Eyeworld

DECEMBER 2021 | EYEWORLD | 49 C Relevant disclosures Donnenfeld: Alcon, Johnson & Johnson Vision Scoper: Alcon Williamson: Johnson & Johnson Vision Contact Donnenfeld: ericdonnenfeld@gmail.com Scoper: sscoper@cvphealth.com Williamson: blakewilliamson@weceye.com fact, Dr. Scoper said the only contraindication to toric IOLs is not having astigmatism. Dr. Don- nenfeld said that patients with treatable corneal disease, such as EBMD or pterygia, should have this addressed first, be given time to heal/stabi- lize, then have measurements and selection of a toric IOL. "The specific condition that is a contrain- dication to a toric IOL is patients who wear a gas permeable or scleral contact lens for visual rehabilitation. Placing a toric IOL will place the cylinder in the eye and not allow it to be treated with a rigid contact lens," Dr. Donnenfeld said. Finally, Dr. Williamson emphasized the importance of having the right toolkit preopera- tively and diagnostically in order to confidently recommend advanced technology lenses. He said topography, an updated biometer, and OCT of the macular are important. He also stressed the importance of refractive touch-ups when needed or IOL explants when necessary. "These lenses aren't for everyone. … If you have good skills for doing a lens exchange, that's an insurance policy. You know in the back of your mind that if everything else fails, … you have the tools to get that lens out," he said. seen dysphotopsias associated with these lenses similar to that of monofocal IOLs. "These two presbyopia-correcting IOLs are refractive rather than diffractive and have become my IOLs of choice for patients who traditionally I would not consider candidates for a [presbyopia-correcting] solution," Dr. Donnenfeld said. "I have placed them in post- LASIK, epiretinal membrane, and mild glauco- matous eyes with good success. The important conversation to have with these patients is the correct expectation of how much near vision they will receive, and I often will offer these patients mini-monovision of 0.50–1.0 D in their non-dominant eye, which provides them with an effective 1.0–1.75 D of near." In general, Dr. Donnenfeld said presby- opia-correcting IOL technologies over time have smoothed transition zones for decreased dys- photopsias in all patients, but especially in those less than perfect eyes. "Any IOL that splits light is going to increase dysphotopsias. The next major breakthrough in presbyopia-correcting IOLs will be true accom- modating IOLs. These lenses will be ideal for less than perfect eyes. For patients with corneal irregularities, the pinhole IOLs will improve dysphotopsias in less than perfect eyes." Dr. Donnenfeld said he's found post-LASIK patients to be among the most interested in presbyopia-correcting solutions. However, some patients in this population can fit in the catego- ry of "imperfect eyes." "Eyes with low hyperopia or myopia corrections with modern ablation profiles and centered ablations do well with all the presby- opia-correcting options," Dr. Donnenfeld said. "Patients with older ablation profiles that were more oblate, decentered ablation, or higher refractive corrections are at greater risk of dys- photopsias with a presbyopia-correcting IOL but I have found do well with the low-add refractive EDOF Vivity and Eyhance lenses." Toric IOLs, which are still out of pocket and considered premium IOLs, are far more forgiv- ing in the face of other ocular conditions. In "The biggest thing that I do is make sure they understand the different eye diseases they have and how those diseases add up to give them what they perceive to be their vision." —Blake Williamson, MD

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