International outlook
The correction of age-related focus dysfunction (ARFD) with advance technology IOLs: The Latin American Society of Cataract and Refractive Surgeons' experience

This month's International outlook features a roundtable chaired by William De La Peña, M.D., chief executive officer of the Latin American Society of Cataract and Refractive Surgeons. He guides this distinguished panel of experts in a discussion on how they use premium channel IOLs. Certain themes are universal, and the challenges we face meeting patient expectations with high technology IOLs are common to surgeons around the world. Patient selection, patient education, and matching the best choice of IOL to the patient's needs are the common denominators of success. I hope you enjoy this enlightening discussion from our South American colleagues on the art of using premium IOLs.

John Vukich, M.D., international editor

Enrique Suárez, M.D.
Docent Medical Centre La Trinidad Venezuela

Edgardo Carreño, M.D.
Medical Director of Centro Oftalmológico Carreño Chile

Virgilio Centurion, M.D.
Clinical Director of the IMO – Instituto de Moléstias Oculares São Paulo, Brazil

William De La Peña, M.D.
Chief executive officer of the Latin American Society of Cataract and Refractive Surgeons

The ALACCSA-R Newsletter, the monthly journal of the Latin American Society of Cataract and Refractive Surgeons, invited three Latin American surgeons experienced in IOL presbyopia-correction surgery to share their experiences. William De La Peña, M.D., CEO of ALACCSA-R, coordinated, and Enrique Suárez, M.D. (Venezuela), Edgardo Carreño, M.D. (Chile), and Virgilio Centurion, M.D., (Brazil) were the guests.
Dr. De La Peña: What ancillary ophthalmological exams do you routinely perform before implanting high technology IOLs for presbyopia correction? Dr. Suárez: A retina specialist exam, including optical coherence tomography (OCT) and infrared and fluorescence, corneal topography, and specular biomicroscopy.
Dr. Carreño: Before implanting high technology IOLs for presbyopia correction, I routinely perform biometry and keratometry with an IOLMaster (Carl Zeiss Meditec, Dublin Calif.); keratometry, topography, aberrometry, and pupilometry with the iTrace (Tracey Technologies, Houston); keratometry and topography with the Pentacam (Oculus, Lynnwood, Wash.), including posterior corneal surface elevation; keratometry with an autorefractometer; endothelial count and macula and optic disc OCT. All these ancillary exams are aimed at optimizing refractive outcomes with these implants. Dr. Centurion: 1) Optical biometry or partial coherence interferometry with the IOLMaster;
2) Contour topography to verify the corneal surface;
3) Specular microscopy to verify endothelial integrity and predict corneal resistance, should any complication arise; 4) Potential visual acuity; if positive, it is an indicator of macular health, if negative, we further evaluate the retinal condition; and 5) Central and peripheral retina evaluation by OCT and indirect ophthalmoscopy.
Dr. De La Peña: What is the role of low-grade corneal astigmatism (≤0.75) when high technology IOLs for presbyopia correction are prescribed? Dr. Suárez: In astigmatism <0.50 D, I perform the main corneal incision in the meridian of the highest keratometric value or topographic curvature. For with-the-rule astigmatism <0.75 D I prefer to implant aspheric IOLs. If it is >0.50 D against-the-rule, I prefer to implant toric IOLs (mono or multifocal).
Dr. Carreño: Accumulated experience after implanting a high number of advanced technology multifocal IOLs has shown me that low corneal astigmatism between 0.50 and 0.75 D may negatively influence the patient's visual acuity. That is why I recommend toric multifocal IOLs (AcrySof IQ ReSTOR Toric, Alcon, Fort Worth, Texas) for presbyopia correction in patients with corneal astigmatism ≥0.50 D. This has produced better visual acuity results and notoriously more satisfied patients.
Dr. Centurion: The best thing would be to implant advanced technology IOLs for presbyopia correction in non-astigmatic eyes. However, statistics show that most of the eyes, ±62%, usually show some degree of corneal astigmatism requiring correction for good quality visual acuity. Toric multifocal IOLs for low-grade astigmatism have improved the chances for good results.
I have not achieved consistent results, and I do not like performing corneal incisions for astigmatism correction (LRI, keratotomy). I think that it is not a good procedure because of its low predictability. The femtosecond laser for corneal astigmatism correction may be more reliable.
Dr. De La Peña: How do you modify your surgical technique when implanting advanced technology IOLs for presbyopia correction? Dr. Suárez: I emphasize preventing residual against-the-rule astigmatism, especially with multifocal IOLs.
Dr. Carreño: Since August 2011 we have been using a femtosecond lased guided by real-time imaging with incorporated OCT (LenSx, Alcon) in multifocal and toric IOL surgery. This technology permits a more precise, safer, and more reproducible procedure. This equipment performs a perfect capsulorhexis and corneal incisions; even though they are automated, they can be controlled and individualized by the surgeon and determine a better performance of these advanced technology IOLs leading to better clinical results.
Dr. Centurion: I am even more careful when performing capsulotomy; it should be central, continuous, and ±5.0-5.5 mm in diameter.
The procedure should not have any complications when performed through a 2.2 mm corneal wound and astigmatically neutral. Both eyes should be operated on within 7 days. Dr. De La Peña: Posterior capsule opacification (PCO): • Does its incidence or prevalence increase with multifocal IOLs? • What are the specific risks of advanced technology IOLs? • Is posterior capsulotomy performed routinely or with any modification? Dr. Suárez: • Its incidence is not higher, but it does induce more disturbances than monofocal IOLs. For that reason the incidence of posterior capsulotomy is higher with this type of IOL.
• We may be more cautious while protecting the posterior capsule during surgery.
• Wide, complete, and circular capsulotomy Dr. Carreño: I have not observed any significant difference in PCO with the ReSTOR or ReSTOR Toric as compared to the monofocal AcrySof IQ and AcrySof Toric. In my personal practice the frequency of PCO with all these IOLs is under 2%. However, I have noticed a higher rate of posterior Nd-YAG laser capsulotomy in patients with multifocal IOLs that can be explained by a higher sensitivity of these IOLs to PCO, compromising visual acuity and leading to an earlier capsulotomy than in monofocal IOLs. Regarding posterior capsulotomy technique, I think that it is safer to perform it slightly external to the lens rings in order to prevent any damage to the central, apodized diffractive area that might affect a patient's vision.
Dr. Centurion: I think that the rate of PCO is higher with multifocal 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 become symptomatic in multifocal IOLs.
Capsulotomy is performed earlier 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 prevent 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 dysphotopsias; however, when the patient learned about losing near vision he decided not to have his IOL changed. A few months later he was no longer troubled by these dysphotopsias.
Dr. Carreño: So far it has not been necessary to explant any advanced technology IOL for presbyopic 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 explantation and IOL exchange by monofocal lenses. Fortunately, the patient decided to follow our advice, adopting an expectant attitude, and the disturbances progressively decreased and eventually disappeared 6 months later. This case illustrates that we should not hurry when indicating multifocal IOL explantation and that managing the situation carefully may prevent IOL explantation.
Dr. Centurion: I have been working since the early 90s with different models of pseudoaccommodative IOLs with no personal case of explantation. The reason? Adequate patient selection, good protocol with pre-op examinations, patient education, and saying no when multifocal IOLs are not indicated.
We have performed a few explantations, generally due to incorrect 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 surgery (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 patients who had refractive surgery performed in one eye for monovision.
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 patients (two cases); and highly hyperopic eyes in patients <40 years of age (nine cases). Dr. Carreño: Our good results after several years of implanting advanced technology IOLs for presbyopic correction are mostly due to our respect for the established inclusion and exclusion criteria for these patients. Among all the cases of implanted IOLs, there have been a few cases out of this routine. Among them I can think of two cases of traumatic, unilateral cataract, 12 cases with pre-op corneal astigmatism >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 formula with very good refractive and visual outcomes.
Dr. Centurion: We look for patients with realistic outcome expectations, 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 forecast of the biometric calculation into high consideration.
Dr. De La Peña: Apart from those eyes with any other ocular condition than cataracts, from a theoretical point of view the first choice for IOL implantation should be advanced technology IOLs for presbyopic correction. Why do you think that the rate of implantation of these IOLs is so low (<10.00%)? Dr. Suárez: There are other intervening factors such as high exigency, economics, and satisfaction with previous monovision achieved by contact lenses.

Figure 1

Dr. Carreño: That is not my personal experience, since I perform over 60% of the cases with advanced technology IOLs for presbyopic correction. However, in my opinion this low global rate of implantation is due to several factors such as: surgeons' lack of confidence in the performance of this type of lens, conformity with the results achieved with monofocal IOLs, and little interest 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 perform a complete pre-op evaluation as required by a presbyopia-correction implant, insufficient patient information 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 implantation of advanced technology IOLs for presbyopic correction (accommodative and pseudoaccommodative) 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 second 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 correction 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? Dr. Suárez: They do not have any additional cost. If they had it and the patient had to pay for it, I think it would play a role and if that was the case for private insurance companies.
Dr. Carreño: In my country, advanced technology IOLs for presbyopic correction have an additional cost for the patient. I think that this economical factor plays a significant role in the amount of implantations. Different Health Systems cover one basic, foldable, hydrophobic IOL with a UV filter, and if the patient chooses an advanced technology IOL, he or she should pay for the difference. From a personal point of view I think that my rate of multifocal IOL implantations (over 60%) could be even higher if the patient did not have to pay an additional cost for the IOL.
Dr. Centurion: In São Paulo, Brazil, advanced technology IOLs are not covered by the Health Service or by private insurances.
If the surgeon recommends these IOLs and the patients want them, they should pay for the difference between the standard IOL and the advanced technology IOL. Approximately 20% of my patients do not have advanced technology IOLs implanted because of the price, thus limiting the expansion of this market.
In order to achieve conversion our most important objective is the education of the patients and their family as well as all the staff engaged in treating these patients (receptionist, nurses, telephone operators, technicians, surgery organizers) by means of explanatory leaflets. However, most of the indications for conversion rely on the word of the surgeon and the outcomes. The focus should be the surgeon's experience, knowledge, and results, and not the IOL.
Dr. De La Peña: Do you think that motivation for IOL implantation is similar to that of other countries such as the U.S. or Europe? Dr. Suárez: It is definitely different. As with corneal refractive surgery (RK, LASIK, etc.), the amount of surgery is proportionally much higher in some Latin American countries where aesthetics plays a more important role, as occurs with cosmetic surgery.
Dr. Carreño: I do not think that there is a great motivational difference among the different countries, but in my opinion the amount of implantations might be favored in more developed countries because of the greater amount of information available among the general population regarding new technology and its advantages, as well as the higher economical capability to reach high cost products. Dr. Centurion: In my clinic, we give a questionnaire to all the patients who are candidates for lens surgery, be it for cataract or refractive surgery, and they are asked the questions [in Figure 1]. Along with the answers, we include the index of conversion of conventional IOLs (spherical monofocal) to advanced technology IOLs (multifocal, toric, aspherical).
Our results show that the number of patients who do not care for elimination of optical correction does not prevent a high index of conversion, provided that the strategy for advanced technology IOLs is adequate. One important limiting factor is the cost of IOLs [Figures 2-4].
Dr. De La Peña: Are the rates of possible visual complaints such as halos, glare, or dysphotopsias similar to those found in the U.S. or Europe? Dr. Suárez: I think that they are similar. The acceptance and tolerance of these disturbances will depend on how the procedure was discussed with the patient during the pre-op "chair time" and how motivated the patient is to be able to read without the aid of spectacles. Dr. Carreño: It is difficult to answer that question, since the reports worldwide about halos and glare are extremely varied. In my personal experience, about 35% of the patients with multifocal implantations spontaneously reported halos when driving at night, even though they usually decrease progressively and eventually disappear after 6 months. In order to prevent post-op dissatisfaction I think that it is of the greatest importance to advise and inform the patient about the possibility of some visual disturbances during the first months after surgery.
Dr. Centurion: When patients are chosen for implantation of multifocal IOLs, we always advise the patients about the possible collateral effects of surgery regarding quality of visual acuity such as halos, glare, dysphotopsias, decreased contrast sensitivity (especially under mesopic conditions), and difficult near vision in twilight, and that these possible disturbances are almost always temporary. In my personal experience, glare complaints do not exist, and halos, when present, do not justify complaints after 8 to 12 weeks.
I think that, following an appropriate patient selection, and especially if biometry showed a predictable refraction, the satisfaction index is extremely high. I think that it is very important for the surgeon to be able to say, "In your case I would not indicate a multifocal IOL for the following reasons ..." It is prevention of complications.

Editors' note: Dr. Carreño has no related financial interests. Dr. Centurion has financial interests with Alcon. Dr. Suárez has no financial interests related to this roundtable.

Contact information

Carreño: edcarreno@vtr.net
Centurion: centurion@imo.com.br
Suárez: ensuca@gmail.com