Eyeworld

EW CATARACT 27 N o matter which presby- opia-correcting IOL you favor, be it the ReSTOR (Alcon, Fort Worth, Texas), Tecnis (Abbott Medical Optics, AMO, Santa Ana, Calif.), or Crystalens (Bausch & Lomb, Rochester, N.Y.), experts agree that achieving the best possible out- comes begins with one critical com- ponent: the pre-op exam. EyeWorld spoke with Richard Tipperman, M.D., Wills Eye Hospi- tal, Philadelphia; Y. Ralph Chu, M.D., adjunct associate professor of ophthalmology, University of Min- nesota, Minneapolis, and clinical professor of ophthalmology, Univer- sity of Utah, Salt Lake City; and William B. Trattler, M.D., cornea specialist, Center for Excellence in Eye Care, Miami, for tips on attain- ing spectacular outcomes with each and every patient. The feedback was largely universal. Proper patient se- lection and an extensive pre-op exam will take you far. "So much of it boils down to pa- tient selection from the get-go," said Dr. Tipperman. "For me, that's some- one who has minimal to no astigma- tism so I don't have to deal with doing a limbal relaxing incision. The number one cause of patient dissat- isfaction with any of the premium IOLs is not hitting plano." Dr. Tipperman stressed the im- portance of doing a comprehensive eye exam, looking for issues such as dry eye and meibomian gland dys- function. Although he agreed that these eye issues and ones like it need to be addressed before surgery, it's not for reasons you might expect. "I think all of those factors af- fect the surgeon's ability to get good biometry," he said. "Treating these things helps because it allows the surgeon to get an accurate biometry, which makes it easier to nail the post-operative refraction." Dr. Chu agreed, noting that achieving good outcomes starts in the clinic, well before the patient is on the operating table. For him, get- ting accurate keratometry readings and a solid pre-op topography are key so any existing astigmatism can be diagnosed and discussed with the patient. "The patient has to understand what the best options are for him or her," he said. Much like the ReSTOR and Crystalens, the key to success with the Tecnis is a healthy ocular sur- face. Any dry eye or blepharitis must be addressed pre-op because an inac- curate keratometry can lead to the wrong IOL power, said Dr. Trattler. To avoid post-op surprises with the Tecnis, he suggested the following pre-op tests: topography, OCT of the macula, and fluorescein staining of the cornea. If a patient still isn't seeing well after surgery, he suggested looking for an often-missed condition. "The second most common issue I find after dry eye is missed epithelial basement membrane dys- trophy," said Dr. Trattler. "It de- grades the quality of vision. As soon as that's treated, results are very good." Both Drs. Chu and Tipperman turn to the IOL Master (Carl Zeiss Meditec, Dublin, Calif.) for their optical biometer. In addition, Dr. Tipperman likes to make sure pa- tients know what they are getting into before they sign off on the sur- gery, calling patient education "criti- cal" to the overall process. For his patients choosing the ReSTOR lens, he likes to use the Eyemaginations (Towson, Md.) module, developed by David F. Chang, M.D., clinical professor of ophthalmology, Univer- sity of California, San Francisco. "I think it's spectacular," Dr. Tipperman said. "Patients get a good understanding of what the lens can and can't do. It tells them more than I ever could in a brief amount of time." Although pre-op exam points apply to all IOLs, specific strategies vary from lens to lens. For example, Dr. Chu recommended surgeons using the Crystalens fully under- stand the induced refractive cylinder so they know where to place the in- cision. "We try to operate on the axis to intraoperatively reduce any pre- existing corneal astigmatism," he said. "Trying to get less than .75 D of astigmatism per patient is critical to having the best outcomes." For the ReSTOR, Dr. Tipperman advised surgeons to avoid making too small a capsulorhexis because the central 3.6 mm of the IOL optic is the apodized diffractive portion, while the remaining peripheral por- tion of the optic is purely refractive and for distance. Keeping the capsulorhexis large enough—so that much of the peripheral refractive portion of the IOL is uncovered— helps ensure excellent photopic and mesopic quality vision. He also spoke about ring centra- tion, pointing out that the ReSTOR should be centered on the patient's true visual axis, which may or may not be the geometric center of the pupil. "Some of the happiest patients I've seen are not well centered, and some of the unhappiest patients I've seen are perfectly centered," he said. "What is almost certainly the geo- metric center of the pupil is not aligned with the true visual axis for every single patient. We know there are some eyes where the actual vi- June 2011 by Faith A. Hayden EyeWorld Staff Writer Presbyopia-correcting IOL pearls I t has been more than 5 years since the currently available presbyopia- correcting IOLs were approved in the U.S. Since then, there have been hundreds—if not thousands—of lec- tures, articles, and discussions on the use of these IOLs. Cataract surgeons have come a long way in a short period of time in terms of understanding the technology behind these IOLs and im- proving clinical outcomes. I have asked three surgeons to share a single impor- tant tip to increase patient satisfaction. Bonnie An Henderson, M.D., cataract editor An implanted ReSTOR IOL (Alcon) Source: Richard Tipperman, M.D. continued on page 28 Cataract editor's corner of the world

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