EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/137624
40 EW REFRACTIVE SURGERY June 2013 Refractive editor's corner of the world Presbyopia case management by Erin L. Boyle EyeWorld Senior Staff Writer I t's an interesting time for a refractive cataract surgeon. The aging patient population is increasing, the demand for our services is growing, and patient expectations continue to rise. Fortunately, we have a lot of different technologies and surgical techniques at our disposal to address a variety of surgical plans. In this "Refractive editor's corner of the world," we present a case of a 65-year-old patient with bilateral cataracts with less than 1 diopter of corneal astigmatism who desires a presbyopic correction at the time of his cataract procedures. We have enlisted a group of international experts and asked them how they would address this patient's surgical plan. We also asked if their plan would change if the patient's history indicated successful or unsuccessful contact lens wear for either previous mono or multifocal vision. As you will see, there are several different ways to approach the patient using a variety of different surgical techniques and technologies. Thanks to Drs. Lawless, Wei, Kent for their time and expertise. T he treatment of older patients with corneal astigmatism and cataracts who want presbyopic correction can pose different solutions with different procedures, including various choices of IOLs. Looking at a specific case—a 65-year-old with less than 1 D of corneal astigmatism with bilateral cataracts who wants presbyopic correction—shows how physicians have multiple ways of treating this example patient. "The key is always to ascertain exactly what the patient wants," said David Kent, MD, in private practice, Kilkenny, Ireland, and other physicians agreed. Preferred procedure Michael Lawless, MD, Vision Eye Institute, Chatswood, New South Wales, Australia, said that he would determine his procedure of choice by first speaking with the patient about vision needs and expectations. If the patient's expectations were within reason and the cornea had a normal anatomy, he would then perform femtosecond laser cataract surgery with the LenSx system (Alcon, Fort Worth, Texas) with an AcrySof IQ ReSTOR multifocal +2.5 add (Alcon) implanted in the dominant eye and a +3.0 add implanted in the nondominant eye. "This, in my hands, gives a high chance of spectacle independence, minimal night haloes, and excellent intermediate vision," said Dr. Lawless. "If I could perform on-axis surgery, I would do so using my standard reverse trapezoidal incision, 2.4-mm internal and 2.3-mm external and an intrastromal astigmatic incision in the opposite quadrant at a diameter of 9 mm and extending for 30 degrees. I would not open the astigmatic incision. If I could not perform on-axis surgery, I would use my usual incision as described above and place paired astigmatic incisions in the steep corneal axis." Other surgeons have different preferences. Marc E. Wei, MBBS, FRANZCO, in private practice, Laser Sight Australia, said he would perform a lensectomy with a multifocal IOL, the trifocal AT LISA tri 839MP (Carl Zeiss Meditec, Dublin, Calif.), which is currently not available in the U.S., and provides relatively pupil-independent near, intermediate and far distance focus with minimal haloes and excellent clarity. Dr. Kent said his experience with multifocal lenses has been limited, but he is not sure he would select a multifocal lens in this case. He said he prefers monovision, aiming for a –1.75 spherical equivalent in the nondominant eye using a C-flex or Superflex aspheric lens (Rayner, East Sussex, England), also not available in the U.S. "Based on patient testimonies and postoperative quality of life questionnaires, I have, for the moment at least, gone away from [multifocal] technology," he said. "I would agree that, in general, in ideal circumstances, multifocal intraocular lenses perform optimally, but many of my patients don't seem to experience optimal conditions for everyday 'run of the mill' visual tasks." continued on page 42 Kerry Solomon, MD, refractive editor This graph depicts the near and intermediate visual acuity of the Carl Zeiss Meditec trifocal IOL. Source: Marc E. Wei, MBBS, FRANZCO