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Anterior Segment Intraocular Lenses/Presbyopia Presbyopic Intraocular Lenses – Managing Unhappy Patients Allon Barsam, 1 Eric D Donnenfeld 2 1. Appointed Ophthalmic Surgeon, Luton and Dunstable University Hospital, UK; 2. Partner, Ophthalmic Consultants of Long Island and Clinical Professor of Ophthalmology, New York University, US Abstract We describe a system for improving patient satisfaction with presbyopic intraocular lenses (IOLs). Pre-operative education to set realistic expectations for the pros and cons of various IOL options are described. Each presbyopic IOL in widespread use in the US is then described in turn. Finally we lay out the seven Cs for improved patient satisfaction with presbyopic IOL surgery. The seven Cs are: consecutive treatment, cylinder and residual refractive error, capsular opacification, cystoid macular oedema, cornea and ocular surface disease, centration and circumference of the pupil relative to the IOL. Keywords Cataract surgery, presbyopia, premium intraocular lenses, multifocal intraocular lenses, dry eye Disclosure: Eric D Donnenfeld is a consultant and performs research for Allergan, Alcon, Advanced Medical Optics and Bausch & Lomb. Allon Barsam has no conflicts of interest to declare. Received: 12 December 2011 Accepted: 18 January 2012 Citation: European Ophthalmic Review, 2012;6(2):112–4 Correspondence: Eric D Donnenfeld, Ophthalmic Consultants of Long Island, Rockville Centre, New York, NY 11570, US. E: Pre-operative Education There are several important steps that should be taken to dramatically increase post-operative success with presbyopic intraocular lens (IOL) cataract surgery. In general, all cataract surgery and specifically premium IOL surgery require careful patient selection and counselling, along with precise surgical technique. The best candidates for multifocal or accommodative IOLs and the cases that less experienced surgeons should begin with are hyperopes and higher myopes, who have more significant cataracts and minimal astigmatism and are motivated to reduce their dependence on spectacles for near and distance. Emmetropes and especially low myopes may feel that their distance or near vision with a presbyopic IOL was preferable prior to surgery and should be counselled accordingly. Patients do best with bilateral multifocal or accommodative IOL implantation and usually have the second cataract surgery performed within one month of the first surgery. Multifocal IOL implantation requires the same surgical technique as conventional monofocal cataract surgery. However, the optics of these presbyopic lenses requires precise centration, necessitating a well-centred capsulorrhexis and good zonular integrity in order to achieve optimal visual results. Accurate biometry with advanced technology such as the IOL Master and LensStar and control of astigmatism are also essential to maximising outcomes and the lens constant must be carefully personalised to the individual surgeon. For this reason tracking postoperative results is imperative to refine surgical outcomes. Post-operative astigmatism needs to be reduced to half a diopter (D) or less. For patients with astigmatism greater than this, limbal relaxing incisions, laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) may be required and the patient should be told about this prior to surgery. Patient understanding of acceptable and expected surgical outcomes are also imperative for the achievement of optimal results. Patients 112 with unrealistic expectations for visual improvement and patients with excessive complaints about spectacles or contact lenses may not be candidates for multifocal IOLs. In addition, patients whose occupation requires significant night driving and those who complain of excessive glare and halo at night may not be ideal candidates for multifocal IOLs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) should be used perioperatively to decrease the risk of cystoid macular oedema and improve retinal function. 1 The first step to any refractive procedure is to determine what the patient’s visual requirements are. Asking the patients to complete a questionnaire like the one shown below which was described by Steven Dell is very helpful for this purpose. It is important to understand the differences between the various presbyopic IOLs in order to tailor the IOL choice to the needs of the individual patient. The key features of the three presbyopic IOLs in most common use are listed below: ReSTOR Intraocular Lens ® On the ReSTOR ® IOL, the central 3.6 mm of the lens surface consists of 12 apodised diffractive optic rings with the 4 D add and nine rings with the 3 D add. The periphery of the lens is a traditional distance refractive optic. The optical profile for the ReSTOR lens provides an equal distribution of energy between the two primary images at near and far for pupils up to 3.6 mm, but as the pupil becomes larger, more of the light goes to the far lens power; the concept being that near tasks generally require more illumination and the pupil constricts for near tasks with the accommodative reflex. Distance tasks, particularly while driving at night, benefit from the distance-dominant periphery of the lens when the pupil is larger. The 3 D add enables better vision at intermediate distances while the 4 D add provides better near vision with less emphasis on intermediate vision. Both lenses have aspheric optics to improve contrast sensitivity. © TOUCH BRIEFINGS 2012