Eyeworld

I N FOCUS 46 | EYEWORLD | AUGUST 2019 CATARACT SURGERY POST-LVC Contact information Hoffman: rshoffman@finemd.com Koch: dkoch@bcm.edu Williamson: wecdoc@gmail.com by Vanessa Caceres EyeWorld Contributing Writer "Extended depth of focus and multifocal IOLs can be used in patients following hyperopic LASIK depending on the demeanor of the patient and the appearance of topography," he said. Dr. Williamson's choices are an aberra- tion-free or positive spherical aberration lens such as enVista (Bausch + Lomb) or Trulign toric (Bausch + Lomb) for a monofocal or astigmatism choice. Although Dr. Williamson will sometimes use a Crystalens accommodating IOL (Bausch + Lomb) in patients with post-hy- peropic LASIK, he's more cautious about multifocals. "The increase in spherical aberra- tions alone mitigates against using a multifocal IOL in these cases," he said. During surgical planning, consider the patient's centration and degree and direction of astigmatism post-treat- ment to help evaluate if a presbyopia-correcting lens is appropriate. "If there is significant coma, multifocal IOLs and perhaps extended depth of focus lenses should be avoided," Dr. Hoffman advised. Previous PRK For patients with previous PRK, the guidelines are essentially the same as those for post- LASIK patients. "The corneal surface becomes a more central issue in preoperative planning because epithelial remodeling can continue for some months post-PRK," Dr. Williamson said. "Monofocal IOLs are the easiest choice to avoid increased glare and halos." Previous RK A monofocal IOL is often the best choice in patients with previous RK, Dr. Williamson said. "Using a monofocal lens and targeting slight myopia often will allow increased depth of focus and ability to read secondary to the multifocal cornea of many RK patients," he said. However, surgeons have some clear opin- ions about the use of other IOL types post-RK. "There have been some successes anecdotally C hoosing the right IOL for patients who have had previous refractive surgery can become a tricky balancing act for cataract surgeons. Each type of refractive surgery has vision-specific nuances, and surgeons must also con- sider unique results for each patient found via imaging. Despite the balancing act, there are some pearls that seasoned surgeons can share to help guide their colleagues. Here's what a few of them advise depending on the type of refractive surgery. Post-myopic LASIK Because the cornea of post-myopic LASIK patients has increased positive spherical aberra- tion, Charles Williamson, MD, prefers an IOL with the most negative spherical aberration available. "I usually use a Tecnis ZCB00 [John- son & Johnson Vision] or Tecnis Toric [John- son & Johnson Vision]," he said. "For greater amounts of astigmatism, I use the AcrySof Toric [Alcon]." Dr. Williamson will only use a presby- opia-correcting IOL if the previous treatment was less then –4 D and there is evidence of a well-centered ablation on topography and mini- mal corneal coma. In those patients, he will use the Symfony lens (Johnson & Johnson Vision). Similarly, Richard Hoffman, MD, will choose a monofocal IOL with negative spheri- cal aberration that matches the positive spheri- cal aberration of the post-LASIK cornea. "Either extended depth of focus or mul- tifocal IOLs can be used following myopic LASIK, depending on the appearance of the topography," he said. Although Dr. Hoffman characterizes extended depth of focus IOLs as likely safer, with fewer patient complaints, multifocal IOLs can be used in these patients occasionally, he added. Post-hyperopic LASIK Because hyperopic LASIK generally includes negative spherical aberration, an IOL with positive spherical aberration is usually a better choice in this patient group, Dr. Hoffman said. Post-refractive surgery IOL selection requires a careful tightrope walk At a glance • Post-myopic LASIK patients have increased positive spherical aberration and are best suited for IOLs with negative spherical aberration. • Post-hyperopic LASIK patients have increased negative spherical aberration and are best suited for aberration-free IOLs or IOLs with positive spherical aberration. • Guidelines for post-PRK patients are similar to those for post-LASIK patients. • Surgeons should proceed with caution when selecting IOLs for patients post-RK. Financial interests Hoffman: Alcon, MicroSurgical Technology Koch: Alcon, Carl Zeiss Meditec, Johnson & Johnson Vision Williamson: None

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