Eyeworld

EW FEATURE 52 Presbyopia treatment • August 2016 AT A GLANCE • Choosing the right candidate for presbyopia-correcting technology is key. Patients should have reasonable expectations, and it helps to make sure all of their options are clearly explained ahead of the procedure. • Certain ocular conditions could be contraindications for presbyopia-correcting IOLs, but it's also important to screen different patient personality types. • Knowing the benefits and limitations of the technologies you're using is also key. Surgeons need to be prepared to convey this information to patients before surgery. by Ellen Stodola EyeWorld Senior Staff Writer Physicians can't let patients control the final decision if another option may be more appropriate, Dr. Donaldson said. "We have to be able to 'just say no' if we feel this tech- nology might not provide the best visual quality despite their primary goal of spectacle independence." Dr. Talley Rostov said that patient selection becomes import- ant in knowing which patients to avoid when using the technology. She finds that older patients may be harder to educate in terms of the amount of recovery time it will take before they are seeing better. Patients who have had previous re- fractive surgery may have unrealistic expectations and may expect to see the way they did after laser vision correction. A careful look at the topography is necessary, she said. Additionally, Dr. Talley Rostov said a previous RK is a contraindication for multifocal lenses because the surgeon doesn't want to put a multifocal lens in a patient who has a multifocal cornea. Dr. Talley Rostov added that us- ing intraoperative aberrometry may be helpful with a presbyopia-correct- ing IOL in a patient who has had previous refractive surgery because it can help ensure accuracy. Dr. Berdahl said that he has had to do an IOL exchange when using Donaldson said. "As you gain expe- rience, you can broaden your range of potential candidates to more challenging situations." When presbyopia-correcting IOLs should not be used Occasionally, patients will present with fixed ideas and expectations for their surgery, Dr. Donaldson said. "They often present with some degree of knowledge of current technology including femtosecond lasers and premium IOLs," she said. "Many of these patients are on the younger side and possibly even interested in clear lens extraction for increased spectacle independence. "It is our job as physicians to screen patients who may not be good candidates despite their intense desire to be free of glasses," she said. The most common reason for this situation is uncontrolled or incompletely treated ocular surface disease (OSD), Dr. Donaldson added. "Some of these patients have under- gone prior LASIK and blepharoplasty and are very aesthetically oriented, hence their desire for increased spec- tacle independence," she said. "We need to explain any OSD and treat preoperatively, repeating measure- ments after treatment and re-evalu- ating the ocular surface to ensure a successful outcome." preoperative condition is considered a 'surgical complication' or 'side effect' of the surgery." Dr. Berdahl said that if he was giving advice to someone just starting with presbyopia-correcting IOLs, he would tell them to "start with a plan to finish." There will be a percentage of patients who have residual refractive error or dryness that the surgeon will have to treat in order for them to get to a satis- fied spot, he said. If you start with the idea that you will need to do an enhancement on some of these pa- tients or rehab the ocular surface, it makes it better for both the patient and surgeon so they are prepared for it to be a 2-step process: lens and then enhancement. Dr. Berdahl's other recommen- dation was to speak very frankly with patients. "Tell them exactly what you would want to know if you were the patient." He tells pa- tients that the hope is for increased flexibility in vision with the tradeoff of some quality. This means patients would need glasses less, but there may be some situations where their vision isn't perfect—such as with visually intense activities like driv- ing at night—because there could be rings around light. Dr. Talley Rostov said that one important key for success is to be- come familiar with the technology's benefits and limitations. It's import- ant to be able to communicate this information to the patient, she said. Gauging patient expectations is important. Educating the patient beforehand may help with this, Dr. Talley Rostov said. Managing astig- matism helps in the overall success. What to avoid Two of the most important things to avoid, Dr. Berdahl said, are putting a presbyopic IOL in an eye that doesn't have the anatomy for it and putting it in a patient who doesn't have the psychology for it. Dr. Donaldson said to avoid un- realistic expectations and highly de- manding personalities. In addition, she said to avoid confounding pa- thology, like ocular surface disease, irregular astigmatism, and macular pathology. Avoid the temptation to perform a clear lens extraction in early cases until you are comfortable using these lenses during routine, uncomplicated cataract surgery, Dr. W hen a surgeon is choosing options for patients with pres- byopia, there are a number of factors to consider. Kendall Donaldson, MD, Bascom Palmer Eye Institute, Planta- tion, Florida; Audrey Talley Rostov, MD, Northwest Eye Surgeons, Seat- tle; and John Berdahl, MD, Vance Thompson Vision, Sioux Falls, South Dakota, weighed in on how they use presbyopia-correcting IOLs and offered pearls, things to avoid, and tips for which patients may be best to receive these implants. Pearls for success Dr. Donaldson's first pearl was to start with the perfect candidate for early cases when introducing any new technology or technique into your practice. "The perfect candidate would be a patient who has reasonable expectations and is highly motivated to increase his or her spectacle independence," she said. It's also important to take into account personality and lifestyle. Second, ruling out other pathology is key. Patients should be screened for any concomitant disease, Dr. Donaldson said, such as ocular surface disease, macular pathology, or irregular corneal astig- matism. Dr. Donaldson's third pearl was to under promise and over deliver, and be honest, she added. "Don't be afraid to discuss potential adverse effects," she said. "Always remem- ber that a missed (or unmentioned) Lessons learned from experience with presbyopia-correcting technology Multifocal IOL with good centration after femtosecond laser-assisted cataract surgery. Proper centration is a key factor when placing multifocal IOLs.

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