Eyeworld

JULY 2021 | EYEWORLD | 79 C Reference 1. Epitropoulos A, et al. Effect of tear osmolarity on repeatability of keratometry for cataract sur- gery planning. J Cataract Refract Surg. 2015;41:1672–1677. Relevant disclosures Epitropoulos: Alcon, Bausch + Lomb, Johnson & Johnson Vision Stephenson: Alcon, Bausch + Lomb White: None Contact Epitropoulos: eyesmd33@gmail.com Stephenson: eyedrdee@aol.com White: dwhite2@skyvisioncenters.com expectations of our patients," Dr. White said. "Because of that, you can't do it without learning a bit about who they are, what makes them tick, what's important to them, and how flexible are they," Dr. White said. "You can't take someone whose happiness in life is driv- en by how well they see at distance and put a presbyopia-correcting IOL in them that is going to have any negative effect on their distance vision. You still have to do a tiny amount of psychological profiling." Dr. Epitropoulos said patients fill out an online questionnaire through software called MDbackline prior to seeing her, which gives her an idea of what their expectations are for their vision. "Patients who come in wanting to see 'perfect' at all distances including good quality vision at night should raise a red flag, highlight- ing the importance of discussing realistic ex- pectations with patients," she said. "For doctors new to presbyopia-correcting IOLs, start with cataract patients who are interested in reducing dependence on corrective lenses, have realistic expectations, and have an otherwise healthy eye." Dr. Epitropoulos said having family listen in during IOL selection discussions can be helpful. "It's important to spend extra chair time with these patients, being transparent and re- viewing the pluses, minuses, pearls, and pitfalls of this technology," she said. Dr. Stephenson said setting patient expec- tations is an art; you want to under promise and over deliver. "It's never going to be what God gave us—a pristine eye that doesn't have a cataract. You have to be honest with them about their own anatomy. We're good at hitting our mark, but we don't have a crystal ball [to see] how the patient heals, how soon they will get fibrosis, where the lens will sit in the eye." Closing points Dr. Stephenson said it's important to understand how presbyopia-correcting lenses work in your hands. She, a long-time Crystalens and Trulign (Bausch + Lomb) user, said she understands it takes special patient buy-in for the time it will take to optimize outcomes. "These are great for post-refractive patients because they are aspher- ic IOLs so have zero aberrations," she said. Dr. Stephenson said she had a harder time gaining success with traditional multifocals and EDOF because of how they split the light but has brought the Vivity and PanOptix trifocal (Alcon) into her practice with success. "There are quite a few options but whatever technology you use, you've got to know how it works in your hands," she said. On a similar vein, Dr. Epitropoulos said it's important to track results and personalize your A constant. She also noted that dissatisfied patients with residual refractive error should be offered a LASIK touch-up, LRI, or IOL exchange when appropriate; patients need to be informed of this possibility preop. "If someone comes in and they're unhappy, it's important to look at the whole picture. Treat any organic problems before telling them they need to get used to it. Let them know you're go- ing to do what you can to resolve these issues. Pay attention to the ocular surface. Evaluate for macular edema or posterior capsule haze. Treat residual refractive error," she said. Dr. White cautioned against considering an EDOF as a bypass for eyes with some issues. "If you have an eye where there is large angle kappa, an eye with an epiretinal mem- brane, an eye with a certain amount of macu- lar degeneration, the extended depth of focus lenses are going to allow those patients to still get an anticipated benefit from putting the lens in. The reality is they're much more forgiving by a full order of magnitude, but they don't fix the epiretinal membrane. They don't fix the corneal irregularities. "While I am absolutely a fan and will switch someone from a bifocal or trifocal to EDOF when I'm concerned about the visual health of the eye, I'm always careful not to get so enthu- siastic that I'm putting it in patients who should have a basic IOL or maybe a toric IOL," he said. "The EDOF lenses are much more forgiving, but they don't resolve the existing problems the eye has coming into the office."

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