Patient selection for premium IOLs requires corneal diagnostics
Key takeaways:
- Managing the ocular surface is part of proper patient selection for presbyopia-correcting IOLs.
- Use corneal diagnostic tools to pick the right candidates.
KOLOA, Hawaii — Ophthalmologists must embrace corneal diagnostics to select the proper patient for premium multifocal IOLs, according to a presenter at Hawaiian Eye 2025.
“You’ve heard already a million times this week: A good ocular surface with good corneal regularity makes [a patient] a proper candidate,” Sheri Rowen, MD, FACS, said.
A high percentage of patients with cataracts are good candidates for presbyopia-correcting IOLs. Patients who underwent myopic or hyperopic LASIK or RK as well as those who have epiretinal membrane, mild irregular astigmatism, dry eye disease or meibomian gland dysfunction should be considered borderline candidates, while those with moderate Fuchs’ corneal dystrophy, irregular astigmatism or retinal pathology are usually poor candidates, Rowen said.
To ensure the best possible results, Rowen recommended that ophthalmologists use corneal topography, wavefront aberration devices, epithelial maps, biometry for keratometry and axial length, multiple keratometry measurements and ocular surface exams.
“You must do the fluorescein stain on every single patient,” she said.
These diagnostics can help detect conditions such as keratoconus, irregular astigmatism, anterior basement membrane dystrophy and dry eye and determine accurate astigmatism measurements, the status of patients after LASIK, and whether they underwent myopic or hyperopic LASIK or experienced a decentered ablation.
Rowen recommended treating dry eye with topical therapy for 3 weeks, which can often turn irregular astigmatism into regular astigmatism and yield better candidates for multifocal IOLs. Wavefront indices can also play a role in distinguishing good candidates from poor candidates by detecting the quality of the cornea, the presence of higher-order aberrations, spherical aberration for matching the proper IOL, angle alpha and contrast sensitivity.
“Poor contrast is our enemy,” Rowen said. “If you can’t achieve good contrast and good visual acuity, [patients] will not be happy. They will be more unhappy even than the ones that have dysphotopsias.”
Overall, a key factor in patient satisfaction with multifocal IOLs is picking patients with the right temperament who may be willing to tolerate some dysphotopsias and contrast issues.
“If they come in saying, ‘I want the best lens — I want it all,’ you have to explain to them why they can’t get it if they have a problem,” Rowen said.
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Rowen S. Patient wants premium implant: How corneal diagnostics help me match the proper implant to the proper patient. Presented at: Hawaiian Eye 2025; Jan. 18-24, 2025; Koloa, Hawaii.
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