Eyeworld

EW CATARACT 77 been quite happy with that," Dr. Chang said. "Their perception of intermediate and near blends together—it's not like a monovi- sion situation where the difference throws them off. Even though their night vision symptoms are slightly different, patients tolerate it well." Previous corneal surgery In patients with previous refrac- tive surgery, the degree of corneal irregularity and the type of prior refractive surgery are the primary drivers of which type of IOL to use, said Dr. Dell. For example, EDOF or multifocal IOLs can be very success- ful in patients who have undergone prior myopic wavefront-guided or wavefront-optimized LASIK. Prior hyperopic LASIK is more problematic owing to the negative spherical aberration these patients typically demonstrate. All multifo- cal IOLs and EDOF IOLs available in the U.S. will add to this negative spherical aberration. Additional- ly, hyperopic LASIK patients also demonstrate more challenging ocular surface disease presentations, which can further complicate the situation. "Patients with prior refractive surgery must be cautioned that hitting the refractive target will be more difficult, but these patients understand they have complex cases," Dr. Dell said. "They can often be very grateful, even with a refrac- tive miss postop, so long as there is a plan in place preop to address that potential outcome." EW Editors' note: Drs. Chang and Garg have financial interests with AMO, which is now Johnson & Johnson Vi- sion (J&J Vision, Santa Ana, Califor- nia). Dr. Dell has financial interests with AMO (now J&J) and Bausch + Lomb (Bridgewater, New Jersey). Dr. Walton has financial interests with Alcon (Fort Worth, Texas). Contact information Chang: dchang@empireeyeandlaser.com Dell: steven@dellmd.com Garg: samgarg@gmail.com Walton: drwalton@visiontexas.com Compared to options Because of their optical advantages, Dr. Chang uses EDOF IOLs as his pri- mary lens for correcting presbyopia. He makes it clear to patients that they will have reduced dependence on glasses for intermediate and near vision but may still need glasses for very small print. He occasionally uses monofo- coal IOLs for monovision in patients who prefer not to pay out of pocket but is careful to limit it to patients who have previously experienced monovision—either with contact lenses or naturally—and enjoy it. In patients with long-standing monovision, Dr. Garg often keeps them with monovision after cata- ract surgery, but he has had success switching some to EDOF IOLs. "There is some data to suggest that EDOF IOLs can be used in patients with subtle macular/optic nerve dysfunction," Dr. Garg said. "I still counsel these patients extensive- ly about the pros and cons of this." Dr. Dell has found accommo- dating IOLs offer a greater margin of safety in some patients. "While many patients with less-than-perfect eyes can receive an EDOF lens safely, the image quality with an accommodating IOL will always be better," Dr. Dell said. "Accommodating IOLs are associat- ed with a different constellation of challenges, such as slightly reduced refractive predictability, suscepti- bility to capsular contraction, and greater PCO formation. Accommo- dating IOLs work extremely well when carefully utilized, but the near vision effect is sometimes variable from patient to patient." Mix and match? Dr. Dell said his practice has ex- tensively mixed EDOF IOLs with multifocal IOLs, which he describes as "an extremely good and underuti- lized strategy." Dr. Chang agreed on good results from mixing lenses, particu- larly in low myopes who received an EDOF lens in the dominant eye and feel like they want more near vision. "I typically use a 3.25 D multi- focal in the other eye, and they've

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