This article is more than 5 years old. Information may no longer be current.
Case presentations
A 62-year-old man presents with 2+ posterior subcapsular cataracts and 3+ nuclear sclerosis. He has 20/40 best corrected visual acuity and 20/100 with brightness acuity testing in both eyes. The patient is slightly hyperopic (+1.5 + 0.5 X 180) and has 0.5 D of against-the-rule astigmatism. His pupils are 5 mm in dim light and 3.5 mm in bright light.
The patient has otherwise healthy eyes but discontinued driving at night because he is bothered by glare. He appears to have an easy-going personality and is interested in improving his ability to function without glasses after cataract surgery. He is willing, however, to wear glasses occasionally to refine his vision.
What is your preferred treatment strategy?
Frank A. Bucci Jr., MD: This patient is an excellent candidate for multifocal IOLs. I think that bilateral ReZoom IOL (Advanced Medical Optics [AMO]) implantation or a combination of ReZoom and ReSTOR (Alcon) would be highly successful in this patient. Although I have been successful implanting bilateral ReZoom IOLs, my default method is to implant a combination of ReZoom and ReSTOR.
David R. Hardten, MD: The patient has relatively healthy eyes, a mobile pupil, and minimal astigmatism and is likely to be easy to work with postoperatively. My first choice would be, therefore, to implant multifocal IOLs.
A 72-year-old man presents with 2+ posterior subcapsular cataracts and 3+ nuclear sclerosis. He has 20/40 BCVA and 20/100 with brightness acuity testing in both eyes. The patient is myopic (–13.5 + 0.5 X 180) and has 0.5 D of against-the-rule astigmatism. His pupils are 5 mm in dim light and 3.5 mm in bright light.
The patient has otherwise healthy eyes but discontinued driving at night, because he is bothered by glare. In addition, he wore monovision contact lenses but discontinued wear at age 65 years because of dry eye. The patient appears to have an easy-going personality and is interested in improving his ability to function without glasses after cataract surgery. He is willing, however, to wear glasses occasionally to refine his vision.
What is your preferred treatment strategy?
|
Kenneth A. Greenberg, MD: I think that the limiting factor in this patient case may be available IOL power. I would consider implanting a ReZoom multifocal IOL if, based on the calculations of axial length in this patient, a ReZoom IOL would meet his needs. Also, this patient will likely tolerate any visual disturbances that may be associated with multifocal IOLs. The patient, however, is comfortable with monovision; therefore, a monofocal IOL, such as the Tecnis IOL (AMO) may be the preferred option. Tecnis is the only IOL with FDA-approved claims for improved night-driving performance, so it may offer this patient the crisp, sharp vision he needs to resume driving at night.
In addition, surgeons should counsel extremely myopic or hyperopic patients on the high likelihood of needing a second procedure to refine vision.
A 52-year-old woman presents with incipient posterior subcapsular cataracts and 1+ nuclear sclerosis. She has 20/20 BCVA and drops to 20/25 with brightness acuity testing in both eyes. The patient is slightly myopic (–0.75 + 0.5 X 180) and has 0.5 D of against-the-rule astigmatism. Her pupils are 5 mm in dim light and 3.5 mm in bright light.
Although the patient has mild dry eye, she has otherwise healthy eyes. She discontinued driving at night and changed her work shift to daytime only, because she is bothered by glare while driving. The patient does not appear to have an easy-going personality and is interested in improving her ability to function without glasses.
What is your preferred treatment strategy?
Hardten: I think this patient will be difficult to satisfy with any multifocal or monovision approach. She has minimal cataracts with disabling symptoms, which persuade me to avoid multifocal IOLs. Also, I do not think she will be satisfied with standard monofocal IOLs. I recommend waiting until her cataracts develop more. If she retains her high sensitivity to glare, a Tecnis IOL with bilateral distance vision is probably her best option when she is ready for surgery. As the only IOL specifically designed to eliminate spherical aberration, the Tecnis IOL should improve her functional vision and may restore her confidence in her ability to drive at night.
While postponing surgical intervention, the surgeon could treat other conditions such as blepharitis or dry eye.
A 69-year-old woman presents with incipient cataracts and 1+ nuclear sclerosis. She has 20/20 BCVA and drops to 20/25 with brightness acuity testing in both eyes. The patient is slightly hyperopic (+1.75 + 0.5 X 180) and has 0.5 D of against-the-rule astigmatism. Her pupils are 3.5 mm in dim light and 2 mm in bright light.
The patient has mild dry eye but otherwise healthy eyes. She has an easy-going personality and is interested in decreasing dependence on glasses and contact lenses. She is willing, however, to wear glasses part-time if needed. The patient experiences minimal glare while driving at night but does not limit her driving except in unfamiliar areas. She does not perform a significant amount of computer work but reads six books per week and would like to read without glasses.
What is your preferred treatment strategy?
Bucci: I may prefer to combine ReZoom and ReSTOR, because, in my experience, distance vision quality, even with a smaller pupil, is going to be better in the ReZoom eye. The patient will probably achieve enough near vision quality with her ReSTOR eye to be satisfied with mixing and matching the IOLs.
Greenberg: For this patient, combining ReSTOR and ReZoom IOLs makes the most sense. Her priorities are clear: she wants to be able to sit comfortably and read up close. Driving is not a significant issue for her, but I would implant the ReZoom IOL in the dominant eye to benefit her driving.
Hardten: I would likely perform a natural lens replacement with bilateral ReSTOR IOLs. In my clinical opinion, the size of her pupil, her near vision needs, and the lack of significant distance vision demands make the ReSTOR IOL a good choice for this patient.