Eyeworld

APRIL 2022 | EYEWORLD | 67 C Contact Koch: dkoch@bcm.edu Raviv: talraviv@eyecenterofny.com Williamson: blakewilliamson@weceye.com Relevant disclosures Koch: Alcon, Carl Zeiss Meditec, Johnson & Johnson Vision Raviv: Johnson & Johnson Vision Williamson: Johnson & Johnson Vision Case example Dr. Raviv provided a case to illustrate how he used his algorithm. Three weeks after receiving a trifocal toric IOL, a patient was in his office complaining of a "film" and "blurry/hazy" vision. Dr. Raviv said the patient had some dry eye preop and had been on topical cyclosporine for a month. First, he refracted the patient. She was correcting to 20/25- with a slight myopic correction. "Since the BCVA wasn't a crisp 20/20, we pursued treatment to improve the vision," he said, noting that OCT showed the macula was flat and unchanged and there was no signifi- cant PCO. "There was some punctate corneal staining. The topical steroid was increased and NSAID was discontinued. Restasis [cyclosporine, Allergan] and preservative-free tears were main- tained." At 2 months postop, the patient's BCVA with a –0.75 D improved to 20/20. From there, Dr. Raviv did an in-office contact lens trial, in which the patient noted significant improvement in distance and near vision. The plan was to continue dry eye drops for a few months, then proceed with PRK. At postop month 4, BCVA was 20/40- and 1+ PCO was present. A YAG capsulotomy was performed followed by another refraction. Dr. Raviv then performed PRK. One month after PRK, the eye was plano 20/20 (and J2), and the patient was very happy, Dr. Raviv said. Other perspectives Blake Williamson, MD, shared his perspective on patients who are unhappy after cataract surgery. He said the question is in what percent of the lenses that you place is there unhappiness such that the surgeon needs to do something about it? Dr. Williamson said his explant rate is less than 1%. "I think that's a testament to how we edu- cate the patients on the preop side, making sure they understand the limitations, set appropriate expectations, pick the right patients, etc.," he said, adding that if surgeons are using presby- opia-correcting lenses, they should have the skills to explant or perform a touch-up or be prepared to refer should the need arise. Reasons for patient unhappiness can be any number of things. Dr. Williamson said often it's an issue between eyes. "It's like having a cowboy boot on one foot and a roller skate on the other. … Everything is off because they need to have the other eye done," he said. "We educate them on the front end and let them know they're not going to love [the time] between eyes." Other issues include glare and halo in the early postop period. Dr. Williamson said pa- tients need to be reminded that it can take 3–4 months for them to neuroadapt. Another issue could be that the patient doesn't love their near vision. They might like it but not love it, Dr. Williamson said. The same issue could happen with distance. It might be a case where mixing and matching IOLs could help. Dr. Williamson said he doesn't think of these as complaints from patients but rather observations. He said he listens to these obser- vations and often uses them to inform what the best course of action is for the second eye. Douglas Koch, MD, discussed the challenge of cataract surgery in patients who have had prior refractive surgery. These patients elected for spectacle independence with initial re- fractive surgery, so they might have the same expectation after cataract surgery, if they're opting for a presbyopia-correcting IOL. Dr. Koch said that these patients often have multifocal corneas whose depth of focus can compensate in part for residual refractive error, but it's not uncommon for them to be off target, and resid- ual refractive error is more problematic with most EDOF and multifocal IOLs. It's especially important that these patients be educated about the added challenge their prior refractive sur- gery poses for hitting the post-cataract surgery refractive target, Dr. Koch said. He thinks that the Tecnis Symfony lens (Johnson & Johnson Vision), with its large "landing zone," is more forgiving in this regard, and in his practice he largely avoids other EDOF and multifocal IOLs in post-refractive eyes. continued on page 68

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