Eyeworld

31 EW REFRACTIVE February 2019 In addition to the health and visual potential a patient has, Dr. Shah said he needs to hear that the patient desires spectacle indepen- dence. "If they are motivated to be free of glasses, then I focus my exam with ATIOLs in mind," he said. If a patient with glaucoma is interested in spectacle independence but due to ocular conditions is not a candidate, Dr. Shah will employ monovision. Even in asymmetric glaucomas where one eye has more visual field loss than the other, he said, monovision can work well. Dr. Shah will do a contact lens trial in these patients first and will assess ocular dominance. "I will sometimes set the more injured eye at near, regardless of the ocular dominance in some situa- tions," he said. EW Editors' note: The physicians have no financial interests related to their comments. Contact information Holz: drhuckholz@gmail.com Lee: samuel.lee.md@gmail.com Shah: manjool@med.umich.edu In the end, provided the patient is a good candidate from an ocular standpoint, Dr. Holz said he allows his patients to make an informed decision about the lens they think they could be happy with. "I'm not in the business of telling people they aren't candidates because I think they have a picky personality," he said. Approaching ATIOLs in the face of glaucoma Though there are many ocular contraindications that could limit a patient's candidacy with an ATIOL, glaucoma is not an absolute contra- indication, said Manjool Shah, MD, assistant professor, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan. With 2.7 million Americans older than 40 diagnosed with glaucoma, this pool of possible candidates is significant. "Based on the severity of the disease, as well as the patient's prog- nosis, it may be reasonable to con- sider multifocal or EDOF technol- ogy," Dr. Shah said. "Of course, we have to be mindful of the fact that even milder glaucomas can have some decline in contrast sensitivity, which can be exacerbated by ATIOL optics." would normally react to all of those questions and how our discussion goes," Dr. Holz said. In the end, Dr. Holz said patients need to be honest with themselves when considering the pros and cons of multifocal or EDOF lenses vs. monofocal varieties. In addition to verbal discussion, he provides a pre-counseling video be- fore their appointment and during the appointment using a laminated placard that features examples of vi- suals of what the lenses can achieve and what glare and halo look like. "I do ask them to be honest with themselves. How picky are you about your vision? How important is fine detail? Are you a person of convenience or are you a person of exacting precision?" What he's paying attention to more recently is the distance at which patients say they do most of their reading. Dr. Holz said most of his patients are using computers, tablets, and phones—not so much books and newspapers—which rely on a more intermediate distance. Typically, patients are showing him a distance of about 20 inches, but he emphasized taking a detailed social history from the patient to identify near-vision hobbies. pathology, ectasia, a certain level of higher order aberrations, and more. As for physical stature and arm length, Dr. Holz said he does observe this but finds it's less of a consideration as he is not implant- ing the Crystalens (Bausch + Lomb, Bridgewater, New Jersey) any longer. They also talk to patients about their priorities and motivations in cataract surgery. "I want to make sure they prioritize convenience of specta- cle independence over nighttime driving clarity, that they don't mind the idea of having a little bit of halo at night. We also look at personal- ity traits. The flexible optimists are the best, but that doesn't mean you can't implant the rigid engineer," he said. Determining patient priorities and personality traits starts with cataract surgery counselors at Dr. Holz's practice. These counselors, he explained, will often alert him to potential problems or personal- ity pitfalls they might sense with a patient. "So much of what we do as ophthalmologists is also psychology work. We get a sense of how pa- tients should react within the 15- to 30-minute exam and counseling ses- sion; we get a sense of how people Intraoperative appearance of ZLB00 (multifocal) vs. ZXR00 (Symfony) Source: Sam Garg, MD

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