Eyeworld

65 EW FEATURE March 2019 • Refractive corrections delivered fairly rapid results (e.g., LASIK or PRK), and the adaptation to their new optical system with cataract surgery can take some time," he said. "I discuss the journey with these patients preoperatively but also make sure to touch on it postoperatively." Dr. Baartman add- ed that neuroadaptation is taking place during the first 6 months after implantation, and it's important to maximize your availability for ques- tions and concerns that may come up from patients. Paying attention to and dis- cussing the plan for addressing residual refractive error is also important to remind patients of the multi-step journey and often helps patients through the recovery. "It's important to plan to see these patients around the 90-day mark to evaluate for presence of posterior capsular opacification, as even small amounts of capsular cloudiness can impact the performance of these optics," Dr. Baartman said. EW Editors' note: Dr. Baartman has finan- cial interests with Allergan (Dublin, Ireland) and Refocus Group (Dallas). Dr. Waltz has financial interests with AcuFocus (Irvine, California) and Johnson & Johnson Vision (Santa Ana, California). Contact information Baartman: brandon.baartman@vancethompsonvision. com Waltz: kwaltz56@gmail.com would be bothered by some of those drawbacks, such as photic phenom- ena and decreased contrast sensitiv- ity." He added that to him, the most important characteristic of a good candidate is one who has a genu- ine interest in as much spectacle freedom as possible, coupled with a good understanding of the refrac- tive cataract journey. "The cornea should have minimal irregularity on the anterior surface, be free of significant higher order aberrations on wavefront testing, and a normal posterior float with enough residual tissue for a laser enhancement," he said. Optimizing chance for success Dr. Waltz said that the first thing to consider is treating the ocular surface. People who are cataract age often have significant ocular surface disease, and many times, this issue can be improved with artificial tears, he said. Improving the ocular sur- face can help get better preoperative measurement, and you'll be more likely to hit the target postoperative- ly. Another issue he mentioned was astigmatism, which he described as a postoperative "killer for quality of vision." Dr. Baartman said that there is good evidence that the postop- erative period is a critical time for refractive cataract patients with presbyopia-correcting IOLs, and this is magnified for those with a history of laser vision correction. "These are often patients with a lot of visual demands who have undergone vision correction procedures that he said. If you've had prior surgery and as you get older, spherical aber- ration gets worse. Who should not have a premium IOL There are some findings that indicate a patient is not a good candidate for a premium IOL. Dr. Baartman said that any evidence of decentered ablation or presence of significant total corneal higher order aberrations are red flags. While some patients are not good candidates for advanced tech- nology IOLs, if there is evidence of a decentered ablation or other topo- graphic irregularity and the patient is interested, Dr. Baartman said he considers using topography-guided ablations to normalize the corneal surface to improve their candidacy for the lenses. "Exam findings can challenge our ability to use ad- vanced technology lenses, such as poor zonule support from PXF or presence of retinal pathology like AMD," he said. "I do pay attention to pupil size as well and emphasize the possibility of photic phenomena to those patients with larger meso- pic pupil diameters." Dr. Baartman said that it is also important to build a relationship with the patients and understand their desires, as well as their atti- tudes. "I think those patients who have a tendency toward perfection- ism may not be great candidates, and I make sure to spend time discussing the possible drawbacks of using advanced optics," he said. "This often helps select those who Diagnostics Dr. Baartman said that some of the things he uses most frequent- ly are topography and wavefront aberrometry to evaluate candidacy for a diffractive optic. He utilizes the OPD-Scan III (Nidek, Fremont, California) and pays close atten- tion to the anterior corneal shape, looking for areas of irregularity that may have been the result of early technology ablation patterns, and the general size of the ablation zone. "I also use the point spread function to evaluate the presence of higher order aberrations, which I think is important to understand preopera- tively," he said. "These corneas often have a bit more spherical aberration than the normal cornea, but paying attention to the presence of other aberrations, such as coma, can help detect those patients with even small decentrations in ablation that may limit the success of multifocal lenses." Dr. Baartman also uses the Pentacam (Oculus, Wetzlar, Ger- many), not only for corneal power estimations but he is also paying attention to the posterior cornea and corneal thickness. Dr. Waltz said that he finds a high-quality topographer to be the biggest diagnostic help for him. He said that it's important to know if the ablation is centered, if there are any areas of ablation that will change the quality of vision, and what the spherical aberration of the cornea is. "It's important to under- stand that as people get older, their lens changes shape and their spher- ical aberration typically gets worse,"

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