Eyeworld

EW FEATURE 38 by Enette Ngoei EyeWorld Contributing Editor Evaluating patients for premium IOLs "Even if [patients] wear glasses, it's important to document that with a full exam," she said. She measures pupil size and does BAT testing for glare problems. On the initial exam, she may not always do the Schirmer's test, al- though she is starting to do it more for her dry eye patients, she said. Dr. Tsai also performs a good retina exam, and if there are any concerns, she'll do an Amsler Grid exam in the office. Although she currently doesn't do an OCT scan on all of her patients, she is thinking of going that way. Patients with the potential for and interest in getting premium IOL implants are then put on Restasis (cyclosporine, Allergan, Irvine, Calif.) or a lubricant drop and are asked to come back for pre-op meas- urements, Dr. Tsai said. "I want to make sure that I can double check my measurements, particularly the astigmatism," she explained. During the second round of measurements, Dr. Tsai rechecks the manual keratometry readings and does topography on all of her pa- tients. "If it hasn't been done, I'll do pupil size and redo the A-scan at that time so when I'm looking at astigmatism I've got the K measure- ments from the initial exam and then I've got repeat Ks, topography, and A-scan from the day that the pa- tient came back," she said. Dr. Tsai always checks the domi- nant eye because she wants to see how vision is going to be integrated in the patient's whole system, she explained. Another essential part of her pre-op exam is the Vision Assess- ment Questionnaire developed by Steven Dell, M.D. Dr. Tsai currently offers the Crystalens AO or HD (Bausch & Lomb, Rochester, N.Y.) and the Tecnis Multifocal IOL (Abbott Medical Optics, Santa Ana, Calif.), and the questionnaire helps her determine which one of those implants might be more accommo- dating for the patient, she ex- plained. All the time or some of the time? Apart from thorough ocular exams, some experts recommend corneal topography mapping as well as OCT scans for all premium IOL patients. Both Dr. Tsai and Leslie Brannon Aden, M.D., Mississippi Vision Correction Center, Flowood, perform topographies on all their premium IOL patients. But when it comes to OCT scans, neither are doing them all of the time. Looking for underlying corneal pathology and making sure to rule out any type of possible keratoconus is important, Dr. Tsai said. While some practices might not have ac- cess to a topography machine, it is becoming the standard of care, she said. On the other hand, OCTs and the imaging of the retina are more difficult to have access to, Dr. Tsai said. She did not have the equip- ment readily available before, but now that she does, she said it doesn't hurt to have more informa- tion that you can share with the pa- tient ahead of time, to show that you spent extra time looking for any abnormalities that could affect the outcome. Patients can sometimes develop retinal pathology like an epiretinal membrane following multifocal IOL implantation, so it is good to be able to show them this was not some- thing that they had before and that they were a good candidate for pre- mium lenses at the time of surgery. Dr. Aden thinks that while the OCT is appropriate in a lot of pre- mium IOL patients, she doesn't be- lieve it's necessary in 100% of the cases. She draws the distinction be- tween multifocal lenses and toric lenses. The toric lens is not as depend- ent upon the retina being perfectly healthy to function in the way it should, Dr. Aden explained. "I will put a toric lens in a pa- tient who has retinal pathology if the patient has astigmatism and wants to be free from wearing pre- scription lenses for distance. I don't think there's a contraindication there because that patient will have to wear glasses for the correction of astigmatism anyway." But she wouldn't put a multifo- cal IOL in a patient with macular pathology who does not have astig- matism and wants a multifocal lens. In such an instance, it takes an OCT to identify that the macular pathol- ogy is there. In terms of measuring axial length, both surgeons prefer the IOLMaster (Carl Zeiss Meditec, Dublin, Calif.). If there are any ques- tions about her IOL measurements, February 2011 Ethics of IOLs August 2011 EyeWorld talks to experts about the extra measures they take when evaluating premium IOL patients D ry eye tests, topography tests, and OCT scans— with high patient expec- tations of gaining complete spectacle inde- pendence following premium lens surgery, detailed pre-op evaluations are needed to ensure optimal out- comes. Lisa Tsai, M.D., assistant profes- sor, ophthalmology and visual sci- ences, Washington University School of Medicine, St. Louis, said her pre-op evaluation for premium lens patients closely resembles what she does for patients undergoing LASIK surgery. First, Dr. Tsai conducts a full ocular exam, including an assess- ment of uncorrected vision at distance and near. AT A GLANCE • While some practices might not have access to a topography machine, it is becoming the standard of care • Apart from thorough ocular exams, some experts recommend corneal topography mapping as well as OCT scans for premium IOL patients. Both Dr. Tsai and Dr. Aden perform topographies on all their premium IOL patients, but when it comes to OCT scans, neither are doing them all of the time • It's important to offer patients the option of a standard IOL or premium IOL even though some practices may feel strongly about the premium IOLs • If the surgeon knows the patient will not do well with a certain tech- nology, the ethical responsibility is on the part of the physician to make the choice against this technology • Testing by itself is not a substitute for having a clinical picture in mind of some of the issues that you're concerned about and having a discussion with the patient using the results of the tests Topography scans are common scans used in evaluating patients for IOLs Source: David T.C. Lin, M.D. continued on page 40

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