Eyeworld

IOLs. At this time, it is uncertain how extended depth of focus lenses will be affected by residual astigma- tism. Even half a diopter can affect the performance of a multifocal IOL. "We tend to be very aggressive at treating those small refractive errors," he said. For residual astigmatism after surgery, Dr. Gupta favors PRK en- hancement. Many patients getting these lenses are older and may have subtle anterior basement membrane dystrophy, which could be a prob- lem with a limbal relaxing incision (LRI). Any laser surgery can increase risk of dry eye, but an LRI can do the same as well as create chronic foreign body sensation. "I like the precision of PRK and laser vision correction in general," she said. Dr. Donnenfeld said for small amounts of cylinder in a patient with no spherical refractive error, astigmatic keratotomy is commonly done. If the patient has a spherical component, IOL exchange or PRK/ LASIK may be used to resolve refrac- tive error. "Refractive cataract surgeons have to be willing and able to perform adjustments in refractive error because it's crucial to achieve optimal results," he said. Explanting the lens Lens explanation/exchange is a definite possibility for larger refrac- tive errors or for any patient that has intolerable visual disturbances, Dr. Gupta said. "Try to make the surgery as least traumatic as possible," she said. Protecting the endothelium is important, as is having a good plan of how you are going to free up and cut the lens, she said. Additionally, Dr. Gupta stressed that counseling patients is vital. Any number of problems can occur in a lens exchange, she said. Dr. Dell said that for small resid- ual refractive errors, he prefers to use laser vision correction. "If there's a large refractive error, particularly hyperopic, we tend to do an IOL exchange or even a sec- ondary piggyback IOL to rectify the situation," he said. Lenses built on the single-piece acrylic platform are easily removable in the early postop- erative period, he added. Resolving other problems before doing an explantation is key, Dr. Donnenfeld said. "[With] presby- opic IOLs, specifically multifocal IOLs, patients are by far the happi- est patients and the most unhappy patients I have in my practice," he said. "It's our responsibility to maximize patients' opportunity to achieve good results, but it's still difficult to predict whether a patient will be happy or unhappy with a simple preoperative evaluation." EW Editors' note: Dr. Gupta has financial interests with TearScience (Morrisville, N.C.), Allergan (Irvine, Calif.), Bio-Tissue (Doral, Fla.), and Shire (St. Helier, N.J.). Dr. Donnenfeld has financial interests with Alcon (Fort Worth, Texas), Abbott Medical Optics (AMO, Abbott Park, Ill.), Bausch + Lomb (B+L, Bridgewater, N.J.), and Allergan. Dr. Dell has financial interests with AMO and B+L. Contact information Dell: steven@dellmd.com Donnenfeld: ericdonnenfeld@gmail.com Gupta: preeya.gupta@duke.edu Managing patients continued from page 115 " [With] presbyopic IOLs, specifically multifocal IOLs, patients are by far the happiest patients and the most unhappy patients I have in my practice. " – Eric Donnenfeld, MD Refractive options March 2015

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