This article is more than 5 years old. Information may no longer be current.
Discussion: OCT important before multifocal IOL implantation
A patient who did not have an OCT before surgery had an epiretinal membrane, which may have affected his postop vision.
Click Here to Manage Email Alerts
 Eric D. Donnenfeld |
Eric D. Donnenfeld, MD, FACS: A patient we previously discussed (July 25, 2008) with two lenses in one eye had glare and halo and was unhappy with his multifocal IOL. I think this has nothing to do with the type of multifocal; this could happen with any IOL.
The patient was managed for ocular surface disease with dry eye. The patient has glaucoma and is treated now for his ocular surface disease with Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch & Lomb), Restasis (cyclosporine ophthalmic emulsion, Allergan) and tears. The patient’s ocular surface is better, but have we finished our evaluation on this patient? Are there more things that should be done to evaluate this patient?
Calvin W. Roberts, MD: I think one of the first things we need to do is an optical coherence tomography and look at the fundus because besides astigmatism, the No. 1 thing that decreases the quality of vision after multifocal lenses is a little bit of edema of the macula. Too little for us to actually see with our 90° lens but enough that we could measure with OCT. Maybe only 10 µm of increase in macular thickness can cause a real difference in the quality of vision and how well the patient sees.
Dr. Donnenfeld: So you would recommend that OCT be performed. That is a nice little pearl, and I know that a lot of physicians do this for every patient who comes in for any cataract surgery, but particularly for premium IOL surgery. Why is that important?
Terry Kim, MD: I have to give credit to Dr. Roberts because he was the one who really taught me to do this, and it has been a worthwhile part of my practice. That has changed the way I screen patients and see patients. Why don’t you tell them about your study? I talk about it, and it is a great pearl.
Dr. Roberts: It all started out with a situation in which a person comes in for routine surgery. It is now a month later. The patient has 20/40 vision. You are trying to figure out why the patient does not have 20/20 vision. You dilate them. You send them for a fluorescein angiogram. You do all the things that we know how to do, and it turns out the patient has a tiny epiretinal membrane. And so you explain to the patient that this was something we could not see before surgery, this little epiretinal membrane that is keeping your patient from seeing 20/20. You say that to the patient, and the patient responds, “Doctor, why don’t you just admit it that you screwed up my eye and that’s why I don’t see 20/20?”
What I was interested to find out was, could you detect these people with tiny epiretinal membranes before surgery, and if you did, would it make a difference in terms of the final outcome? What we did was 2,000 consecutive patients undergoing cataract surgery had a preoperative OCT. We found that a full 6% of the patients had some form of an epiretinal membrane. It did not mean that 6% of the patients did not achieve excellent vision, but 6% of the patients had an epiretinal membrane. What is more important, I feel, is that when you looked at the other 94% of the patients, if they had both preoperative nonsteroidals, and postoperative nonsteroidals, not one of those patients developed any macular edema postoperatively. So I feel strongly that if you start out with a normal macula and you use nonsteroidals, you will get excellent macular function.
Dr. Kim: I also now use this as part of our screening for patients with premium IOLs so that if I see an existence of a little epiretinal membrane, I usually will get a retina consult. But I will tell folks that in my mind that is a red flag and that they are not really a candidate for multifocal IOLs. So it has been useful in many ways.
Dr. Donnenfeld: I agree, a nice little pearl there.
 Moderate cystoid macular edema is seen in the right eye with an epiretinal membrane.  Moderate cystoid macular edema is seen in the left eye with an epiretinal membrane and a possible retinal hole. Images: Ophthalmic Consultants of Long Island |
Multifocal IOLs are kind of on the back burner for these patients, but I think a crystalens (Bausch & Lomb) would be a reasonable lens to put in this type of patient. Would you have any problem putting a crystalens in a patient with an epiretinal membrane?
Richard L. Lindstrom, MD: If they are going to have a 20/30 or 20/40 visual potential, I would probably just plan on doing an aspheric IOL. I think with any of the premium lenses, we probably want to have an eye that is close to 20/20 potential.
Dr. Donnenfeld: Great. There are many potential problems after multifocal IOL implantation, but I want to concentrate on four Cs that are important for people who have glare: contrast sensitivity loss, cylinder and refractive error, capsular opacity and cystoid macular edema.
Cylinder and refractive error are important. Capsular opacity certainly can play a significant role. We all do YAGs earlier than we ever did before with these capsular opacities. And I mention the cornea ocular surface disease as being important, but cystoid macular edema is extraordinarily important, and any CME is not tolerated in these patients at all. These multifocal IOL patients can be difficult to manage, and if they are unhappy, they can make everyone unhappy.
So we want to do everything we can do to manage these patients preoperatively, and Dr. Roberts mentioned preoperative OCT. Here is the patient’s OCT of the right eye (Figure 1). Tell us about this OCT and your concerns.
Frank A. Bucci Jr., MD: You want to correlate the OCT to what the vision is, but as Dr. Lindstrom said, you really want to have almost maximum visual potential before using multifocal lenses or accommodating lenses. With the crystalens, the patient is going to pay out of pocket, and they will have higher expectations, and you at least have to demonstrate 20/25 plus visual potential to proceed in that direction. But here you are going to be looking for some retinal pathology. Is this some retinal edema? Is this an epiretinal membrane? And you want to confirm the impact of this on the visual potential before you make your decision regarding multifocals or any lens.
Dr. Donnenfeld: I agree 100%. This patient did not have OCT preoperatively. We do not know if this problem existed preoperatively. It is important that we look at the other eye, and it looks like there may be a lamellar retinal hole (Figure 2).
Dr. Lindstrom: With that OCT, the patient is not seeing too well.
Dr. Donnenfeld: Exactly. You know that patient is not seeing well. I have become a world-class retinal doctor with the addition of OCT. I cannot see any of these things when I look at this patient. When I do physical examinations, I do not know how my retinal colleagues see these things. But when you have the use of an OCT that gives you the diagnosis, it makes it so much easier to make your physical diagnosis with these patients. And if you see this preoperatively, it tells you that there is a potential problem. This patient did not have OCT done, so we do not know whether this existed preoperatively. If it were there preoperatively, I certainly would have changed my conversation with the patient. I would have clearly told him not to have a multifocal IOL implanted.
What do you do for this patient? This is where we went. I thought this patient needed a retinal and a glaucoma referral. We started the patient on nonsteroidal and steroid. There was improvement in visual acuity over the next 2 months with vision ending up at 20/25 in the right eye and 20/30 in the left. Still not a great result. This patient still has glare and halo but is tremendously better than when he walked in, so this is a case in which we did not solve all the problems, but we improved them and that was important. And the key was managing CME and managing ocular surface disease.
For more information:
- Frank A. Bucci Jr., MD, can be reached at Bucci Laser Vision Institute, 158 Wilkes-Barre Township Blvd., Wilkes-Barre, PA 18702; 570-825-5949; fax: 570-825-2645.
- Eric D. Donnenfeld, MD, FACS, can be reached at OCLI, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714.
- Terry Kim, MD, can be reached at Duke University Eye Center, Erwin Road, P.O. Box 3802, Durham, NC 27710-3802; 919-681-3568; fax: 919-681-7661.
- Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 DuPont Ave. S, Suite 200, Bloomington, MN 55431; 952-888-5800; fax: 952-567-6182.
- Calvin W. Roberts, MD, can be reached at 876 Park Ave., New York, NY 10021; 212-734-7788; fax: 212-734-4476.