Eyeworld

48 | EYEWORLD | DECEMBER 2021 ATARACT C by Liz Hillman Editorial Co-Director About the physicians Eric Donnenfeld, MD Ophthalmic Consultants of Long Island Garden City, New York Stephen Scoper, MD Virginia Eye Consultants Norfolk, Virginia Blake Williamson, MD Williamson Eye Baton Rouge, Louisiana diseases add up to give them what they perceive to be their vision." Dr. Scoper said with multifocal lenses, such as PanOptix (Alcon), which became the first trifocal approved in the U.S. in 2019, significant ocular pathology will negatively impact lens performance. He said he won't offer this lens to patients who have any macular pathology, moderate epiretinal membrane, or significant ocular surface disease. If dry eye is mild, he's open to treating the patient with artificial tears, plugs, Xiidra (lifitegrast, Novartis), or Restasis (cyclosporine, Allergan). If after that course of treatment the surface improves, he's comfort- able offering them the trifocal. "But I remind them that dry eye can be a chronic disease and they're going to have to commit to treating the dry eyes indefinitely for this trifocal lens to work its best for the rest of their life," Dr. Scoper said. If a patient has more significant ocular sur- face disease, like epithelial basement membrane dystrophy, Dr. Scoper said he'll do a superficial lamellar keratectomy to get the surface smooth. If after recovery it looks good, he'll offer a mul- tifocal. If patients are not candidates for "any lens with a ring in it" due to ocular conditions, Dr. Scoper considers Vivity a viable option to pro- vide some independence from glasses. "The Vivity lens has no rings in it, so it's not light splitting. Because it's not light splitting, we don't have to be as concerned about ocular pathology," he said, describing it as a great lens for patients who wanted a multifocal. He still considers significant ocular pathology a contra- indication for Vivity in his practice. As Dr. Donnenfeld put it, the more near vision a presbyopia-correcting IOL provides, the more dysphotopsias can be expected. He said clinical trials showed that dysphotopsias were reduced with lower add multifocal IOLs. Lower add EDOF lenses also showed improve- ments in dysphotopsias. Further, Vivity and Eyhance (Johnson & Johnson Vision), he said, provide 0.75 D–0.5 D of near vision, but he's Premium IOLs in imperfect eyes T here is often discussion about the conditions an eye should meet in or- der to be successful with a premium, advanced technology IOL, but what about patients who desire indepen- dence from spectacles but who have less than perfect eyes? According to Eric Donnenfeld, MD, Stephen Scoper, MD, and Blake Williamson, MD, there are some conditions that are complete no-go's for any presbyopia-correcting IOL, but with more options available in the presbyopia-cor- recting IOL market, some can be suitable even if the patient has existing ocular pathology. "At least once a day I have a patient who wants a multifocal implant and has some- thing going on that makes it so they probably wouldn't be a candidate," Dr. Williamson said, adding, however, that diabetic eye disease or glaucoma, for example, aren't discussion stop- pers. "It's a severity scale," he said. Patients with severe glaucoma, macular edema, uveitic disease, neovascularization, his- tory of retinal detachments, moderate to severe amblyopia, or double vision are not suitable candidates for a presbyopia-correcting IOL in Dr. Williamson's practice. Patients who have mild to moderate glaucoma, mild, insignificant epireti- nal membrane, stable macular degeneration, or those who've had previous refractive surgery are patients who, in the past, wouldn't have been considered for presbyopia-correcting IOLs. New- er technology, such as extended depth of focus (EDOF) IOLs and the AcrySof IQ Vivity (Alcon), which is a non-diffractive EDOF IOL, can offer the opportunity for presbyopia correction. "I would lean toward Vivity and Symfo- ny [Johnson & Johnson Vision] in these eyes because we know these are EDOF technologies and do not have multiple focal points. They can be more forgiving in eyes that are less pristine. EDOF as a category is a better solution than bifocal or trifocal in eyes such as this that are borderline," Dr. Williamson said. "The biggest thing that I do is make sure they understand the different eye diseases they have and how those

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