SEP 2012

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

Issue link: https://digital.eyeworld.org/i/82503

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Page 59 of 103

60 EW FEATURE February 2011 Refractive cataract surgery September 2012 At the multifocal junction by Maxine Lipner Senior EyeWorld Contributing Writer AT A GLANCE • Despite good outcomes, multifocal IOLs remain a question mark for some • Factors such as whether a patient is on an antidepressant medication or has excellent post-op acuity can help to elucidate who will do well • Correct management of the patient before and after lens implantation can influence patient satisfaction Weighing which IOL train to place a patient aboard I t's one of those choices that practitioners are facing more frequently—weighing whether or not to implant a multifocal or a monofocal lens in a pa- tient's eye. While in the U.S. pre- mium lenses account for 14.7% of the market, with hopes of this reach- ing 25-30% in the near future, not everyone is on board with them in Europe, according to Joseph Colin, M.D., professor of ophthalmology, Bordeaux University Hospital, Bordeaux, France. Despite often glowing reports from the podium, premium lenses remain in the doldrums in some sec- tors. "We have a wide choice of re- fractive implants, and some of them are very popular in Europe," Dr. Colin said. "However, when we look at the global market last year, 3 million cataract surgeries were per- formed in Europe, and only 7.8% of the IOLs were premium IOLs." Likewise, predictions for 2013 show an ample increase in the toric lens sector in Europe but not as much of a rise with multifocal IOLs. The unhappy berth To determine why this was occur- ring, Dr. Colin considered his own experience with 20 consecutive unhappy multifocal cases that had been referred to his hospital. In these cases, he found that patients' unhappiness was linked to a variety of underlying factors including early posterior capsular opacification (PCO), dry eye and blepharitis, sig- nificant refractive error, forme fruste keratoconus, IOL decentration, lens displacement, macular edema, and epiretinal membranes. Sometimes Multifocal lens funnel Source: Gary Foster, M.D. seemingly minor issues were to blame. "Even minimal PCO may re- sult in a significant reduction in the quality of vision in these patients," Dr. Colin said. Likewise, even the mildest CME may result in a signifi- cant reduction in the quality of vision in a multifocal lens patient. To increase the market for multifocal lenses, Dr. Colin touts improving patient selection, preven- tion, and treatment of complica- tions, as well as education. Punching a multifocal ticket Gary J.L. Foster, M.D., Fort Collins, Colo., agreed that proper patient selection is imperative. He recently conducted a study on patient satis- faction with multifocal lenses. "I started the study with the hypothe- sis that if we could profile patients' personalities, we could predict who would be less likely to be satisfied with multifocal lenses." However, no specific scientific measure of person- ality was found to be predictive of who would be happy with their outcomes. Some factors did appear to be related; if patients were on antidepressant medication they were less likely to be satisfied with their multifocal. Paradoxically, whether they were actually depressed or not was not predictive. Whether or not patients had high or low levels of negativity in their personalities was also not prog- nostic. "My interpretation of the data collected is while you can't pre- dict who's going to be happy based upon their personality profiling, you can predict based on their personal- ity how they would react if they happen to be in the unsatisfied group. The key is to avoid clinic- busting personalities," Dr. Foster said. The study also showed that the better the patient's uncorrected visual acuity post-op, the happier he or she ultimately tended to be with multifocal lenses. Based on this, Dr. Foster changed his strategy from try- ing to predict who would be satisfied based on personality type to which personalities he would enjoy sup- porting if they were unhappy and which patients would have the highest chance of achieving great UCVA, he said. Likewise, for those who had the monofocal lens implanted, the study indicated that the better their best corrected vision, the happier they tended to be, casting doubt on maxi- mum satisfaction for those with pre- existing retinal issues. To determine who should receive the premium lens, Dr. Foster has developed what he terms a multifocal lens funnel. "I would try to keep people in a mono- focal lens if they had a lower chance of great uncorrected visual acuity or if they had clinic-busting personali- ties," he said. Also being funneled toward monofocal lenses are those with a preference for reading glasses and occupational night drivers, as well as those with bad corneas, retinas, or tear film. Dr. Foster sees remaining patients as excellent candidates. "If they make it through that funnel then I'm quite enthusiastic about what a multiple focus lens could do for them," Dr. Foster said. On the treatment track Still, some patients may end up unhappy. To offset those cases, Dr. Colin calls for practitioners to treat any complication that may diminish outcomes with multifocal lenses immediately. Dr. Colin also sug- gested employing careful prophy- laxis to avoid difficulties. He recommended treating dry eye and blepharitis in anyone being considered for a multifocal lens. He also urged use of OCT to identify those with exfoliation syndrome, which brings the risk of secondary IOL decentration. continued on page 62

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