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Understand patient expectations in residual refractive error with presbyopic IOLs
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WAILEA, Hawaii — There are surgical and nonsurgical options for the management of patients who were implanted with a presbyopic IOL and have residual refractive error, according to Audrey Talley Rostov, MD.
“It’s important to meet patient expectations and have patient considerations [in mind],” Talley Rostov said at Hawaiian Eye 2018.
Rostov recommends determining if the patient is functional and if there is any co-existing pathology. Understanding the best-corrected vision is also important.
Determine whether the refractive error is stable or unstable. Be sure to carefully evaluate the ocular surface, she said.
“In the clinical evaluation you always want to pay careful care to the topography and the OCT,” Talley Rostov said. “Sometimes you’re going to have a surprise back there which may be why the patient isn’t seeing well.”
Also, “is it surgeon expectations or patient expectations that is the source of error—or it is something more definitive like IOL calculation, position or previous history of refractive surgery?”
During treatment planning she recommends fully understanding what the patient wants and whether it is possible. Address any necessary patient comorbidities, she said.
Trying glasses or contact lenses first to see what they want to achieve can be helpful.
“When a patient is unhappy with distance vision greater than 1.5 D, I consider an IOL exchange. You could also consider a piggyback IOL. If it’s less than 1.5 D laser vision correction could be a nice option or a piggyback IOL,” Talley Rostov said.
For intermediate vision, if you have a situation where there is a multifocal lens in both eyes, consider an IOL exchange for a multifocal with less add, or an IOL exchange for an extended depth of focus (EDOF) lens, she said.
If the patient is interested in near vision, an exchange for increase add is possible, if there is an EDOF in the first eye. “It works really well to put in a multifocal IOL with increase add for the second eye,” she added.
“If you need to treat residual astigmatism, you also want to look at where the astigmatism is. If it’s an incorrect axis, rotate the IOL ... if it’s greater than 1 D you could do an IOL exchange with corneal relaxing incision or even PRK,” Talley Rostov said.
In keratoconus, Rostov does not recommend corneal relaxing incisions (CRI), LASIK or PRK.
“In previous RK, I do not recommend CRI, you can do PRK,” she said.
In a previous corneal transplant, CRI or PRK can be used. “The combination of toric IOL and corneal relaxing incision with previous corneal transplant patient actually gives you more astigmatism management than you expect,” Talley Rostov said.
In summary, Rostov sets patient and surgeon expectations preoperatively. Know the expectation and limitations of different technologies and IOLs, do not over-promise and under-deliver. Access to an excimer laser is helpful for touch-ups and in IOL exchange, she said. – by Abigail Sutton
Reference:
Talley Rostov A. Management of presbyopic IOL with residual refractive error. Presented at: Hawaiian Eye; Jan. 13-19, 2018; Wailea, Hawaii.
Disclosure: Talley Rostov reports relevant financial disclosures with Allergan, Bausch + Lomb, Omeros, Shire, Sun Pharmaceuticals and SightLife.