Eyeworld

115 EW FEATURE March 2015 Refractive options For the accommodating IOL, Dr. Donnenfeld said there is less risk of glare and halo, but there is also less reading function. Often, he has to do a mild monovision to give the patient significant reading function. Additionally, because the lens is more flexible, the refractive results at distance are not as accurate as conventional IOLs, so patients have to understand that there is an increased risk that they made need a laser enhancement to correct for residual refractive error. "The good news is there's very little loss of contrast sensitivity," he said. With multifocal IOLs, there will be more reading ability, but these are not truly multifocal IOLs, Dr. Donnenfeld said. They are truly bifocal IOLs, so they get a near point and a distance point, and interme- diate distances may be out of focus. "They also have more glare and halo at night," he said. Multifocal IOLs require good lighting and are depen- dent on quality refractive outcomes. The most important thing for all of the IOLs available is the preoper- ative evaluation of the patient and the informed consent, he said. "Patients have to have a rea- sonable set of expectations before surgery," Dr. Donnenfeld. With that said, he uses a group of concepts known as the "5 Cs" to achieve opti- mal results. These include managing cylinder and refractive error; manag- good intermediate vision to a func- tional level without the symptoms that would normally be associated with multifocality, Dr. Dell said. "Accommodating lenses have very good distance quality vision, equal to a monofocal optic," he said. They also provide good intermedi- ate vision but do not offer the same level of near vision as a multifocal. The challenge with accommodating lenses is that they are sensitive to capsulotomy size, Dr. Dell said. They cannot be used in the presence of an open posterior capsule or tear in the posterior capsule. Additionally, patients with zonular weakness may be less than ideal candidates. "Because these lenses are designed to move in the eye, this can result in changes in the optic position and tilting of the optic in response to aggressive healing re- sponses," Dr. Dell said. Meanwhile, side effects associated with multi- focals are well described and may include glare, halos, or unwanted images. Dr. Donnenfeld said the first thing you need when dealing with options for presbyopic patients is to have informed consent from the pa- tient about what the visual realities of the different types of IOLs are. EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line. Poll size: 262 ing the corneal surface and especial- ly dry eye; making sure the capsule is clear; avoiding cystoid macular edema (CME); and centering the IOL on the pupil and the visual axis. Ocular surface Dr. Donnenfeld evaluates the ocular surface in all patients. Dry eye test- ing is the first step. If he finds that a patient does have some form of dry eye disease, it is important to treat it aggressively before surgery. For patients who have aqueous deficient dry eye, he may use loteprednol or cyclosporine drops. For those with meibomian gland disease, hot compresses or omega-3 fish oils may help. Problems with the ocular surface can have an impact on these lenses. "I think it's well described that multifocal IOLs in particular are more susceptible to degradation in performance when the ocular sur- face is less than ideal," Dr. Dell said. The surgery, including all the topical medications, incisions in the cornea, and manipulation of the eye, can tip the balance in a nega- tive direction in any eye teetering on poor ocular surface health, he said. Residual astigmatism Dr. Dell said residual astigmatism is more of a factor with multifocal IOLs than with accommodating Meibomian gland dysfunction with eyelid margin telangiectasias. Issues such as these can affect the outcomes of presbyopic IOL patients. Source (all): Preeya Gupta, MD continued on page 116

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