Eyeworld

by Sumit (Sam) Garg, MD Succeeding with multifocal IOLs I under promise and try to over deliver. The questionnaire and slit lamp examination are important components of a comprehensive examination. In my opinion, pa- tients should have no ophthalmic comorbidities that could degrade visual quality with their new IOL. If they do have early signs of pathol- ogy, I make sure they are aware that if the condition worsens, a multi- focal IOL may degrade their vision disproportionately. I perform diagnostic testing on multiple devices with the hopes that the measurements agree and are reproducible. If disparities occur, I try to determine why. I use a pinhole test for near vision, with a very bright light to determine visual potential in patients with moderate to advanced cataracts. If they don't achieve J1 or J1+, I explore possible etiologies for decreased potential vision. For all multifocal patients, I perform biom- etry, topography, and OPD-Scan III, which provides angle kappa, spher- ical aberration, and point-spread functions. If angle kappa is higher than 0.45 D, the surgeon may not want to implant a multifocal IOL because the patient's line of sight may not line up with the optics of the multifocal, thereby degrading vision. I also perform tomography (Pentacam) to help determine total corneal refractive power. This helps me determine the need for astigmat- ic correction. Additionally, if there is any indication that the patient's visual potential is not perfect, it is useful to perform optical coherence tomography (OCT) of the macula. If ocular surface disease (OSD) is present, I aggressively treat the patient before implanting any IOL because I think that OSD not only affects preoperative testing, but postoperative performance of the IOL as well. Treatments for OSD must be individualized to each pa- tient, and point-of-care testing can be helpful. Patients must understand that dry eye is chronic; it takes a long time to emerge and does not have a quick fix. After treatment, it's important to recheck the patient's measurements before surgery. Careful patient selection, a comprehensive preop examination, and precise intraoperative and postop strategies are key to patient satisfaction M ultifocal intraocular lenses (IOLs) are an attractive option for patients seeking pres- byopia correction. To deliver the results patients expect, meticulous preoperative, intraopera- tive, and postoperative management are key. Case report Cataract reduced vision in a 78-year- old man, with glare impeding his ability to drive at night. His mani- fest refraction was –0.75 D +1.75 D x 005, and his best corrected vision was 20/50 (glare 20/100). His aver- age axial length and keratometry on the IOLMaster were consistent with the manifest refraction. I implanted a Tecnis ZKB00 mul- tifocal IOL (+21.0 +2.75 add). I con- firmed my IOL selection using the Barrett Universal II formula (www. apacrs.org/barrett_universal2). My goal was to leave the patient slightly myopic (–0.10 D). Discussion During the preoperative evaluation, I ask patients to rate themselves on a scale ranging from "easy going" to "perfectionist." For those just beginning to implant presbyopia- correcting IOLs, I don't recommend starting with candidates who consid- er themselves perfectionists. Patients need to have realistic goals and expectations. I emphasize that multifocal IOLs reduce depen- dence on glasses and they may need glasses in certain situations. They need to know that no IOL is perfect. Astigmatism can be corrected with on-axis incisions or limbal relaxing incisions. The surgeon must be sure the capsulorhexis overlaps 360 degrees. Intraoperative aberrom- etry is a useful tool during surgery. Intraoperatively, surgeons also should assure IOL centration and rule out zonulopathy. If zonulopa- thy is present, surgeons may want to use a capsular tension ring. In addition, all OVD must be removed from behind the IOL. When centering a multifocal IOL, the subject-fixated, coaxially sighted corneal light reflex is a use- ful centration point (Figure 1). 1 One week after surgery, if the patient's vision misses the target, the first step is to examine the manifest refraction. The surgeon will need to determine whether glasses, an IOL exchange, laser vision correction, or limbal relaxing incisions will provide the best outcome. Astigmatismfix.com is a valuable tool in this process. Patients have high expectations of premium IOLs, and surgeons must ensure that they are appro- priate candidates and take steps preoperatively, intraoperatively, and postoperatively to achieve optimal results. Reference 1. Chang DH, Waring GO 4th. The subject-fix- ated coaxially sighted corneal light reflex: a clinical marker for centration of refractive treatments and devices. Am J Ophthalmol. 2014;158:863–874. Dr. Garg is vice chair of clinical ophthalmology and medical director of the Gavin Herbert Eye Institute, University of California, Irvine. He can be contacted at 714-456-0327 or gargs@uci.edu. 133 Supported by unrestricted educational grants from Alcon Laboratories and Bausch + Lomb Note centration of IOL on axial and paraxial lights from operating microscope " Patients have high expectations of premium IOLs, and surgeons must ensure that they are appropriate candidates. " –Sumit (Sam) Garg, MD Sumit (Sam) Garg, MD

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