CONSULTATION SECTION
Glaucoma Surgical Problem Edited by Thomas W. Samuelson, MD
A 78-year-old women presents with a moderately dense cataract in the left eye. She has obvious exfoliation syndrome in each eye. However, in both eyes the intraocular pressure (IOP) is normal (14 mm Hg), the optic nerve rim tissue is healthy, and the visual field is normal. Both eyes have a normal central corneal thickness. There is no visible phacodonesis or pseudophacodonesis in either eye. A surgeon from a different state had implanted an Acrysof Restor multifocal intraocular lens (IOL) (Alcon Laboratories, Inc.) several years earlier in the right eye. The IOL has remained well centered, and the patient is happy with the outcomes of that procedure and has requested a similar IOL in the fellow eye. Her manifest refraction is 0.50 +0.25 62 in the right eye and 1.50 diopter (D) sphere in the left eye. The macula is normal in each eye. Pertinent questions are as follows: Do you use multifocal IOLs in patients with exfoliation syndrome or exfoliative glaucoma? If so, do you take measures to improve maintenance of IOL centration, such as the use of a capsular tension ring (CTR)? What preoperative counseling do you provide to properly inform patients that eyes with exfoliation syndrome have a higher incidence of IOL decentration and frank subluxation? Do you alter the size of your capsulorhexis in such eyes? Do you prefer a specific multifocal design in such patients (eg, 3-piece design versus 1-piece design)? Do you modify the anterior capsule to prevent capsule phimosis in such patients (eg, relaxing incisions with a neodymium:YAG [Nd:YAG] laser)? Do you advocate multifocal IOLs in patients with manifest visual field loss? In the event that you do not recommend a multifocal IOL in the left eye of this patient, would you implant a standard monofocal IOL or send her back to her original surgeon for consideration of a multifocal IOL? What is your experience with a multifocal IOL in 1 eye and a monofocal IOL in the fellow eye? - Although the majority of patients who receive multifocal IOLs are satisfied with the results, proper patient selection remains a paramount factor in predicting a successful outcome. Several factors have
162
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
been reported to influence the visual outcomes, including pupil size,1,2 corneal astigmatism,3 corneal clarity,4 and amount of IOL decentration.2 Although pseudoexfoliation (PXF) is not an absolute contraindication, I generally do not recommend a multifocal IOL in these patients because of the unpredictability of the progression of this disease. However, because this patient has had a successful outcome in the first eye with a multifocal IOL and there is no evidence of phacodonesis or of glaucomatous optic nerve damage, I would implant the same model of multifocal IOL in the second eye. If the patient had evidence of glaucomatous field loss or phacodonesis/pseudophacodonesis, I would not implant a multifocal IOL but rather would choose a monofocal IOL. In a retrospective study of patients who had a multifocal IOL in 1 eye and a monofocal IOL in the other, 95% of patients were satisfied with the combination (unpublished results). Patients who have this combination were usually unhappy with the results of the multifocal IOL in the first operative eye for a variety of reasons, including decentration, and therefore chose to have a monofocal IOL in the second eye. Even in this situation of an unsatisfactory result, the mix of a multifocal IOL and monofocal IOL appeared to be acceptable and yielded a satisfied patient without the need for an exchange of the multifocal IOL. Intraoperatively, I make several modifications. I pay closer attention to the size and centration of the capsule opening. I attempt to make the opening slightly smaller than 6.0 mm to allow 360-degree contact of the optic and the anterior capsule. I find that IOL decentration often happens when there are asymmetric amounts of optic–capsule overlap, leading to fusion of the anterior capsule and posterior capsule in areas without optic cover. In addition, implantation of a CTR can be useful in distributing the forces around the equator and centering the IOL. Although I am not convinced that the CTR will prevent late subluxation of the entire capsular bag–CTR–IOL complex, I routinely implant a CTR in patients with zonular abnormalities to improve centration of multifocal IOLs and even toric IOLs. Finally, a thorough preoperative discussion of the possible risks associated with implanting a multifocal IOL in the setting of PXF is crucial. If patients are prop-
0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.10.020
CONSULTATION SECTION
erly informed and accept the risks, it is appropriate to implant a multifocal IOL in these cases. Bonnie An Henderson, MD Boston, Massachusetts, USA Dr. Henderson is a consultant to Alcon and Bausch & Lomb. REFERENCES 1. Koch DD, Samuelson SW, Haft EA, Merin LM. Pupillary size and responsiveness; implications for selection of a bifocal intraocular lens. Ophthalmology 1991; 98:1030–1035 2. Koch DD, Samuelson SW, Villarreal RV, Haft EA, Kohnen T. Changes in pupil size induced by phacoemulsification and posterior chamber lens implantation: consequences for multifocal lenses. J Cataract Refract Surg 1996; 22:579–584 3. Hayashi K, Hayashi H, Nakao F, Hayashi F. Influence of astigmatism on multifocal and monofocal intraocular lenses. Am J Ophthalmol 2000; 130:477–482 4. Dick HB, Krummenauer F, Schwenn O, Krist R, Pfeiffer N. Objective and subjective evaluation of photic phenomena after monofocal and multifocal intraocular lens implantation. Ophthalmology 1999; 106:1878–1886
- Whether to implant a multifocal IOL is frequently a complex decision that must be individualized and must take many factors into consideration. Patient motivation for reduced spectacle dependence and the absence of other ocular pathology are foremost prerequisites because of the optical compromises inherent in a diffractive multifocal design. This patient already understands and is satisfied with the function of her first multifocal IOL and is requesting the same IOL model for her second eye. I would recommend against a multifocal IOL in the presence of any ocular comorbidity, such as glaucomatous optic neuropathy, but would otherwise respect her preference with a few caveats. In my experience, relative to a monofocal IOL, diffractive multifocal IOLs are very unforgiving of tilt and decentration. This may generate symptomatic higher-order aberrations that reduce contrast and image quality. This is a particularly important consideration for patients with PXF, who are at risk for progressive zonulopathy. Preoperatively, assuming that a patient with PXF desires multifocality, I would discuss the possibility that the zonular fibers may be or may become abnormal over time. If obvious zonulopathy is evident during surgery, I would recommend placement of a monofocal IOL. The risk for decentration or tilt of a multifocal IOL would be too high, and this potential scenario should be discussed preoperatively. Patients certainly tolerate mixing monofocal and multifocal platforms, although uncorrected reading function will not match that of bilateral multifocality. If the zonular fibers seem normal at the time of surgery, I would implant the same multifocal model
163
in the second eye, as requested. I would implant a CTR to facilitate centration and to reduce the risk for late bag tilt, decentration, or subluxation. Although I do not routinely implant CTRs in PXF eyes without evidence of zonulopathy, it should be considered when implanting a multifocal IOL. I prefer 3-piece IOL designs for PXF when a CTR is not implanted because the greater compressive force of 3-piece haptics should resist capsule contraction.1 However, if a CTR is implanted, I am comfortable implanting a 1-piece acrylic IOL. I would be careful not to leave the capsulorhexis diameter too small. Once the IOL is implanted and the multifocal optic is properly centered on the visual axis (usually nasal to the center of the capsular bag), a small-diameter capsulorhexis can be secondarily enlarged with a capsule forceps following an oblique cut in its edge. Alternatively, Nd:YAG laser relaxing cuts to a contracting fibrotic capsulorhexis edge can be made postoperatively to prevent capsulophimosis. David F. Chang, MD Los Altos, California, USA REFERENCE 1. Chang DF. Prevention of bag-fixated IOL dislocation in pseudoexfoliation [letter]. Ophthalmology 2002; 109:1951–1952
- The indications for the use of multifocal IOLs are controversial. In general, they are contraindicated in patients with concurrent ocular conditions that diminish visual acuity and/or the visual field, such as glaucoma and macular or corneal disease. Degradation of light in multifocal IOLs resulting in decreased vision is the concern. These problems are in addition to the more symptomatic concerns related to glare. The patient in this case has passed the first test of a multifocal IOL; that is, she is functioning quite well visually and tolerates the IOL without glare after initial cataract surgery. Whether she will develop elevated IOP, optic nerve damage, and visual field loss from the PXF is not possible to predict. Assuming no glaucomatous loss and stable zonular support, a 1piece multifocal IOL in the second eye should also be well tolerated and appreciated. I would place a CTR after lens cortex removal. I would strive to place my standard 5.0 mm capsulorhexis and monitor postoperatively for phimosis. Studies to determine whether a capsulorhexis completed by a femtosecond laser is less likely to develop phimosis is this setting have not been completed. If phimosis develops, I would use an Nd:YAG laser to create relaxing incisions to the capsule. Richard A. Lewis, MD Sacramento, California, USA
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
Glaucoma Surgical Problem Edited by Thomas W. Samuelson, MD
A 78-year-old women presents with a moderately dense cataract in the left eye. She has obvious exfoliation syndrome in each eye. However, in both eyes the intraocular pressure (IOP) is normal (14 mm Hg), the optic nerve rim tissue is healthy, and the visual field is normal. Both eyes have a normal central corneal thickness. There is no visible phacodonesis or pseudophacodonesis in either eye. A surgeon from a different state had implanted an Acrysof Restor multifocal intraocular lens (IOL) (Alcon Laboratories, Inc.) several years earlier in the right eye. The IOL has remained well centered, and the patient is happy with the outcomes of that procedure and has requested a similar IOL in the fellow eye. Her manifest refraction is 0.50 +0.25 62 in the right eye and 1.50 diopter (D) sphere in the left eye. The macula is normal in each eye. Pertinent questions are as follows: Do you use multifocal IOLs in patients with exfoliation syndrome or exfoliative glaucoma? If so, do you take measures to improve maintenance of IOL centration, such as the use of a capsular tension ring (CTR)? What preoperative counseling do you provide to properly inform patients that eyes with exfoliation syndrome have a higher incidence of IOL decentration and frank subluxation? Do you alter the size of your capsulorhexis in such eyes? Do you prefer a specific multifocal design in such patients (eg, 3-piece design versus 1-piece design)? Do you modify the anterior capsule to prevent capsule phimosis in such patients (eg, relaxing incisions with a neodymium:YAG [Nd:YAG] laser)? Do you advocate multifocal IOLs in patients with manifest visual field loss? In the event that you do not recommend a multifocal IOL in the left eye of this patient, would you implant a standard monofocal IOL or send her back to her original surgeon for consideration of a multifocal IOL? What is your experience with a multifocal IOL in 1 eye and a monofocal IOL in the fellow eye? - Although the majority of patients who receive multifocal IOLs are satisfied with the results, proper patient selection remains a paramount factor in predicting a successful outcome. Several factors have
162
Q 2013 ASCRS and ESCRS Published by Elsevier Inc.
been reported to influence the visual outcomes, including pupil size,1,2 corneal astigmatism,3 corneal clarity,4 and amount of IOL decentration.2 Although pseudoexfoliation (PXF) is not an absolute contraindication, I generally do not recommend a multifocal IOL in these patients because of the unpredictability of the progression of this disease. However, because this patient has had a successful outcome in the first eye with a multifocal IOL and there is no evidence of phacodonesis or of glaucomatous optic nerve damage, I would implant the same model of multifocal IOL in the second eye. If the patient had evidence of glaucomatous field loss or phacodonesis/pseudophacodonesis, I would not implant a multifocal IOL but rather would choose a monofocal IOL. In a retrospective study of patients who had a multifocal IOL in 1 eye and a monofocal IOL in the other, 95% of patients were satisfied with the combination (unpublished results). Patients who have this combination were usually unhappy with the results of the multifocal IOL in the first operative eye for a variety of reasons, including decentration, and therefore chose to have a monofocal IOL in the second eye. Even in this situation of an unsatisfactory result, the mix of a multifocal IOL and monofocal IOL appeared to be acceptable and yielded a satisfied patient without the need for an exchange of the multifocal IOL. Intraoperatively, I make several modifications. I pay closer attention to the size and centration of the capsule opening. I attempt to make the opening slightly smaller than 6.0 mm to allow 360-degree contact of the optic and the anterior capsule. I find that IOL decentration often happens when there are asymmetric amounts of optic–capsule overlap, leading to fusion of the anterior capsule and posterior capsule in areas without optic cover. In addition, implantation of a CTR can be useful in distributing the forces around the equator and centering the IOL. Although I am not convinced that the CTR will prevent late subluxation of the entire capsular bag–CTR–IOL complex, I routinely implant a CTR in patients with zonular abnormalities to improve centration of multifocal IOLs and even toric IOLs. Finally, a thorough preoperative discussion of the possible risks associated with implanting a multifocal IOL in the setting of PXF is crucial. If patients are prop-
0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2013.10.020
CONSULTATION SECTION
erly informed and accept the risks, it is appropriate to implant a multifocal IOL in these cases. Bonnie An Henderson, MD Boston, Massachusetts, USA Dr. Henderson is a consultant to Alcon and Bausch & Lomb. REFERENCES 1. Koch DD, Samuelson SW, Haft EA, Merin LM. Pupillary size and responsiveness; implications for selection of a bifocal intraocular lens. Ophthalmology 1991; 98:1030–1035 2. Koch DD, Samuelson SW, Villarreal RV, Haft EA, Kohnen T. Changes in pupil size induced by phacoemulsification and posterior chamber lens implantation: consequences for multifocal lenses. J Cataract Refract Surg 1996; 22:579–584 3. Hayashi K, Hayashi H, Nakao F, Hayashi F. Influence of astigmatism on multifocal and monofocal intraocular lenses. Am J Ophthalmol 2000; 130:477–482 4. Dick HB, Krummenauer F, Schwenn O, Krist R, Pfeiffer N. Objective and subjective evaluation of photic phenomena after monofocal and multifocal intraocular lens implantation. Ophthalmology 1999; 106:1878–1886
- Whether to implant a multifocal IOL is frequently a complex decision that must be individualized and must take many factors into consideration. Patient motivation for reduced spectacle dependence and the absence of other ocular pathology are foremost prerequisites because of the optical compromises inherent in a diffractive multifocal design. This patient already understands and is satisfied with the function of her first multifocal IOL and is requesting the same IOL model for her second eye. I would recommend against a multifocal IOL in the presence of any ocular comorbidity, such as glaucomatous optic neuropathy, but would otherwise respect her preference with a few caveats. In my experience, relative to a monofocal IOL, diffractive multifocal IOLs are very unforgiving of tilt and decentration. This may generate symptomatic higher-order aberrations that reduce contrast and image quality. This is a particularly important consideration for patients with PXF, who are at risk for progressive zonulopathy. Preoperatively, assuming that a patient with PXF desires multifocality, I would discuss the possibility that the zonular fibers may be or may become abnormal over time. If obvious zonulopathy is evident during surgery, I would recommend placement of a monofocal IOL. The risk for decentration or tilt of a multifocal IOL would be too high, and this potential scenario should be discussed preoperatively. Patients certainly tolerate mixing monofocal and multifocal platforms, although uncorrected reading function will not match that of bilateral multifocality. If the zonular fibers seem normal at the time of surgery, I would implant the same multifocal model
163
in the second eye, as requested. I would implant a CTR to facilitate centration and to reduce the risk for late bag tilt, decentration, or subluxation. Although I do not routinely implant CTRs in PXF eyes without evidence of zonulopathy, it should be considered when implanting a multifocal IOL. I prefer 3-piece IOL designs for PXF when a CTR is not implanted because the greater compressive force of 3-piece haptics should resist capsule contraction.1 However, if a CTR is implanted, I am comfortable implanting a 1-piece acrylic IOL. I would be careful not to leave the capsulorhexis diameter too small. Once the IOL is implanted and the multifocal optic is properly centered on the visual axis (usually nasal to the center of the capsular bag), a small-diameter capsulorhexis can be secondarily enlarged with a capsule forceps following an oblique cut in its edge. Alternatively, Nd:YAG laser relaxing cuts to a contracting fibrotic capsulorhexis edge can be made postoperatively to prevent capsulophimosis. David F. Chang, MD Los Altos, California, USA REFERENCE 1. Chang DF. Prevention of bag-fixated IOL dislocation in pseudoexfoliation [letter]. Ophthalmology 2002; 109:1951–1952
- The indications for the use of multifocal IOLs are controversial. In general, they are contraindicated in patients with concurrent ocular conditions that diminish visual acuity and/or the visual field, such as glaucoma and macular or corneal disease. Degradation of light in multifocal IOLs resulting in decreased vision is the concern. These problems are in addition to the more symptomatic concerns related to glare. The patient in this case has passed the first test of a multifocal IOL; that is, she is functioning quite well visually and tolerates the IOL without glare after initial cataract surgery. Whether she will develop elevated IOP, optic nerve damage, and visual field loss from the PXF is not possible to predict. Assuming no glaucomatous loss and stable zonular support, a 1piece multifocal IOL in the second eye should also be well tolerated and appreciated. I would place a CTR after lens cortex removal. I would strive to place my standard 5.0 mm capsulorhexis and monitor postoperatively for phimosis. Studies to determine whether a capsulorhexis completed by a femtosecond laser is less likely to develop phimosis is this setting have not been completed. If phimosis develops, I would use an Nd:YAG laser to create relaxing incisions to the capsule. Richard A. Lewis, MD Sacramento, California, USA
J CATARACT REFRACT SURG - VOL 40, JANUARY 2014
