Eyeworld

98 | EYEWORLD | DECEMBER 2020 C ORNEA "If you have someone with no dry eye, they can benefit from just about any IOL as long as the retinal architecture is intact," Dr. Sheppard said. "If you have patients with recalcitrant dry eye, I'll talk them out of a multifocal." A toric lens makes a lot more sense for these patients, he added. Dr. Pflugfelder agreed that toric lenses are well tolerated and also advised caution when recommending multifocal and EDOF IOLs in patients with tear instability, corneal epitheliop- athy, or moderate to severe conjunctivochalasis. "I am a firm believer in providing patients with the best possible vision through lens-based surgery, viewing cataract surgery as a refractive procedure," Dr. Matossian said. "If possible, why not decrease dependence on spectacles?" She said that 0.5–1 D of astigmatism can be treated with LRIs or femto AIs, while astig- matism greater than 1 D can be treated with toric IOLs. "Astigmatism correction will ensure clearer images at all distances," she said. Presbyopia correction is ideal for patients who want to have greater independence from their glasses, Dr. Matossian said, adding that trifocal, multifocal, and EDOF IOLs provide nice options for patients to see far, intermediate, and near with little reliance on reading spectacles. However, she did note that macular and retinal health are key to ensure success with these IOLs. For patients with moderate to severe dry eye or for those with significant corneal pathol- ogy, Dr. Matossian discourages multifocal or EDOF IOLs. Surface stabilization and accurate pre-sur- gical measurements are mandatory to nail the refractive target for best outcomes, Dr. Matos- sian said. "Thereafter, a commitment by the patient to maintain their ocular surface health by adhering to their prescribed daily routines and undergoing their annual or semi-annual in-office procedures is paramount." Considerations for patients with previous refractive surgery "Previous refractive surgery patients are the great nightmare of the cataract surgeon," Dr. Sheppard said. The worst of these, he said, are the patients who have had RK because they have "amazing amounts of distortion." Sometimes, they're so distorted that you're not sure where the axis lid margins may not only help with blepharitis control but also potentiate the effects of other office-based therapeutics. "Treatments focused on heating and evacuating impacted meibum from the meibomian glands, such as LipiFlow [Johnson & Johnson Vision], TearCare [Sight Sciences], iLUX [Alcon], or intense pulsed light treatments [Optima IPL, Lumenis], to reduce inflammation by closing off abnormal blood vessels around the meibomian glands may be required," she said. "To quell the flare-ups triggered by prolonged screen time, allergies, or contact lens overwear, short-term steroids are recommended [loteprednol, Eysuvis, Kala]." Another key aspect is explaining the opti- mization process to the patient. Dr. Matossian emphasized that communication prior to cata- ract surgery is crucial. "The patient has to un- derstand that s/he has two diseases: a cataract that can be 'cured' and dry eye disease, which is chronic and progressive, requiring treatment for life." Dr. Matossian said it's important that this discussion with the patient happens before cat- aract surgery, or it may add chair time post-cat- aract surgery and further confuse or frustrate the patient. "Patient education is key not only to set proper expectations but also to get buy-in from the patient to adhere to the recommend- ed at-home remedies and continue with the prescribed medications," Dr. Matossian said. If properly explained, patients have no problem with a short wait time in order for their eye surgeon to obtain more reliable measurements to use for IOL calculation and astigmatism planning." In patients with more severe disease, it may take weeks or months to adequately tune up the ocular surface. To obtain pre-surgical topography, keratom- etry, and biometry, Dr. Matossian said, adequate tear film stabilization can typically be achieved within 2–3 weeks, assuming the patient adheres to the recommended at-home therapies and/ or agrees to undergo an out-of-pocket, in-office treatment. Lens choices There are a variety of lens options that can be used for dry eye patients. Sometimes the patient makes it easy, Dr. Sheppard said, if they know what they do or don't want or if they just want the option that will be covered by insurance. continued from page 97

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