Eyeworld

EW FEATURE 110 New technology in cataract surgery • April 2016 by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Patient selection for MFIOLs has evolved as lenses have changed. • Ocular findings, previous refractive surgery, occupation, and psychological factors play a role in MFIOL patient selection. • A longer period between first- and second-eye surgery can help surgeons assess where a patient's refraction settles and gauge the patient's opinion of MFIOLs. • Femtosecond laser technology during MFIOL implantation may be most beneficial for astigmatism. • Keratopathy. This can be anteri- or, such as dry eye or epithelial basement membrane dystrophy, or posterior, such as Fuchs' dys- trophy. "All of these reduce image quality," he said. • Pupillopathy. This refers to when the pupil is too small or too large, varying with the optic design. • Zonulopathy. "If there is a prob- lem with weak zonules, the lens may be unstable over time," Dr. Masket said. • Optic neuropathy. Dr. Masket has seen a few patients referred from others who have MFIOLs and are not doing well because of contrast sensitivity issues due to glaucoma or other optic nerve diseases. • Maculopathy. Any form of macular disease contraindicates MFIOLs, in his view. • Psychopathy. This covers the gamut of patients who are too demanding, not willing to under- stand limitations, and are fixated on minor details. Dr. Masket always prefers to keep patient expectations in check by informing them that even in the U.S. Food and Drug Administration trials for MFIOLs, 6–7% of patients would choose not to have the same lenses again. Although D. Rex Hamilton, MD, health sciences clinical profes- sor of ophthalmology, Jules Stein Eye Institute, and director, UCLA Laser Refractive Center, Los Angeles, uses MFIOLs in many patients, he is still reluctant to use them in most post-refractive eyes. After myopic LASIK, for example, a patient's spherical aberrations tend to be higher than normal, a feature that makes the eye less compatible with the multifocal optics. The optics in a post-radial keratotomy eye are typically not clean enough to be compatible with multifocal optics, he said. Bryan Lee, MD, JD, Altos Eye Physicians, Los Altos, California, also takes corneal aberrations into consideration. "If a patient has sig- nificant cylinder, I steer the conver- sation toward a toric IOL. However, even if the amount of cylinder isn't IOL technology and patient selection evolve T he factors that surgeons consider when deciding who is the best multifocal intraocular lens (MFIOL) candidate have evolved over the past 10 years. At the same time, there are some tried-and-true principles surgeons use to best match the technology with the right patient. A first step used by Samuel Masket, MD, clinical professor of ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles (UCLA), is to make sure that both patients and surgeons understand what MFIOLs can—and cannot—do. "With any strategy we use to reduce spectacle indepen- dence after surgery, there's always a compromise in quality of vision," he said. However, it's helpful that some of the newer IOL technology has im- proved quality of vision, he added. One characteristic that surgeons consider before MFIOL use is occu- pation. For example, a person who spends his or her life at a desktop computer may fall within the weak spot of MFIOLs, Dr. Masket said. When considering MFIOL use, Dr. Masket prefers to avoid patients with what he calls "the opathies," which cover the following: Pinpointing the best patients for multifocal IOLs … and the best IOLs for those patients Dr. Masket recommends avoiding patients with "the opathies" for multifocal success. Source: Samuel Masket, MD Optic neuropathy Pupillopathy Zonulopathy Maculopathy Keratopathy that high, if patients have a lot of coma or other higher-order aberra- tions, I show them their scan and explain that a multifocal IOL is a bad choice for them," Dr. Lee said. One previous concern with MFIOLs that Dr. Hamilton is less worried about now is nighttime glare and halos, as he finds the new- est version of the Tecnis multifocal IOL (Abbott Medical Optics, Abbott Park, Illinois) has significantly less nighttime quality of vision issues. "I don't get scared off by nighttime quality of vision issues anymore with the new low-add power Tecnis multifocal IOLs," he said.

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