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EW FEATURE 108 Refractive options March 2015 "I find that those 'type A' pa- tients have already done their home- work and read about the difficulties of multifocal IOLs," she said. "They understand the limitations but are willing to accept them in return for less spectacle dependence." Astigmatism management Another important criterion for mul- tifocal IOL implantation is that the patient has manageable astigmatism that requires no treatment or can be treated reasonably with limbal relax- ing incisions (LRIs) or other corneal incisions, Dr. Koch said. "Addressing the astigmatism up- front is critical," Dr. Weinstock said. "It's a process of preop, intraop, and even postop management." Astigmatism management starts with good topography and refractions preoperatively, he said. Measure multiple topographies on different devices to ensure that it's regular astigmatism and that the measurements are repeatable from device to device. Some residual astigmatism is often tolerated with monofocal IOLs, Dr. Henderson said, but with multifocal IOLs, even small amounts can lead to poor vision and patient dissatisfaction. Her goal is to leave the patient with less than 0.5 D of residual astigmatism by operating on the steep axis or making LRIs or laser corneal incisions. New lens options The first toric multifocal IOLs will likely enter the U.S. market this year, allowing physicians to loosen the astigmatism restrictions and offer the technology to a whole new groups of patients. "I'm eagerly awaiting the new multifocal designs that are coming out," Dr. Koch said. "I think that the toric multifocal would be a wonderful advance, and I'm looking forward to recently approved lower- add multifocal IOLs from AMO [Abbott Medical Optics, Abbott Park, Ill.]." A toric version of the AcrySof IQ ReSTOR multifocal IOL (Alcon, Fort Worth, Texas) will be available to U.S. physicians this year, as well as a lower add version of the lens (the ReSTOR +2.5 D), which will give patients sharper distance vision. In addition to toric and low add versions of existing multifocals, Drs. Koch and Weinstock are looking for- ward to the approval of the TECNIS Symfony extended range of vision lens (AMO) in the U.S. The Sym- fony's diffractive echelette design elongates the focal point, giving the wearer a continuous, full range of vision, with incidences of glare and halos comparable to a monofocal IOL. "I think that's going to be one of the most optimal options we're going to have going forward for our patients," Dr. Koch said. The Symfony's advanced optical system might be a tipping point in reducing unwanted side effects associated with multifocals, Dr. Weinstock said, which could lead to implantation in a larger percentage of patients. 'Mix and match' lenses Bilateral implantation is the most tried and true way of using a mul- tifocal lens, Dr. Weinstock said, allowing the brain to receive similar images and facilitating neuroadap- tation, but some surgeons have had success mixing and matching multi- focal and monofocal IOLs. Dr. Koch will sometimes operate on the non-dominant eye first and implant a multifocal IOL. "If they are pretty satisfied with the near vision but bothered by the halos, I might do a monofocal in the fellow eye," he said. For a seasoned refractive cataract surgeon, a similar option would be to put a monofocal or Crystalens accommodating IOL (Bausch + Lomb, B+L, Bridgewater, N.J.) in the dominant eye to give the patient crisp, high-resolution vision, and then place a multifocal IOL in the non-dominant eye, Dr. Weinstock said. Although there has been success with this technique, Dr. Weinstock said, he sees it as a niche procedure rather than a mainstream one. "It's a little bit more work to start mixing and matching—it takes more time and energy," he said. "There have been some studies that show it's beneficial, but in my opinion, it's going to be a niche methodology." "Patients are often happier with their uncorrected near vision when both eyes are implanted with multi- focal IOLs," Dr. Henderson said. "If patients only have one eye implant- ed, usually that eye allows them to retinal disease preoperatively, he added. Take a family history and look for risk factors such as diabetes and smoking, he said. Personality is another major factor in determining who is a good candidate for a multifocal IOL. According to Dr. Weinstock, the best candidates are those who have dense cataracts and have not been both- ered by them. "That lets you know that they have somewhat of an easygoing personality—the fact that they haven't rushed into cataract sur- gery," he said. "In addition, a dense cataract causes a lot of glare at night, so these patients are already used to glare. If it's not bothering them that much, there's a good chance that the glare from the multifocal won't bother them." Although surgeons have histor- ically avoided implanting multifo- cal IOLs in "type A" personalities, do not exclude these patients as candidates, Dr. Henderson said— they might have the most realistic expectations. Multifocal IOLs continued from page 107 Are you a fan of EyeWorld? Like us on Facebook at facebook.com/EyeWorldMagazine Find us on social media Average cataract annual volume: 490 –Toric IOLs: 8.4% –Presbyopia-correcting IOLs: 7.2% Global Trends in Ophthalmology ™ Copyright © 2015 Global Trends in Ophthalmology and the American Society of Cataract & Refractive Surgery. All rights reserved. EyeWorld@EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews According to the 2014 ASCRS Clinical Survey, presbyopia-correcting lenses make up less than 10% of cataract surgeons' annual volume. Source: ASCRS

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