EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/1468183
76 | EYEWORLD | JUNE 2022 R EFRACTIVE Relevant disclosures Braga-Mele: Alcon Davidson: Alcon, Johnson & Johnson Vision Vendal: Alcon, Johnson & Johnson Vision Contact Braga-Mele: rbragamele@rogers.com Davidson: richard.davidson@cuanschutz.edu Vendal: zvendal@westlakeeyes.com success. You need to have a good biometer, good formulas (she prefers the Barrett Universal or the Barrett True K), good refractive outcomes from your monofocal IOLs, and a good topog- raphy with multiple sources of corneal astig- matism measurements. For efficiency, in some practices it might make sense to have a tech, she said. Dr. Vendal said the learning curve among the different advanced technology IOLs is similar. "We are not reinventing the wheel but rather improving our already existing options for patients, so new users should not be hesitant about trying the new advanced technology mod- els. There are pearls that I think can help set us up for success," she said, offering the following: 1. Extra chair time is needed to learn the patient's needs. 2. Preoperative testing is required to uncover subtle retinal disease that could make a differ- ence in lens choice. 3. Extra attention should be paid to dry eye and improvement prior to biometry. 4. Use multiple measurement modalities to cal- culate the most accurate IOL power possible. 5. Manage astigmatism aggressively. 6. Use intraoperative biometry, if available, to add additional data for decision making. Dr. Braga-Mele said that some physicians, like those in their last 5 years of practice, might not want to get into offering a whole range of relatively new IOLs. However, she thinks they should still let patients know what's available, and if the patient wants that technology, refer them to a surgeon who offers it. "Even if you don't do trifocal or multifocal IOLs because you don't think it's worth the visual aberration that could occur, you should at least let them know that there is this availability and why you don't like that technology and let them make that decision," she said. continued from page 75 Multifocal and trifocals: Dr. Braga-Mele said it's important to have a pristine eye for these lenses. Patients cannot have corneal issues like dry eye or EBMD, visual field defects, or retinal patholo- gy or potential for progression of retinal pathol- ogy. She will consider a patient who has had a very mild refractive ablation for these lenses. Dr. Davidson said he'll use these lenses in otherwise healthy eyes. He's also willing to do them on patients who are post-refractive, provided they have good-looking topography. Astigmatism should be minimal and regular, he said. Ideal patients in Dr. Vendal's practice for trifocals or multifocal lenses are those with healthy retinas and optic nerves who want as much indepen- dence from glasses as possible and who can tolerate some nighttime artifact. Extended depth of focus (EDOF): These IOLs, Dr. Braga-Mele said, can be offered to patients with mild dry eye, but she veers away from other corneal pathology. She said these lenses can also be offered to patients with mild to mod- erate glaucoma and those with mild macular degeneration or small epiretinal membrane because contrast sensitivity is not reduced. "The patient [should be] informed that they will get a range of vision that may not be 20/20 because of their ERM but they won't lose contrast sensi- tivity, and that's the key with these lenses," Dr. Braga-Mele said. Dr. Davidson said if a patient is concerned with glare or halo, these lenses are a better option for them. Dr. Vendal also noted the benefit of good contrast sensitivity at distance and said ideal candidates are those who spend most of their time looking at an intermediate/ computer distance and who can tolerate some nighttime artifact. There is a non-diffractive EDOF option now that doesn't have any night- time glare/artifact, she said. "As a cataract/refractive surgeon who also prac- tices glaucoma, it has been exciting to have a non-diffractive option for my subset of glauco- ma patients who previously could only choose monofocal implants at the time of cataract surgery," she said. "I think it's very important that when you're starting to venture into the presbyopia-mitigat- ing IOL portfolio, even with the EDOF lenses, you should start with pristine eyes so you can optimize your outcomes," Dr. Braga-Mele said. Ideal candidates for presbyopia-mitigating IOLs