Careful patient selection necessary for trifocal IOLs
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Trifocal IOLs may be an option for patients with less-than-perfect eyes, but selection should be made case by case, according to one specialist.
“We all know that the ideal candidate has cataract but otherwise completely normal eyes, as in the registration trials, but this is not always the case in our everyday practice,” H. Burkhard Dick, MD, PhD, said at the virtual European Society of Cataract and Refractive Surgeons winter meeting.
While eyes with previous RK, severe dry eye and compromised corneas due to corneal dystrophies, stromal scars and opacifications should always be excluded, suspect or early glaucoma without visual field loss might not be an absolute contraindication. With mild glaucoma, Dick recommended 10-2 visual field testing to exclude early centration fixation involvement.
“Moderate to severe advanced glaucoma cases are not recommended because the already decreased contrast sensitivity would be further reduced,” he said.
Post-keratorefractive surgery patients are the most difficult to decide upon because they are used to spectacle independence and willing to pay for it. These cases require careful evaluation, accurate preoperative diagnostics and chair time to set the right expectations.
The Bochum algorithm, which Dick personally developed, may guide surgeons in the choice of IOLs in post-keratorefractive surgery patients.
“If patients have unrealistic expectations, a dry eye that cannot be treated, significant ocular pathologies, a myopic ablation of more than 6 D, a hyperopic ablation of over 4 D, RK or decentered ablation, I would not go for trifocal IOLs but rather for a monofocal plus, a Light Adjustable Lens (RxSight) or a small-aperture IOL. If this is not the case, and the angle kappa and alpha are below 0.5, the total higher-order aberrations are low, and coma and trefoil are below 0.4 µm, then we check the spherical aberration, and if it’s over 0.1 µm, I would recommend an aspheric trifocal like the Synergy (Johnson & Johnson Vision) or the At Lisa tri 839 (Zeiss). If it is below 0.1 µm, a neutral or spherical multifocal IOL is preferable,” he said.
For power calculation, he recommended the ASCRS calculator and ray tracing analysis.
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Dick HB. Trifocals: Only for the perfect eye? Presented at: European Society of Cataract and Refractive Surgeons winter meeting; Feb. 18-20, 2022 (virtual meeting).
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