Cataract
July 2021

by Ellen Stodola
Editorial Co-Director

When a patient comes in prior to cataract surgery, it’s important to do a careful evaluation to see what conditions they might have and how this could impact IOL selection. Marjan Farid, MD, and Maria Scott, MD, discussed some conditions to be aware of when considering presbyopia-correcting IOLs and how to talk to patients about this before surgery.

Be on the lookout

When a patient comes in for a cataract evaluation, Dr. Farid said she looks at both the front and back of the eye, identifying irregularities that could impact candidacy for a presbyopia- correcting lens.

She does an OCT of the macula to ensure there is no significant macular pathology that could disqualify them from receiving an EDOF or multifocal. She will do a corneal topography to look for irregularities, which could include things like unstable or irregular tear film that could produce irregular astigmatism. She is also looking for irregularities that may be related to lumps and bumps on the cornea. “There are a lot of things on the cornea that can create enough irregularity in the optical system and higher order aberrations where I wouldn’t be comfortable putting in a presbyopia-correcting lens,” Dr. Farid said.

Sometimes a patient may be “on the border,” like a dry eye patient with an irregular tear film, and it’s possible that after treatment and optimization, the patient will then become a candidate for a specific lens. “Sometimes you can treat the cornea with a minor in-office procedure such as superficial keratectomy and wait for the cornea to heal and stabilize, then repeat topography,” Dr. Farid said. If it becomes normal, you can consider a presbyopia-correcting IOL.

Glaucoma and retinal issues can be more complicated. “If a patient has advanced glaucoma, their contrast sensitivity is decreased already, so we don’t want to split light further going into the eye,” Dr. Farid said. Thus, she steers away from presbyopia-correcting lenses in moderate to advanced glaucoma. Patients may be candidates if glaucoma or ocular hypertension is mild.

If a patient has subtle macular pathology with good foveal reflex, Dr. Farid will usually consult with a retinal specialist prior to considering an EDOF IOL.

Dr. Farid noted that some of the newer EDOF lenses, like the Symfony (Johnson & Johnson Vision), have less potential for optical aberrations. Lenses like the Symfony and Vivity (Alcon) have been used in patients with subtle macular pathology or early glaucoma because contrast sensitivity is good, she said. Dr. Farid also noted the AcuFocus pinhole lens (premarket approval was submitted to the FDA in February 2021) as an option for irregular eyes. The IC-8 uses pinhole optics to try to optimize depth of focus without using a multifocal or diffractive optic technology.

Dr. Scott noted that pseudoexfoliation and trauma are conditions that can cause poor capsular support or zonular weakness. She also mentioned that issues like dry eye, Fuchs dystrophy, optic neuropathies, diabetic retinopathy, old central serous retinopathy with macular scarring, dense floaters, high chord mu, and high corneal aberrations are all conditions that would make her hesitant to offer a presbyopia-correcting lens to a patient.

When determining if it’s appropriate to proceed with lens implantation in these cases, Dr. Scott said it depends on the severity of the condition and the age of the patient. For example, she said that if a patient has very mild drusen but is 85 years old and wants a presbyopia-correcting lens, she would consider implanting one. However, if the patient is 45 years old, she likely would not consider it. A mild glaucoma suspect patient could do well with a presbyopia-correcting lens, she said. But she generally avoids these lenses with EBMD and epiretinal membranes because they are unpredictable. “Since pseudoexfoliation is progressive, I avoid presbyopia-correcting lenses in these patients,” she added.

Dr. Scott said in patients who are not good candidates for presbyopia-correcting lenses, she will discuss monovision or mini-monovision. This slightly under corrects the non-dominant eye to give patients the ability to see the dashboard and eat their food without glasses, she said, adding that the Eyhance (Johnson & Johnson Vision) may be a good option for those patients.

Dr. Scott said she is a big proponent of multifocal lenses. “I have enjoyed watching my mother function without glasses after her presbyopia-correcting lenses. She had cataract surgery in 2006 and has enjoyed 15 years of great near and distance vision. At 90, she drives to and from Philadelphia and Annapolis like she is going to the grocery store and reads the recipes to me when we cook together,” Dr. Scott said. “Now that I am presbyopic, I understand the frustration that patients feel. I look forward to the choices of presbyopia-correcting lenses growing and improving so that we as surgeons can give our patients the most freedom from glasses without the side effects of starbursts and halos. As a surgeon, you must believe in the technology, be excited about it, and be willing to take the extra steps to hit the target and enhance the patients who need further treatments.”

Talking to patients prior to surgery

Dr. Scott said she educates patients on their options and finds out what their hobbies, nighttime driving demands, and work demands are. “I try to tailor the lens discussion to what they enjoy and what would work best for them,” she said.

Dr. Scott also warns multifocal patients about halos and starbursts and explains that most patients have them initially, and 95% resolve. While 5% persist, 95% of those patients still like the lens so much that they gladly put up with the halos for the convenience of no glasses, she said. A lens exchange may be needed in the less than 1% of patients who can’t neuro-adapt. “Also, less than 1% of the time, the support is not sufficient to use the multifocal,” she said. “I always ask if the patient would rather distance or near vision if we can’t implant the multifocal.”

Dr. Farid said one of the key points she makes to patients is that “every eye is different, and every patient is different.” Everyone comes in wanting what their friend has, but it’s important to explain to the patient that an individual’s ocular health determines the best lens choice. “I want to make sure the patient understands that we’re customizing the lens choice to their specific situation and their ophthalmic tests,” she said.

Dr. Farid said she’s an advocate of showing patients images of their tests, pointing out any irregularities or reasons why she might not be selecting a presbyopia-correcting lens for them. This approach has come from experience, and it’s important that patients aren’t left wondering why they weren’t offered a specific lens. “Lens technologies are fantastic, and we have lenses for all types of eyes,” she said, noting that she will usually make one or two lens recommendations to patients based on the data for their eye.

“We’re looking forward to continued innovations in intraocular lens technology to improve contrast and quality of vision to such an extent that even patients with imperfect eyes can be candidates for depth of focus and improved range of vision,” Dr. Farid said.

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About the physicians

Marjan Farid, MD
Professor of Ophthalmology
Gavin Herbert Eye Institute
University of California, Irvine
Irvine, California

Maria Scott, MD
Medical Director
Chesapeake Eye Care and Laser Center
Annapolis, Maryland

Relevant disclosures

Farid: Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision
Scott: Carl Zeiss Meditec, Johnson & Johnson Vision

Contact

Farid: mfarid@hs.uci.edu
Scott: mariacscott@yahoo.com