Eyeworld

52 | EYEWORLD | WINTER 2025 R EFRACTIVE Contact Berdahl: john.berdahl @vancethompsonvision.com Donnenfeld: ericdonnenfeld @gmail.com Thompson: vance.thompson @vancethompsonvision.com Relevant disclosures Berdahl: Alcon, Bausch + Lomb, Johnson & Johnson, RxSight Donnenfeld: Alcon, Bausch + Lomb, Johnson & Johnson Thompson: Alcon, Bausch + Lomb, BVI, Johnson & Johnson, Rayner, Zeiss pulsation treatment. "The key is setting expec- tations; if they're willing to work with me, I'll work with them. At our clinic, our optometrists do most of the heavy lifting in dry eye manage- ment, but I stay involved to reinforce to patients that we're in it together," he said. If after addressing dry eye the image quality is still reduced, Dr. Thompson will perform a YAG capsulotomy at 3 months if there is PCO. If there isn't PCO, Dr. Thompson said he will do a gas permeable contact lens over refraction. "If that is crisp, we consider occult anterior basement membrane dystrophy, and we treat that with a corneal epithelial debridement often with a little PTK to establish a firmer epithelial adherence." Epithelial remodeling from this procedure can take up to 3 months. Dr. Donnenfeld said that he'll also wait 3 months before performing a YAG capsulotomy for PCO, though he'll consider it sooner if it's significant and the patient was initially happy with their outcome. He noted that if patients were not happy with their presbyopic cataract surgery at the outset, the YAG might not com- pletely solve their problem. As for ocular surface disease and dry eye, Dr. Donnenfeld said this is one of the most important aspects of improving quality of vision after a presbyopia-correcting IOL surgery, and practices should have someone who manages these patients, whether it be an ophthalmologist or optometrist. "When I see someone with a dry eye, I want to recognize the dry eye preoperatively," he said. "I want to tell the patient they have dry eye. I want to treat it appropriately. Then if they have dry eye postoperatively, I explain that we're going to continue to treat it, but we recognized it preoperatively." Dr. Donnenfeld noted that if the patient has dry eye that cannot be resolved preoperatively, it's a contraindication for a mul- tifocal IOL. If after 6 months postop image quality is still reduced, Dr. Thompson considers vitreous opacities and consults with retina. "Rarely, a vit- rectomy is needed, and it is amazing how much it can help the patient's image quality," he said. Dr. Berdahl said for the right patient, vitrectomy for vitreous opacities can "dramatically improve satisfaction." He said more is being done than it has been in the past. Dr. Donnenfeld said he's been interested in improving presbyopic IOL outcomes for the last 20 years, and for 18 of them, he ignored the contribution of the vitreous. "What I have learned subsequently is that the vitreous abso- lutely plays a significant role in patient quality of vision. And doing optical vitrectomies to improve quality of vision has been one of the greatest advances that I've seen in improving patient happiness and quality of vision with presbyopic IOLs." Dr. Donnenfeld said he will wait a minimum of 3 months and optimally 6 months before referring for an optical vitrecto- my for a patient who describes a blob moving across their line of vision. "What I hope is that blob will settle and move out of the visual axis, which does happen a lot. I encourage patients to wait 6 months when possible before I refer. And one of the caveats is that if I'm going to have the patient have an optical vitrectomy, I always do a YAG capsulotomy first." Despite these interventions, sometimes a LASIK touchup is necessary. There are times, rarely, that an implant exchange is needed to achieve patient satisfaction, Dr. Thompson said. "But if they understand the journey and we do our job completely, that should be rare. The patient satisfaction with modern-day advanced implants is amazing," he said. continued from page 51 Dr. Donnenfeld's 6 Cs These are Dr. Donnenfeld's easy ways to remember how to work up the unhappy multifocal IOL patient: 1. Cylinder and refractive error 2. Cornea and dry eye 3. Capsule opacification 4. Centration of the IOL 5. Cystoid macular edema 6. Condensation of the vitreous "My seventh C is 'crazy,' and that is I was crazy to put the lens in that patient," he said.

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