JUN 2013

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

Issue link: https://digital.eyeworld.org/i/137624

Contents of this Issue


Page 34 of 74

32 EW FEATURE February 2011 2013 Presbyopia June Comorbidities with multifocal IOL implantation by Ellen Stodola EyeWorld Staff Writer AT A GLANCE • Physicians agree on the value of discussing options with the patient and exploring each individual's motivations for wanting a multifocal IOL. • The way comorbidities affect a patient's eligibility for a multifocal IOL depends on the severity of the issue and ability to treat the condition before implantation of the IOL. • A patient's compliancy with treatment is an important factor in deciding if he or she is an ideal candidate for a multifocal IOL. When selecting patients for multifocal IOLs, physicians must consider conditions that could cause complications or impact the effectiveness of the IOL W hen it comes to considering patients for multifocal IOLs, comorbidities are factors that need to be weighed, along with a patient's motivation and goals for changes to his or her vision. "The first and single most important thing to me is what the patient's visual goals are," said John Berdahl, MD, Sioux Falls, S.D. Depending on whether a patient wants to be glasses-free or doesn't mind wearing glasses helps to shape his approach. If patients are visually picky, Dr. Berdahl said, then they may not be satisfied with the tradeoffs that can come with the IOL. In addition, he said the eye's condition has to be good to implant a multifocal IOL. "The eye has to be pretty pristine," he said. Both Richard J. Mackool Sr., MD, and RJ Mackool Jr., MD, Mackool Eye Institute, Astoria, N.Y., agreed that a patient's motivation for wanting a multifocal IOL plays a large role in determining who is a good candidate. At their practice, patients fill out a detailed questionnaire beforehand. "Educating patients first and having them express interest in the lens, I think that is important," Dr. Mackool Jr. said. Oftentimes, patients will want a specific lens because they know it is special or a friend has it, he said, so it's important to determine patients' motivation and to give them as much information as possible about the different lenses. Ocular surface disease Rick Wolfe, FRACS, medical director, Peninsula Eye Centre, Melbourne, Australia, said the tear film is particularly important because it is the principal refracting surface. "A quick assessment of the tear film is easy in all patients presenting for cataract surgery," he said. However, multifocal IOLs require a closer and more careful assessment. Dr. Wolfe said knowing a patient's history of dry eye symptoms is helpful, although that should not necessarily disqualify someone from getting a multifocal IOL. "In cases with ocular surface problems, preoperative treatment might be required if there is likely a reversible element," Dr. Wolfe said. "Management includes treatment for lid problems, lubricants, anti-inflammatories, cyclosporine, and punctal plugs." He said this problem would need to be assessed until the tear film proves to be adequate, and if it does not improve, a multifocal IOL may not be the best option. Dr. Berdahl said ocular surface disease can be worked around for those wanting a multifocal IOL. "If they have ocular surface disease, that doesn't automatically disqualify them. But I want to see how good I can rehab the ocular surface before deciding which lens to use." If he can improve the ocular surface and tear film quality before implanting the lens, he would be happy to use a multifocal IOL. However, he said it is important to address the problem beforehand because it may pose a problem if the multifocal IOL is im- An eye exhibiting epithelial basement membrane dystrophy (EBMD). This corneal condition, like corneal guttata and other co-morbidities, should be identified and dealt with before implanting a multifocal IOL in a patient. Source: Richard J. Mackool Sr., MD planted and then attempts were made later to address the tear film. Dr. Mackool Sr. said dealing with ocular surface disease for potential multifocal IOL candidates can be challenging. "Not only is it a very complex subject, it comes in all different degrees, creates all different degrees of disability, and there are a number of different ways that you can deal with it preoperatively and postoperatively." With ocular surface disease, Dr. Mackool Jr. said motivation is crucial. It's important to look at how far a patient is willing to go in certain measures to become a better candidate. For example, if a patient has dry eye, compliancy with treatment plays a major role in determining how successful a multifocal IOL would be for that individual. "The motivated patients can overcome almost anything," he said. Corneal guttata Dr. Berdahl said a few scattered corneal guttata does not automatically rule out a candidate for a multifocal IOL, but a patient's motivation and severity of the guttata also need to be considered. It would probably be better to put the multifocal IOL in a patient who is a bit older because it could be challenging to deal with if the condition worsens over time. Dr. Mackool Jr. said it's important to get a cell count with corneal guttata to determine how significant it is. "You need to evaluate the possibility that these guttata will advance to the point that they're visually significant," he said. Determining if a patient with some corneal guttata is still a candidate for a multifocal IOL centers around if contrast sensitivity is affected. "The more contrast sensitivity they have, the less likely the operation will be successful." Dr. Mackool Jr. said just a few guttata should be fine. Dr. Wolfe said if a patient has a few guttata with a normal endothelial cell count, then that is not a problem for a multifocal IOL. "I think the severely undulating endothelium of cornea guttata compromises vision even before detectable edema occurs," he said. "As the condition progresses it will only further compromise the visual function with a multifocal IOL." He said he would not use a multifocal IOL in these patients. Macular RPE changes or drusen Dr. Wolfe said when considering a multifocal IOL in a patient with macular retinal pigment epithelium (RPE) changes or drusen, you must first consider what the patient's current visual function is. Someone with good visual function could do

Articles in this issue

Archives of this issue

view archives of Eyeworld - JUN 2013