MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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32 EW CATARACT May 2013 Contact continued from page 31 "a multifocal contact lens is just going to make things that much worse. Putting a multifocal contact lens on a patient with a significant cataract is a pretty inaccurate way to gauge how the patient would do with a multifocal IOL after the cataract has been removed. Other surgeons will "occasionally" use a contact lens trial, but only in cases of refractive lens exchange. "If a patient has a cataract, a multifocal lens trial is not going to help assess patient acceptance," said William Trattler, MD, in private practice, Center for Excellence in Eye Care, Miami. "I use contact lens trials more for blended vision with a planned accommodating IOL, although this is not common, either." Outside the U.S., however, surgeons are more open to the idea. Arthur Cummings, MD, in practice, Wellington Eye Clinic, Ireland, said he typically uses multifocal contact lenses in his potential multifocal IOL patients "in each and every case of refractive lens exchange where monovision appears to be unsuited." Patient perceptions Older patients are also more likely to have ocular surface issues that may adversely affect any potential vision improvements a contact lens may provide, whether the lens is monofocal, toric, or multifocal. Further, multifocal IOLs have different optics from multifocal contact lenses, and the latter can have fitting issues the former will not. How patients react with multifocal contact lenses in the "real world" may differ significantly from how they react while reading a letter chart in the office. "You need to be careful with the multifocal add, however," Dr. Cummings said. "When prescribing multifocal contact lenses, we typically get the add we need at that point in time for the patient's level of presbyopia/age. But the IOLs have an add closer to the "high add" contact lens reading prescription." He said that general formula has changed a little with the recent use of the ReSTOR +2.5 (Alcon, Fort Worth, Texas), which provide "good intermediate vision." The high add contact lenses "would have demonstrated quite clearly to any patient that distance and near visual acuity are good, but the intermediate vision was the least improved," he said. For ophthalmologists who do opt to use contact lens trials first, "patients only need a few hours to confirm they're comfortable in the lenses," Dr. Trattler said. Another issue with the multifocal contacts is that some patients may say they dislike the lenses, "but the problem is not vision quality with the multifocal contacts, instead it's the decentration of the contact lens every time they blink," Dr. Tipperman said. "This obviously doesn't happen with an IOL, but that can be difficult to explain to patients that the blur is due to the lens moving and not to the multifocality itself." On the other hand, "when you tell someone that the only solution if they're unhappy after a multifocal IOL implantation is to explant the IOL, the patient readily sees the value of a multifocal contact lens trial," Dr. Cummings said. Dr. Tipperman agreed, saying if patients are in their 40s or 50s and wearing soft contact lenses already, "then it benefits them to have a brief trial of a multifocal contact lens, as it would give more information if and when they had cataract surgery in the future." If patients like the vision a multifocal contact lens provides, "they may opt to simply go with that solution rather than having a clear lens extraction. If they don't like the vision after a multifocal contact lens trial, they're not likely to go ahead with a clear lens extraction with a multifocal implant," Dr. Safran said. "It's potentially a lose-lose situation for you." As with any potential premium lens patient, strategic counseling will help ensure a positive patient experience. As the middle-aged population continues to grow, more and more patients are likely to seek out treatments for their increasing presbyopia, and for some, a multifocal contact lens trial should be considered a potential option before undergoing clear lens exchange. EW Editors' note: The physicians have no financial interests related to this article. Contact information Cummings: abc@wellingtoneyeclinic.com Safran: safran12@comcast.net Tipperman: rtipperman@mindspring.com Trattler: wtrattler@gmail.com

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