June 2013




Refractive editor's corner of the world

Presbyopia case management

by Erin L. Boyle EyeWorld Senior Staff Writer


Kerry Solomon, MD

It's an interesting time for a refractive cataract surgeon. The aging patient population is increasing, the demand for our services is growing, and patient expectations continue to rise. Fortunately, we have a lot of different technologies and surgical techniques at our disposal to address a variety of surgical plans. In this "Refractive editor's corner of the world," we present a case of a 65-year-old patient with bilateral cataracts with less than 1 diopter of corneal astigmatism who desires a presbyopic correction at the time of his cataract procedures. We have enlisted a group of international experts and asked them how they would address this patient's surgical plan. We also asked if their plan would change if the patient's history indicated successful or unsuccessful contact lens wear for either previous mono or multifocal vision. As you will see, there are several different ways to approach the patient using a variety of different surgical techniques and technologies. Thanks to Drs. Lawless, Wei, Kent for their time and expertise.

Kerry Solomon, MD, refractive editor

Visual acuity graph

This graph depicts the near and intermediate visual acuity of the Carl Zeiss Meditec trifocal IOL. Source: Marc E. Wei, MBBS, FRANZCO

The treatment of older patients with corneal astigmatism and cataracts who want presbyopic correction can pose different solutions with different procedures, including various choices of IOLs. Looking at a specific casea 65-year-old with less than 1 D of corneal astigmatism with bilateral cataracts who wants presbyopic correctionshows how physicians have multiple ways of treating this example patient."

The key is always to ascertain exactly what the patient wants," said David Kent, MD, in private practice, Kilkenny, Ireland, and other physicians agreed.

Preferred procedure

Michael Lawless, MD, Vision Eye Institute, Chatswood, New South Wales, Australia, said that he would determine his procedure of choice by first speaking with the patient about vision needs and expectations.

If the patient's expectations were within reason and the cornea had a normal anatomy, he would then perform femtosecond laser cataract surgery with the LenSx system (Alcon, Fort Worth, Texas) with an AcrySof IQ ReSTOR multifocal +2.5 add (Alcon) implanted in the dominant eye and a +3.0 add implanted in the nondominant eye.

"This, in my hands, gives a high chance of spectacle independence, minimal night haloes, and excellent intermediate vision," said Dr. Lawless. "If I could perform on-axis surgery, I would do so using my standard reverse trapezoidal incision, 2.4-mm internal and 2.3-mm external and an intrastromal astigmatic incision in the opposite quadrant at a diameter of 9 mm and extending for 30 degrees. I would not open the astigmatic incision. If I could not perform on-axis surgery, I would use my usual incision as described above and place paired astigmatic incisions in the steep corneal axis."

Other surgeons have different preferences. Marc E. Wei, MBBS, FRANZCO, in private practice, Laser Sight Australia, said he would perform a lensectomy with a multifocal IOL, the trifocal AT LISA tri 839MP (Carl Zeiss Meditec, Dublin, Calif.), which is currently not available in the U.S., and provides relatively pupil-independent near, intermediate and far distance focus with minimal haloes and excellent clarity.

Dr. Kent said his experience with multifocal lenses has been limited, but he is not sure he would select a multifocal lens in this case. He said he prefers monovision, aiming for a 1.75 spherical equivalent in the nondominant eye using a C-flex or Superflex aspheric lens (Rayner, East Sussex, England), also not available in the U.S.

"Based on patient testimonies and postoperative quality of life questionnaires, I have, for the moment at least, gone away from [multifocal] technology," he said. "I would agree that, in general, in ideal circumstances, multifocal intraocular lenses perform optimally, but many of my patients don't seem to experience optimal conditions for everyday 'run of the mill' visual tasks."

Patient history

Would physicians' preferred procedure with this patient change if the background was differentthe patient had successful or unsuccessful monovision, or wore multifocal contact lenses? Yes, physicians said. "If [the patient was] previously happy with monovision I would, after a conversation, not use a multifocal but would use an aspheric monofocal lens in each eye targeting monovision," Dr. Lawless said. "If not successful previously, I would go with the multifocal option. If [the patient has] never experienced monovision, I would mention it as a possibility in the preop discussion, but would only occasionally choose it these days as a surgical option."

However, if that patient had been successful with multifocal contacts, Dr. Lawless said he would be even more encouraged to proceed with a multifocal IOL. If the patient had been unsuccessful with multifocal contacts, he would determine the reason preoperatively and would lean toward bilateral +2.5 multifocal ReSTOR implantation or mini-monovision in that patient.

Dr. Wei said he thinks that the same neuroadapative mechanism in monovision could assist in the adaption of a multifocal lens. "In those cases with successful monovision prior to surgery, patients will most likely adapt to multifocal images, and this has been my preferred practice for 10 years," he said.

"Those that are not successful, which in my practice is about 10% of candidates, I would not use monovision IOLs or multifocal IOLs, which is contrary to current thinking. Those patients would be more suited to bilateral distance dominant lenses such as the Crystalens [Bausch + Lomb, Rochester, N.Y.] in this instance," Dr. Wei said.

In the same way, patients with success using multifocal contact lenses would suggest an adequate ability for adaptation to a multifocal IOL, he said. Dr. Kent said if monovision had not been successful, he would seek answers. Reasons could include unreasonable expectations or poor counseling on both the benefits and drawbacks of monovision.


Preop preparations for this patient are important to outcomes, physicians said. Dr. Kent recommended careful patient selection.

"Clearly identify what your patients want and make sure they understand the concepts being discussed and the options that are available and the fact that none of the options available are a panacea," he said.

Dr. Lawless recommended careful preop discussion of patient choices.

"The conversation prior to surgery is a conversation. After surgery, it's managing a problem, so spend plenty of time preop listening rather than talking, and then make a recommendation with a relative or friend in the room with the patient," he said.

Dr. Wei recommended monovision contact lens trials for all patients, to rule out poor candidates. "These are the ones to avoid multifocal lens and the cause of some of the problems traditionally associated with diffractive multifocal lenses," he said.

Editors' note: Dr. Lawless has financial interests with Alcon. Drs. Kent and Wei have no financial interests related to this article.

Contact information

Kent: dkent@liverpool.ac.uk
Lawless: michael.lawless@visioneyeinstitute.com.au
Wei: drmarcwei@yahoo.com.au

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