Eyeworld

EW REFRACTIVE SURGERY 34 July 2015 by Steven J. Dell, MD M any patients present with a request for good vision at all distances without spectacle dependence. Previous generations of multifocal IOLs usually left patients with good distance vision, good near vision, but less satisfactory intermediate vision. To achieve good vision at multiple ranges in the 3 principal areas people want to see—distance, intermediate, and near—I would employ a bit of monovision with bilateral accommodating lenses or mix accommodating and multifo- cal technologies together. Since the recent FDA approval of 2 Tecnis Multifocal IOLs (Abbott Medical Optics, Abbott Park, Ill.) in lower add powers, surgeons now have the ability to personalize outcomes for patients based on their lifestyles and preference for near, intermediate, and distance vision. While more IOL options can make the surgeon's job easier in some ways, it may compli- cate it in other ways. Managing patient expectations Patients who enter my office have a visual problem they desire to fix. Many are seeking a purely refractive remedy while others have quite sig- nificant cataracts. In either situation, most patients desire a greater range of vision without spectacles than they currently have. In this scenario, the cataract patient is an easier approach because overall vision quality improves just by removing the cataract. Addi- tional spectacle independence is a bonus for this patient. However, the patient seeking a refractive surgical solution has higher expectations, and the challenge is to select a solution that preserves good visual quality while also increasing the quantity of what they can see with- out correction. The Tecnis Multifocal lenses offer these patients a quality of vision advantage over earlier multifocal lens options, and I feel comfortable using these in patients who start out with very good quality vision. I have found that the key to success in implementing this new technology is to quickly and accurately ascertain what the patient really wants to see without correction and match it to the best IOL to achieve that goal. I accomplish this by requiring each patient to complete a simple, 1-page questionnaire to determine what the patient's desired outcome is. The questionnaire helps patients pin- point what they really want, while also shaping expectations before they even meet with me; patients begin to realize that there are certain optical compromises that they may be required to make. I utilize the information garnered from the questionnaire, in conjunction with my discussion with the patient, to customize a solution to help them to meet their visual target or to help them understand that they may have unrealistic goals. Managing patient expectations is an import- ant step in determining successful outcomes. Developing the surgical plan Developing the surgical plan begins by determining the best level of add power, or combination of add powers, to achieve the patient's de- sired outcome. This decision should never be left in the hands of the patient; this is the surgeon's respon- sibility. Finding the best solution is dependent upon ensuring that the surgeon and patient are working within the same confines of context Where do low add lenses fit into my practice? +2.75 Tecnis Multifocal lens Source: Steven J. Dell, MD and that the patient has a complete understanding of the advantages and disadvantages associated with each lens. This is an area where the questionnaire proves valuable. I use the Tecnis Multifocal family of IOLs, which are currently available in 3 add powers, offering enhanced vision at 1 of 3 focal points: +2.75 D, +3.25 D, and +4.0 D. In my experience, as well as in published studies, the Tecnis Mul- tifocal lenses provide a quality of vision advantage over earlier multi- focal lenses, particularly in multiple lighting conditions, with patients reporting lower incidences of halos and night glare. 1 Additionally, Tecnis lenses are shown to reduce chromat- ic aberration for improved optical quality, 2 have a wavefront-designed aspheric surface that corrects spher- ical aberration to essentially zero, 3 and are made of a lens material not associated with glistenings. 4 Other benefits include a UV-blocking and glare-reducing design. 5,6 Patients surveyed for FDA approval reported extraordinary satisfaction rates. Up to 98% reported the ability to func- tion comfortably without glasses at intermediate and far distances, and up to 97% stated that they would implant the same IOL again. 1 This level of satisfaction is extraordinary. Intermediate to distance vision (~50 cm theoretical read- ing distance): For the patient who requests good distance and interme- diate vision, I will typically select the +2.75 D IOL for bilateral implan- tation. This lens provides patients superior distance quality and favors longer intermediate vision activities such as working at the computer and reading labels while grocery shopping. However, for the finest print the patient may need to utilize reading glasses. The highest levels of satisfaction in the FDA study as well as from my patients are with this particular lens. Intermediate to near vision (~42 cm theoretical reading dis- tance): I will select the +3.25 D lens- es for patients who prefer enhanced performance for closer intermedi- ate activities. This might include reading a handheld device, such as a tablet or phone. Near vision (~33 cm theoret- ical reading distance): Patients who prefer engaging in near vision activities such as reading, sewing, or knitting benefit most from the tradi- tional +4.0 high add-power lenses. Mix and match: This is the most common approach I utilize in my practice for implanting bilateral multifocal lenses. For a typical case, I will implant the +2.75 D in the

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