November 2009

 

CATARACT/ IOL

 

Improved outcomes in advanced premium lens surgery


by Michelle Dalton EyeWorld Contributing Editor

   

At ASCRS, one European surgeon detailed 10 steps to successful multifocal IOL surgery

Challenges abound when implanting multifocal IOLs, but with some guidance and pearls from those who are successful, the process can be beneficial to the entire cataract population, said one European surgeon. A key factor to the low market share of these IOLs is that “surgeons are afraid to embark on new and difficult procedures that entail a higher risk of patient dissatisfaction in exchange for minimal benefits to the surgeon,” said Matteo Piovella, M.D., scientific director of Centro Microchirugia Ambulatoriale Outpatient Microsurgery Center, Monza, Italy. Dr. Piovella prefers to custom match (combining a refractive and diffractive lens) premium IOL patients and said 94% are happy with both near and distance vision. But he said it took him years of not seeing his practice develop to realize the boon premium IOLs could offer. “You have to fully understand the patients’ needs when using multifocal IOLs, and the time and resources that this step-by-step process entails must be taken into account,” he said. Using multifocal IOLs in his patients increased the benefits for the whole practice, he said. “We have reduced the number of surgical complications and surgeon-patient misunderstandings in more routine cataract surgery as well as with specialized lenses,” he said. When discussing premium lenses with potential patients, he advises not to promise complete spectacle independence and to explain there will be an adjustment period.

“Patients must understand that the visual system works best when both eyes have had surgery and are working together,” he said. “Each patient has different needs based on his or her lifestyle. There is not one premium IOL lens solution that is perfect, so limiting your presbyopia solution to one lens limits the quality of the solution.”

When and what to implant

Knowing which eye is the dominant one is helpful in premium IOL patients, Dr. Piovella said. In his premium IOL patients, he prefers to use the ReZoom, a refractive IOL, and the Tecnis, a diffractive IOL. Both lenses are marketed by Abbott Medical Optics (AMO, Santa Ana, Calif.). He places the Tecnis in the non-dominant eye and the ReZoom in the dominant eye, he said. In Italy, two other multifocal lenses are also available: the AcriLisa (Acri.Tec-Zeiss, Hennigsdorf, Germany) and the Optivis (OII, Ontario, Calif.). Both of those lenses are also designed to be distance-dominant.

“The diffractive Tecnis is less pupil dependent than the ReZoom, which is important if you are routinely using mydriatics in the post-operative period,” he said. Because the Tecnis is less pupil dependent, a patient’s stress about adverse events such as glare and halos is somewhat reduced.

Ideally, the second eye should undergo surgery about a week after the non-dominant eye, Dr. Piovella said. The closer the two surgeries can be planned, the quicker the patient will have the benefit of both lenses, Dr. Piovella said. Before implanting the second lens, however, Dr. Piovella will evaluate the patient’s initial satisfaction level before finalizing the second lens choice. When he first began implanting multifocal IOLs, “I became very interested in achieving outstanding near visual acuities and avoiding any significant decrease in the quality of vision,” he said. To do that, he matches the lens to the patient’s pupil size. He calculates the diameter under mesopic conditions. If the diameter is larger than 5.2 mm, he will implant the Tecnis bilaterally. “In my experience, even cataract patients with 6.0-mm pupils who are implanted with monofocal IOLs may experience visually significant glare and halos. I also choose bilateral Tecnis multifocal IOLs for patients with equal dominance in both eyes and for those who seem to be especially sensitive to glare and halo,” he said. “However, bilateral Tecnis IOLs may not be the best choice for heavy computer users. A refractive lens that provides more intermediate vision is desirable for these patients.”

Premium lens integration

Ideally, Dr. Piovella said, obtain two different sets of measurements pre-op with two different technologies in order to compare the results and avoid errors. “I prefer the IOL Master [Carl Zeiss Meditec, Dublin, Calif.] and contact A-scan. In addition to advanced biometry, mesopic pupillometry is very helpful. I prefer to use an aspheric IOL with larger pupil sizes,” he added. Dr. Piovella also suggests using the Eyevispod Analysis System (PGB, Milano, Italy) to test near vision and determine reading speed at one week, one month, and six months after both eyes have been implanted. “We typically see a 14% improvement in reading speed during the first month alone,” he said. Also, surgeons should keep a lower threshold for intervention if or when it becomes necessary. “If there’s any posterior capsular opacification, Nd:YAG capsulotomy should be performed earlier rather than later,” he said. “Specific attention is needed if silicone IOLs are implanted.”

In 100 patients in whom Dr. Piovella employed the custom match strategy, he needed to YAG 13 eyes with the ReZoom (four eyes at six months, four at one year, and five at two years), and 10 eyes with the Tecnis (one at one month, five at one year, and four at two years). Of the 32 bilateral Tecnis implants, 17 required a YAG (four at six months, three at one year, and 10 at two years). Even the most minor corrections of residual sphere or cylinder can dramatically improve the patient’s vision if he or she is especially bothered by glare and halos, Dr. Piovella noted. If there is residual refractive error, he will prescribe low-power “emergency spectacles” at one month post-op, usually only if the error is within 0.75 D. Larger residual refractive errors will need laser surgery, he advised, and he suggested waiting until 6 months post-op. “If you’re not willing to incorporate these new strategies, don’t consider implanting multifocal IOLs,” he said. “If you are willing to invest time and attention, it is certainly possible to achieve a successful multifocal IOL practice with high rates of patient satisfaction.”

Editors’ note: Dr. Piovella has no financial interests related to his comments.

Contact information

Piovella: +39 039 38 9498; piovella@piovella.com

Improved outcomes in advanced premium lens surgery Improved outcomes in advanced premium lens surgery
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