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
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
