JAN 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 54 of 71

January 2012 EWInternational 55 dysfunction (ARFD) with advance technology IOLs: and Refractive Surgeons' experience Enrique Suárez, M.D. Docent Medical Centre La Trinidad Venezuela IOLs simply because these lenses, by definition, induce a lower contrast sensitivity; any mild or early PCO that does not interfere with visual quality in monofocal IOLs will be- come symptomatic in multifocal IOLs. Capsulotomy is performed ear- lier in multifocal IOLs. My favorite technique, which I call circular or merry-go-round, is through the periphery of the optics in a circular pattern in order to pre- vent damage to the center of the IOL and inducing post-op optical phenomena. Dr. De La Peña: Have you ever explanted any advanced technology IOLs for presbyopic correction in your practice? What was the cause and procedure? Dr. Suárez: No. The only case programmed for IOL explantation was due to negative temporal dys- photopsias; however, when the pa- tient learned about losing near vision he decided not to have his IOL changed. A few months later he was no longer troubled by these dys- photopsias. Dr. Carreño: So far it has not been necessary to explant any ad- vanced technology IOL for presby- opic correction. I think I should mention one patient who had a ReSTOR IOL implanted and felt a great discomfort caused by halos and 2 months after surgery asked for a second opinion from a different surgeon who indicated bilateral ex- plantation and IOL exchange by monofocal lenses. Fortunately, the patient decided to follow our advice, adopting an expectant attitude, and the disturbances progressively de- creased and eventually disappeared 6 months later. This case illustrates Edgardo Carreño, M.D. Medical Director of Centro Oftalmológico Carreño Chile that we should not hurry when indi- cating multifocal IOL explantation and that managing the situation carefully may prevent IOL explanta- tion. Dr. Centurion: I have been work- ing since the early 90s with different models of pseudoaccommodative IOLs with no personal case of ex- plantation. The reason? Adequate patient selection, good protocol with pre-op examinations, patient education, and saying no when mul- tifocal IOLs are not indicated. We have performed a few ex- plantations, generally due to incor- rect indication or surgical complications. Dr. De La Peña: In what "special situation," non-routine cases have you implanted advanced technology IOLs for presbyopic correction? Dr. Suárez: Previous LASIK sur- gery (22 cases); I only perform this surgery in patients with low pre- LASIK refractive defects with little or no central post-op topographic change, such as lowly myopic pa- tients who had refractive surgery performed in one eye for monovi- sion. Other cases include patients who had lost the fellow eye (three cases) or had severe amblyopia in the fellow eye (five cases); unilateral, traumatic cataracts in young pa- tients (two cases); and highly hyper- opic eyes in patients <40 years of age (nine cases). Dr. Carreño: Our good results after several years of implanting ad- vanced technology IOLs for presby- opic correction are mostly due to our respect for the established inclu- sion and exclusion criteria for these patients. Among all the cases of im- planted IOLs, there have been a few Virgilio Centurion, M.D. Clinical Director of the IMO – Instituto de Moléstias Oculares São Paulo, Brazil cases out of this routine. Among them I can think of two cases of traumatic, unilateral cataract, 12 cases with pre-op corneal astigma- tism >1.5 D who had post-op LASIK planned for the correction of the residual cylinder (multifocal toric IOLs were not available at that time), and more recently four cases with previous refractive surgery (LASIK) who had ReSTOR Toric IOLs implanted, using the Haigis L for- mula with very good refractive and visual outcomes. Dr. Centurion:We look for pa- tients with realistic outcome expec- tations, who are highly motivated for presbyopia correction. We are implanting IOLs in fixed myotic pupils (surgically treated), marked vitreous synchisis, after keratotomy (four incisions, wide optic area), and after hyperopic and myopic LASIK. In these cases we take potential visual acuity and the refractive fore- cast of the biometric calculation into high consideration. Dr. De La Peña: Apart from those eyes with any other ocular condition than cataracts, from a the- oretical point of view the first choice for IOL implantation should be ad- vanced technology IOLs for presby- opic correction. Why do you think that the rate of implantation of these IOLs is so low (<10.00%)? Dr. Suárez: There are other in- tervening factors such as high exi- gency, economics, and satisfaction with previous monovision achieved by contact lenses. Dr. Carreño: That is not my per- sonal experience, since I perform over 60% of the cases with advanced technology IOLs for presbyopic cor- rection. However, in my opinion William De La Peña, M.D. Chief executive officer of the Latin American Society of Cataract and Refractive Surgeons this low global rate of implantation is due to several factors such as: sur- geons' lack of confidence in the performance of this type of lens, conformity with the results achieved with monofocal IOLs, and little in- terest in adopting a more complex procedure that demands more time and effort, lack of confidence in their capability to perform a more exigent surgery with no margin for mistakes, lack of technology to per- form a complete pre-op evaluation as required by a presbyopia-correc- tion implant, insufficient patient in- formation regarding the advantages of multifocal IOLs, and last but not least the economical factor, which undoubtedly plays an important role in Latin America. Dr. Centurion: In my opinion, two factors may limit the implanta- tion of advanced technology IOLs for presbyopic correction (accom- modative and pseudoaccommoda- tive) below 7.5%. First, fear of collateral effects such as halos and glare as has been widely reported in the U.S. and has been the cause for some of the explantations. The sec- ond reason is economical. The cost of these IOLs seems to be very high for most of our patients who are usually retired and are not worried about using near correction. Dr. De La Peña: In your country, do the financial costs of advanced technology IOLs for presbyopic cor- rection have an additional cost for the patient? Do you think that this fact may influence the quantity of implantations? Do you perform "conversion" from conventional IOLs to advanced technology IOLs? Which is your method? Does the Health Service cover the expenses? continued on page 56

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