Eyeworld

78 | EYEWORLD | JULY 2021 ATARACT C by Liz Hillman Editorial Co-Director About the physicians Alice Epitropoulos, MD Ophthalmic Surgeons and Consultants of Ohio Columbus, Ohio Dee Stephenson, MD, FACS Stephenson Eye Associates Venice, Florida Darrell White, MD SkyVision Centers Westlake, Ohio W hen patients see Darrell White, MD, for a cataract evaluation, they all get on the same train, what he calls the refractive cat- aract train. Dr. White uses this analogy to describe the journey of patients as they seek out a toric and/or presbyopia-correct- ing IOL. There are stops along this ride where pa- tients get off the train, either for their own rea- sons or at the recommendation of the physician. "In our practice, … we are committed to the premium channel, specifically presbyopia-cor- recting IOLs," Dr. White said. "We go in under the assumption that every patient who is in the office for a cataract evaluation is a candidate for a presbyopia-correcting intraocular lens until ei- ther we say they're not or they say they're not." Stop #1: Diagnostic testing and assessment At this stage, as Dr. White put it, he's looking for reasons to not offer a presbyopia-correcting IOL. Every patient in Dr. White's office gets a macular OCT, and anyone with significant macular pathology gets off the train. Alice Epitropoulos, MD, and Dee Stephenson, MD, also said macular OCT is a must for premium IOL candidates. They also mentioned topography. "You don't want to use these premium IOLs in patients with irregular astigmatism or keratoconus," Dr. Epitropoulos said, emphasiz- ing later the importance of consistent biometry measurements. Inconsistent measurements could signal an ocular surface issue. In 2015, Dr. Epitropoulos coauthored a paper that showed patients with hyperosmolarity had significant variability in their average Ks and anterior corneal astig- matism, resulting in differences in IOL power calculations. 1 "You have to treat the dry eye. It's aston- ishing to me that there are some well-regarded training programs where the attendings don't, and you have young surgeons coming out who are trained but they're not emphasizing treat- ing the ocular surface beforehand," Dr. White said. "You'll have a meaningful problem at least a third of the time, and you can't do that in an area where the public relations part is so important." Dr. Stephenson said every patient she sees gets homework, which includes using hypo- chlorous acid lid scrubs, artificial tears, cyclo- sporine, and/or a topical steroid before they have diagnostic testing performed and measure- ments taken. Both Dr. White and Dr. Epitropoulos dis- cussed the importance of identifying the angle kappa and chord mu to ensure optimal IOL centration to achieve maximum optical perfor- mance and minimize the risk of dysphotopsia or "waxy vision." "We use the IOLMaster 700 [Carl Zeiss Meditec] and like to see the angle kappa (chord length) less than 0.5 mm for patients con- sidering a presbyopia-correcting IOL. A large angle kappa is a relative contraindication for a multifocal lens due to a decrease in optical performance and high percentage of subjective complaints in these patients," Dr. Epitropoulos said. As Dr. White put it, most presbyopia-cor- recting IOLs have bullseye designs. With that design, if the lens doesn't line up with the opti- cal center of the patient's visual system, aberra- tions and reduced contrast sensitivity could be induced, he said. "It's like the optic and the focal lens of a telescope. If you don't have the optic and the optical element lined up, you won't be able to see with a telescope. The same thing in many ways occurs with a true presbyopia-correcting IOL," Dr. White said. Stop #2: Patient personality and expectations While there are quite a few presbyopia-correct- ing IOL options in the U.S. market, multifocal, trifocal, extended depth of focus (EDOF), and newer options like Eyhance (Johnson & John- son Vision) and Vivity (Alcon), patient personal- ity remains an important factor in the selection process. "We want to make sure that our ever-im- proving but still imperfect presbyopia-correcting technology is going to be able to match the Pearls and pitfalls of premium IOLs

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