Eyeworld

84 | EYEWORLD | JULY 2021 ATARACT C by Ellen Stodola Editorial Co-Director About the physicians Marjan Farid, MD Professor of Ophthalmology Gavin Herbert Eye Institute University of California, Irvine Irvine, California Maria Scott, MD Medical Director Chesapeake Eye Care and Laser Center Annapolis, Maryland W hen a patient comes in prior to cataract surgery, it's important to do a careful evaluation to see what conditions they might have and how this could impact IOL selection. Marjan Farid, MD, and Maria Scott, MD, discussed some conditions to be aware of when considering presbyopia-correcting IOLs and how to talk to patients about this before surgery. Be on the lookout When a patient comes in for a cataract evalu- ation, Dr. Farid said she looks at both the front and back of the eye, identifying irregularities that could impact candidacy for a presbyopia- correcting lens. She does an OCT of the macula to ensure there is no significant macular pathology that could disqualify them from receiving an EDOF or multifocal. She will do a corneal topography to look for irregularities, which could include things like unstable or irregular tear film that could produce irregular astigmatism. She is also looking for irregularities that may be related to lumps and bumps on the cornea. "There are a lot of things on the cornea that can create enough irregularity in the optical system and higher order aberrations where I wouldn't be comfortable putting in a presbyopia-correcting lens," Dr. Farid said. Sometimes a patient may be "on the bor- der," like a dry eye patient with an irregular tear film, and it's possible that after treatment and optimization, the patient will then become a candidate for a specific lens. "Sometimes you can treat the cornea with a minor in-office procedure such as superficial keratectomy and wait for the cornea to heal and stabilize, then repeat topography," Dr. Farid said. If it becomes normal, you can consider a presbyopia-correct- ing IOL. Glaucoma and retinal issues can be more complicated. "If a patient has advanced glau- coma, their contrast sensitivity is decreased already, so we don't want to split light further going into the eye," Dr. Farid said. Thus, she steers away from presbyopia-correcting lenses in moderate to advanced glaucoma. Patients may be candidates if glaucoma or ocular hyper- tension is mild. If a patient has subtle macular pathology with good foveal reflex, Dr. Farid will usually consult with a retinal specialist prior to consid- ering an EDOF IOL. Dr. Farid noted that some of the newer EDOF lenses, like the Symfony (Johnson & Johnson Vision), have less potential for optical aberrations. Lenses like the Symfony and Vivity (Alcon) have been used in patients with subtle macular pathology or early glaucoma because contrast sensitivity is good, she said. Dr. Farid also noted the AcuFocus pinhole lens (premar- ket approval was submitted to the FDA in Feb- ruary 2021) as an option for irregular eyes. The IC-8 uses pinhole optics to try to optimize depth of focus without using a multifocal or diffractive optic technology. Dr. Scott noted that pseudoexfoliation and trauma are conditions that can cause poor capsular support or zonular weakness. She also mentioned that issues like dry eye, Fuchs dystrophy, optic neuropathies, diabetic reti- nopathy, old central serous retinopathy with Using presbyopia-correcting IOLs in imperfect eyes continued on page 86 Salzmann's nodule creating irregular astigmatism in a preop cataract patient Source: Marjan Farid, MD

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