164
CONSULTATION SECTION
- In general, I consider patients with exfoliation syndrome or exfoliative glaucoma to be poor candidates for multifocal IOLs. Patients with glaucoma are poor candidates for multiple reasons including reduced contrast sensitivity, risk for progressive visual field loss limiting acuity, ocular surface disease due to medication use, and a possible need for eventual filtering surgery and subsequent change in cylinder or axial length. This patient carries a risk for glaucoma development; however, with no evidence of disease at age 78 years, I would not consider glaucoma as the limiting factor in IOL selection. Concerns regarding zonular stability and pupil size are more significant issues for this patient. Both IOL tilt and decentration have a marked impact on optical quality with multifocal IOLs. With an average life expectancy of approximately 10 years, a 78-year-old patient with exfoliation syndrome who currently has no evidence of phacodonesis has an increased lifetime risk for IOL decentration and tilt. Less than 1.0 mm of decentration can have a marked impact on optical quality with refractive IOLs and diffractive IOLs. If the patient's optical biometry results from the first surgery are accessible, the anterior chamber depth (ACD) could be evaluated, looking for comparisons between the ACD between eyes before the first eye surgery and relative to current measurements. Unequal ACD measurements before surgery or an altered ACD in the phakic eye after the first set of measurements might indicate zonular laxity and be a contraindication to placement of a multifocal IOL at this time. Reduced pupil size and function can affect the surgery, making it more difficult to make an adequately sized capsulorhexis and may require mechanical dilation, leading to reduced pupil motility after surgery. A surgically dilated pupil may lead to poorer visual function with multifocal IOLs. For the above-mentioned reasons, I would discuss the long-term concerns of multifocal IOLs with this patient. If she has been fairly independent of spectacles with her current situation, I would recommend that she consider a mildly myopic refractive outcome with a standard IOL in her left eye, similar to her current refraction. Implantation of multifocal IOLs has been shown to provide good outcomes in patients who have unilateral cataract. Longer-term risks aside, the patient is likely to have a satisfactory outcome with a multifocal IOL in the left eye initially based on her current satisfaction with the IOL in the right eye. If after discussion of the risks the patient still desires a multifocal IOL, I would implant the same type of IOL in her second eye, taking care to make a generous capsulorhexis and carefully polish the posterior surface of the anterior capsule in hopes of reducing
the risk for capsule phimosis and strain on the zonular fibers. I would not implant a CTR unless I encountered evidence of poor zonular fibers intraoperatively. Theoretically, a 3-piece IOL design may provide better resistance to zonule stretching with capsule contraction than a 1-piece IOL. I would not, however, change IOL designs for a patient who has been satisfied with the outcome of his or her first multifocal IOL. Barbara A. Smit, MD, PhD Spokane, Washington, USA
- I very carefully consider multifocal IOLs in patients with exfoliation syndrome; however, I typically avoid them in patients with exfoliative glaucoma. The main reason for not using multifocal IOLs in patients who have existing glaucoma is because of the threat of reduced contrast sensitivity. I prefer using a CTR in most patients with exfoliation syndrome, especially when using a 1-piece IOL, because the risk for capsule phimosis seems to be higher and in the event of IOL dislocation, I can suture the CTR to the sclera. I frankly discuss with patients the risk for IOL decentration or subluxation and how multifocal IOLs are ideally suited for anatomically pristine eyes. Given the lack of phacodonesis and no evidence of glaucoma, I think that it is reasonable to place a multifocal IOL in this eye. I would use a 5.0 mm capsulorhexis in this eye, just as I do in standard cataract surgery, with a preference for a 1-piece multifocal IOL with a CTR to allow ideal centration. A prophylactic relaxing anterior Nd:YAG capsulotomy is probably not warranted, and I would not alter the anterior capsule unless there were signs of capsule phimosis. If early phimosis started to occur, I would immediately use an Nd:YAG laser on the anterior capsule. The heart of cataract surgery is matching a patient's visual goals and expectations with the physiologic and anatomic capabilities of his or her eye. As such, I do not advocate implanting multifocal IOLs in patients with visual field loss. In general, multifocal IOLs are reserved for disease-free eyes. Because this patient had successful multifocal IOL despite exfoliation, I am more confident in placing a multifocal in this situation. My experience has been that multifocal IOLs work best when 1 is present in each eye. In this case, because the manifest refraction is 1.50 D sphere the left eye, I would cover that eye and make sure the patient is truly happy with her vision at distance and near with the multifocal IOL. If she is, I think it makes a lot of sense to implant the multifocal IOL model used in the right eye. If she is relying on the left eye for intermediate vision, I would consider a monofocal
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
CONSULTATION SECTION
IOL targeted at 1.50 D. My preference would be multifocality in both eyes. John Palmer Berdahl, MD Durham, North Carolina, USA
- I do implant multifocal IOLs in patients with exfoliation syndrome, as in this particular case. I typically use multifocal IOLs with a 1-piece design. I do not use multifocal IOLs in patients with manifest visual field loss because I am concerned it might decrease contrast sensitivity further in glaucoma patients. I do not mix and match multifocal IOLs and monofocal IOLs. I would place a multifocal IOL in the left eye in this patient. I do not routinely use a CTR in exfoliation unless I see evidence of zonular weakness intraoperatively. I am not sure there is evidence that a CTR is necessary in this elderly patient without phacodonesis. When counseling patients preoperatively, I typically describe a host of potential complications with cataract surgery in patients with exfoliation. These include possible difficulty dilating the pupil and that zonular support may be less than ideal, which could lead to vitreous loss and difficulty centering an IOL in the capsular bag. During surgery, I try to make the capsulorhexis a bit larger than usual. At the end of the case, if I am concerned that the capsulorhexis is too small, thus creating a risk for capsule phimosis, I make several radial tears in the capsulorhexis edge with microscissors. Leon W. Herndon Jr, MD Durham, North Carolina, USA
165
EDITOR’S COMMENT There was general agreement among our experts in favor of placement of a multifocal IOL in this patient with exfoliation syndrome who is happy with the multifocal IOL in her first eye. However, each of our consultants stated that they do not advocate multifocal IOLs in patients with manifest visual field loss or in the setting of zonular instability. There was less consensus regarding the use of a CTR. Slightly more than half the experts would use a CTR in this patient to improve the chances of maintaining good IOL centration. Each consultant would fashion a capsulorhexis of approximately 5.0 mm. Although our experts would use the Nd:YAG laser postoperatively to make relaxing incisions in the anterior capsule in the event of phimosis, they would not make primary relaxing incisions at the time of surgery. Each consultant mentioned that the patient should be counseled about the increased risk for IOL decentration or tilt. Despite these caveats, our experts would favor multifocal IOL implantation in this patient's second eye. Although there seemed to be a general reluctance to use multifocal IOLs in the setting of exfoliation, our experts seemed emboldened by the fact that the patient was happy with the multifocal IOL placed in the fellow eye by a different surgeon.
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
Thomas W. Samuelson, MD Minneapolis, Minnesota, USA
CONSULTATION SECTION
- In general, I consider patients with exfoliation syndrome or exfoliative glaucoma to be poor candidates for multifocal IOLs. Patients with glaucoma are poor candidates for multiple reasons including reduced contrast sensitivity, risk for progressive visual field loss limiting acuity, ocular surface disease due to medication use, and a possible need for eventual filtering surgery and subsequent change in cylinder or axial length. This patient carries a risk for glaucoma development; however, with no evidence of disease at age 78 years, I would not consider glaucoma as the limiting factor in IOL selection. Concerns regarding zonular stability and pupil size are more significant issues for this patient. Both IOL tilt and decentration have a marked impact on optical quality with multifocal IOLs. With an average life expectancy of approximately 10 years, a 78-year-old patient with exfoliation syndrome who currently has no evidence of phacodonesis has an increased lifetime risk for IOL decentration and tilt. Less than 1.0 mm of decentration can have a marked impact on optical quality with refractive IOLs and diffractive IOLs. If the patient's optical biometry results from the first surgery are accessible, the anterior chamber depth (ACD) could be evaluated, looking for comparisons between the ACD between eyes before the first eye surgery and relative to current measurements. Unequal ACD measurements before surgery or an altered ACD in the phakic eye after the first set of measurements might indicate zonular laxity and be a contraindication to placement of a multifocal IOL at this time. Reduced pupil size and function can affect the surgery, making it more difficult to make an adequately sized capsulorhexis and may require mechanical dilation, leading to reduced pupil motility after surgery. A surgically dilated pupil may lead to poorer visual function with multifocal IOLs. For the above-mentioned reasons, I would discuss the long-term concerns of multifocal IOLs with this patient. If she has been fairly independent of spectacles with her current situation, I would recommend that she consider a mildly myopic refractive outcome with a standard IOL in her left eye, similar to her current refraction. Implantation of multifocal IOLs has been shown to provide good outcomes in patients who have unilateral cataract. Longer-term risks aside, the patient is likely to have a satisfactory outcome with a multifocal IOL in the left eye initially based on her current satisfaction with the IOL in the right eye. If after discussion of the risks the patient still desires a multifocal IOL, I would implant the same type of IOL in her second eye, taking care to make a generous capsulorhexis and carefully polish the posterior surface of the anterior capsule in hopes of reducing
the risk for capsule phimosis and strain on the zonular fibers. I would not implant a CTR unless I encountered evidence of poor zonular fibers intraoperatively. Theoretically, a 3-piece IOL design may provide better resistance to zonule stretching with capsule contraction than a 1-piece IOL. I would not, however, change IOL designs for a patient who has been satisfied with the outcome of his or her first multifocal IOL. Barbara A. Smit, MD, PhD Spokane, Washington, USA
- I very carefully consider multifocal IOLs in patients with exfoliation syndrome; however, I typically avoid them in patients with exfoliative glaucoma. The main reason for not using multifocal IOLs in patients who have existing glaucoma is because of the threat of reduced contrast sensitivity. I prefer using a CTR in most patients with exfoliation syndrome, especially when using a 1-piece IOL, because the risk for capsule phimosis seems to be higher and in the event of IOL dislocation, I can suture the CTR to the sclera. I frankly discuss with patients the risk for IOL decentration or subluxation and how multifocal IOLs are ideally suited for anatomically pristine eyes. Given the lack of phacodonesis and no evidence of glaucoma, I think that it is reasonable to place a multifocal IOL in this eye. I would use a 5.0 mm capsulorhexis in this eye, just as I do in standard cataract surgery, with a preference for a 1-piece multifocal IOL with a CTR to allow ideal centration. A prophylactic relaxing anterior Nd:YAG capsulotomy is probably not warranted, and I would not alter the anterior capsule unless there were signs of capsule phimosis. If early phimosis started to occur, I would immediately use an Nd:YAG laser on the anterior capsule. The heart of cataract surgery is matching a patient's visual goals and expectations with the physiologic and anatomic capabilities of his or her eye. As such, I do not advocate implanting multifocal IOLs in patients with visual field loss. In general, multifocal IOLs are reserved for disease-free eyes. Because this patient had successful multifocal IOL despite exfoliation, I am more confident in placing a multifocal in this situation. My experience has been that multifocal IOLs work best when 1 is present in each eye. In this case, because the manifest refraction is 1.50 D sphere the left eye, I would cover that eye and make sure the patient is truly happy with her vision at distance and near with the multifocal IOL. If she is, I think it makes a lot of sense to implant the multifocal IOL model used in the right eye. If she is relying on the left eye for intermediate vision, I would consider a monofocal
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
CONSULTATION SECTION
IOL targeted at 1.50 D. My preference would be multifocality in both eyes. John Palmer Berdahl, MD Durham, North Carolina, USA
- I do implant multifocal IOLs in patients with exfoliation syndrome, as in this particular case. I typically use multifocal IOLs with a 1-piece design. I do not use multifocal IOLs in patients with manifest visual field loss because I am concerned it might decrease contrast sensitivity further in glaucoma patients. I do not mix and match multifocal IOLs and monofocal IOLs. I would place a multifocal IOL in the left eye in this patient. I do not routinely use a CTR in exfoliation unless I see evidence of zonular weakness intraoperatively. I am not sure there is evidence that a CTR is necessary in this elderly patient without phacodonesis. When counseling patients preoperatively, I typically describe a host of potential complications with cataract surgery in patients with exfoliation. These include possible difficulty dilating the pupil and that zonular support may be less than ideal, which could lead to vitreous loss and difficulty centering an IOL in the capsular bag. During surgery, I try to make the capsulorhexis a bit larger than usual. At the end of the case, if I am concerned that the capsulorhexis is too small, thus creating a risk for capsule phimosis, I make several radial tears in the capsulorhexis edge with microscissors. Leon W. Herndon Jr, MD Durham, North Carolina, USA
165
EDITOR’S COMMENT There was general agreement among our experts in favor of placement of a multifocal IOL in this patient with exfoliation syndrome who is happy with the multifocal IOL in her first eye. However, each of our consultants stated that they do not advocate multifocal IOLs in patients with manifest visual field loss or in the setting of zonular instability. There was less consensus regarding the use of a CTR. Slightly more than half the experts would use a CTR in this patient to improve the chances of maintaining good IOL centration. Each consultant would fashion a capsulorhexis of approximately 5.0 mm. Although our experts would use the Nd:YAG laser postoperatively to make relaxing incisions in the anterior capsule in the event of phimosis, they would not make primary relaxing incisions at the time of surgery. Each consultant mentioned that the patient should be counseled about the increased risk for IOL decentration or tilt. Despite these caveats, our experts would favor multifocal IOL implantation in this patient's second eye. Although there seemed to be a general reluctance to use multifocal IOLs in the setting of exfoliation, our experts seemed emboldened by the fact that the patient was happy with the multifocal IOL placed in the fellow eye by a different surgeon.
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
Thomas W. Samuelson, MD Minneapolis, Minnesota, USA
