Eyeworld

111 EW FEATURE April 2016 • New technology in cataract surgery One eye or 2? Surgeons must assess if a patient is best suited for bilateral use of the same MFIOL or the use of 2 different MFIOL technologies. Many have their personal preferences. When Dr. Hamilton finds a patient who is an MFIOL candidate, he explains that he will operate on 1 eye and then the other eye about 2 weeks later. He lets patients know that they may initially see halos at night, which he likens to seeing the frames of glasses when one gets a new pair. In other words, the halos may still be there, but the patient will ignore them over time. At 1 week after surgery in the first eye, Dr. Hamilton will then ask patients about their vision while using a computer and their vision while using a cell phone. If patients are pleased with their vision in both cases, he uses the same IOL in both eyes: the ZKB00 Tecnis multifocal IOL. If the patient needs a boost with near vision, he will use a higher add power lens in the second eye. In a study that Dr. Hamilton will report on at the 2016 ASCRS• ASOA Symposium & Congress, he found the same uncorrected near visual acuity in patients who had bilateral implantation of the same IOL versus those with different IOLs when the decision to place the same versus different was based on the computer/cell phone surveying after the first eye surgery. Dr. Masket supports using the same technology in both eyes if that is what best suits the patient. If he performs surgery in patients who have older IOL technology in 1 eye, he'll use newer technology with a lower add in the second eye. Dr. Lee likes to start with the lowest-add multifocal in the first eye and then wait at least 3 weeks for the patient to stabilize from a refractive standpoint and see if the patient is plano. The longer time between eyes gives patients more time to make sure they like having a multifocal IOL and to decide if they want to increase the add for the second IOL. Weighing in on femtosecond laser use Femtosecond laser use in cataract surgery has been a hot topic the past few years, but do the bells and whistles of the laser actually make a difference in outcomes? If it's a routine case, Dr. Masket does not think it's necessary. "I have very specific indications for the fem- tosecond laser. Those include people with dense cataracts, shallow cham- bers, compromised endothelium, zonular issues, or specific capsule issues," he said. One area where Drs. Masket and Hamilton think the femtosecond laser may be of help is in treating astigmatism. "If the surgeon can be assured of a well-placed capsuloto- my, then I'm not sure femtosecond capsulotomy is helpful. But if the surgeon isn't comfortable with reproducible capsulotomy, I think having the laser is better," Dr. Masket said. "I think I'm hitting my targets better than I would with manual astigmatic keratotomies, and that's critical for multifocals in the U.S. since we currently have no access to toric multifocals," Dr. Hamilton said. Ultimately, the benefit of the femtosecond laser during MFIOL procedures depends on the surgeon, Dr. Masket said. Dr. Lee does not think that use of the femtosecond laser during cataract surgery in MFIOL patients makes a difference in outcomes. Incorporating low-add MFIOLs There's one major cultural change in the past 10 years that's pushed for some changes to MFIOLs: the inces- sant use of smartphones and other mobile devices, which prompt the need for more intermediate vision. "We now all live with smartphones at arm's distance, for better or worse," Dr. Masket said. "The com- panies have responded and made lenses with a closer approximation to the way we live." The newer low-add IOLs avail- able now in the U.S. include 2 from Abbott Medical Optics (+2.75 D and +3.25) and 1 from Alcon (Fort The overlay from the Callisto markerless system helps with centration of the Tecnis ZKB00 low-add multifocal IOL. After the IOL is centered, curved intraocular scissors are used to resize and recenter the capsulorhexis on the new IOL position. Source: Bryan Lee, MD Worth, Texas; AcrySof IQ ReSTOR +2.5 D). For better intermediate vision with the Alcon low-add IOL, there is a trade-off with not as sharp near vision, Dr. Lee said. In fact, patients will need readers more for near tasks when using the Alcon low-add IOL. However, there's a more continuous range of vision compared with older MFIOLs, and fewer patients should complain about halos, he added. Dr. Hamilton has been partic- ularly pleased with his use of the ZKB00 low-add MFIOL (+2.75 D), achieving spectacle independence 70% of the time when he uses the low-add MFIOL in a bilateral fash- ion. He's been using the lens a little over a year. EW Editors' note: Dr. Hamilton has financial interests with Alcon and Abbott Medical Optics. Dr. Masket has financial interests with Alcon. Dr. Lee has no financial interests related to his comments. Contact information Hamilton: hamilton@jsei.ucla.edu Lee: bryan@bryanlee.pro Masket: avcmasket@aol.com

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