore, an aspherical IOL with negative aberration is recommend- ed for patients after myopic LASIK. Hyperopic LASIK induces negative spherical aberrations. In these cases, if ablation is central, which is not always the case in hyperopic cases, you can choose a MFIOL, but find a positive spherical aberration IOL if you can or zero aberration IOL." Dr. Kaskaloglu's standout patient characteristics for MFIOL im- plantation include patients who do not want to wear glasses, those with easy-going personalities, and highly motivated emmetropic presbyopes. Negative characteristics include individuals who do not mind wear- ing glasses, hypercritical patients, certain professional groups, and low myopes. "Often after a successful op- eration, the patient will come in with burning and stinging. Many will then tell you that they had this problem before the operation," he said. "If you diagnose ocular surface disorders before the operation, it is the patient's problem, but if you diagnose it after the operation, it is your problem. The best strategy is to carefully examine and question the patient beforehand for signs and symptoms of dry eye and meibo- mian gland dysfunction." Patients who complain about visual quality postoperatively with- out an ocular pathology need special attention. Dr. Kaskaloglu's approach is to check refraction and prescribe glasses to gauge the situation, asking for the patient's response after a Specialist speaks about precautions he takes before and after refractive surgery to keep his patients happy M ultifocal intraocular lenses (MFIOL) are largely chosen on the basis of matching pa- tient criteria, although numerous factors come together to play an integral role in achieving optimum outcomes. Experts say that a careful and thorough preoperative examination is crucial in getting it right. "For happy patients and doc- tors, I support a careful preopera- tive exam and evaluation. For the highest patient satisfaction, I strive for a complication-free surgery, and postoperatively, I am ready to deal with residual refractive errors," said Mahmut Kaskaloglu, MD, Izmir, Turkey, in a talk he gave on the "Management of unhappy patients and the decision tree for selection of proper premium IOLs" at the 2018 World Ophthalmology Congress. According to Dr. Kaskaloglu, time is the best remedy. "Post-refrac- tive surgery care extends to not just hours or months, but it can be years. In my experience, most patients will adapt to the vision provided by MFIOLs—it just may take time," he said. "Neuroadaptation is the key word, sometimes requiring more than a year's time. It is important to assure and support the patient and maintain an open door poli- cy for unhappy patients. Keeping the patient close to you is the best approach. In my practice, I find that most patients will not accept a lens exchange even if I offer it to them," he explained. Patient choice "Post-LASIK patients are motivated for MFIOLs. We limit MFIOLs to patients who had LASIK for low refractive errors because LASIK for Managing unhappy patients An eye with perfect centration of a PanOptix IOL (Alcon, Fort Worth, Texas) in the capsular bag after optic capture, taken 6 months after the operation. There was no refractive error, and the patient was happy with 20/20 vision. Source: Mahmut Kaskaloglu, MD

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