Eyeworld CME Supplements

EW_JAN 2017_Supported by an unrestricted educational grant from Abbott Medical Optics

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3 Supported by an unrestricted educational grant from Abbott Medical Optics by John Berdahl, MD Surgical options for presbyopia correction Surgeons need to share the complete range of possibilities with presbyopic patients T o make the most of an expanding range of presbyopia-cor- recting technologies and deliver the visual outcomes patients expect, it is important to understand the benefits and limitations of each. Treatment alternatives Two intracorneal inlays have been approved by the U.S. Food and Drug Administra- tion to correct presbyopia. 1,2 These are generally appro- priate for that sweet spot of a new presbyope, who is in stage 1 of dysfunctional lens syndrome (DLS), without signs of a cataract. For patients in stage 3 of DLS, I use monovision and mini-monovision only in those who have responded well to monovision contact lenses or LASIK. If patients have not had monovision in the past, we cannot perform a contact lens trial once a cata- ract has been diagnosed. We use accommodating IOLs for patients who do not have a pristine ocular sys- tem, such as those with mild macular degeneration, mild glaucoma, or corneal irreg- ularities, or patients whose profession makes minimal amounts of glare intolerable (Figure 1). I explain that the accommodating IOL will reduce their need for specta- cles, but they will need glasses for fine, up-close reading. 3 In addition, accommodating IOLs are associated with a small amount of variability in spherical outcomes because the effective lens position is slightly less predictable. 4 Extended depth of focus IOLs are also a bit more toler- ant of small irregularities in the eye. 5 I prefer to use a low power multifocal or extend- ed depth of focus IOL in the dominant eye and a medi- um power multifocal with approximately a 3.0 D add in the non-dominant eye. In my experience, this approach has provided good distance vision in both eyes and a good range of near vision, helping most of my patients achieve com- plete spectacle independence. To deliver optimal out- comes, it is critical to precisely correct astigmatism during surgery and treat residual astigmatism. Two presbyopic toric IOLs are available to treat astigmatism. Residual astigmatism must be treated with astigmatic keratotomy or an excimer laser. 6 Tailoring treatment To select the best treatment for each patient, surgeons need to understand patients' visual needs, based on their profession, hobbies, and other activities. Although many of us are uncomfortable discussing pro- cedures or technologies that are not covered by insurance, we should not hesitate to cov- er the full range of options, just as any physician would for a medical condition. That is our duty as physicians. Sur- geons who are uneasy discuss- ing costs should delegate this task to a staff member. Conclusion Presbyopia correction has evolved to a point where sur- geons can achieve very good, predictable outcomes, but it is not yet perfect. Patients need to know all of their options, and surgeons need to develop enhancement strategies to provide optimal outcomes. References 1. Dexl AK, et al. Long-term outcomes after monocular corneal inlay implan- tation for the surgical compensation of presbyopia. J Cataract Refract Surg. 2015;41:566–575. 2. Whitman J, et al. Treatment of presbyopia in emmetropes using a shape-changing corneal inlay: one- year clinical outcomes. Ophthalmolo- gy. 2016;123:466–475. 3. Mesci C, et al. Visual performances with monofocal, accommodating, and multifocal intraocular lenses in patients with unilateral cataract. Am J Ophthalmol. 2010;150:609–618. 4. Potvin R, et al. Toric intraocular lens orientation and residual refractive astigmatism: an analysis. Clin Oph- thalmol. 2016;10:1829–1836. 5. Cochener B, et al. Clinical outcomes of a new extended range of vision intraocular lens: International Mul- ticenter Concerto Study. J Cataract Refract Surg. 2016;42:1268–1275. 6. Abdelghany AA, et al. Surgical options for correction of refractive error following cataract surgery. Eye Vis (Lond). 2014;1:2. Dr. Berdahl is in private practice at Vance Thompson Vision, Sioux Falls, South Dakota. He can be contacted at johnberdahl@gmail.com. Figure 1. Insertion of Crystalens accommodating IOL

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