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situations in which you'd prefer the Crystalens over multifocals? Dr. Dell: Implanting a diffractive multi- focal in both eyes of a patient with macular degeneration is probably a bad idea; any time we see macular pathology (and to some degree corneal pathology) that makes us worry about irregular astigmatism, multifocals are off the table. Those cases are automatically better off with a Crystalens AO. Dr. Lindstrom: I think Dr. Ang's data confirms multiple sets of data we've seen over the years: There is a differ- ence between the lenses, and contrast sensitivity and intermediate vision are better with the aspheric optic of the Crystalens AO, but near is often slightly less. Now, really knowing how these lenses perform, how do you decide which one to use? Dr. Yogi: A large number of baby boomers underwent refractive surgery in the last 15 years, and I think the Crystalens AO is a very nice option in these cases because I believe that patients who have undergone refractive surgery before will not want to wear glasses after surgery. The Crystalens AO provides good vision without inducing more aberrations. I think aberrations are a major cause of complaints that is sometimes underes- timated by cataract surgeons. Dr. Lindstrom: What about glaucoma and glaucoma damage? Would that make anyone shy away from multifocal IOLs? Dr. Ang: Yes, I think so. With glaucoma, there's some generalized decrease in sensitivity detectable by visual field testing. Multifocals will further decrease contrast sensitivity, so the Crystalens AO would definitely be a better option, causing the least harm to the patient. Dr. Lindstrom: Dr. Fernandez, how do you decide on which lens to use? Dr. Fernandez: You have to choose your patients carefully. You have to identify patients who will experience discomfort with dysphotopsias after surgery. It is the worst scenario to have that problem with a patient. I don't believe so much in neuroadap- tation, I think it's more of a "neurores- ignation"—and that is the worst scenario. You are going to need an- other surgery to explant the multifocal lens in a patient like that. After that, you have to choose the correct option for treating that patient. Dr. Dick: The choice between multifo- cals and the Crystalens AO depends. If a patient really wants to read books long term, I would offer a multifocal lens. But if a patient will be reading more from computers, I would go for the Crystalens AO. Multifocal IOLs have an issue regarding photic phe- nomena—starbursts, halo, glare. It's inherent in the system because you're March 2012 5 redistributing the light, part for the near focus, part for the distance focus, but also for some other foci that the patient cannot use. That means you always have some image degradation, some deterioration in the optical qual- ity. On the other hand, the Crystalens AO has a much lower incidence of halo and glare complaints. A patient who really wants to have perfect vision at near for long-term tasks, with the highest level of preci- sion without glasses, would be a better candidate for a multifocal because that's what multifocals offer. What a multifocal IOL often does not offer is sufficient intermediate vision, which is the realm of the Crystalens AO. More people work on computers, laptops, iPads, and so forth, and these people work at intermediate more than near. Near is at about 30 to 40 cm; intermediate is more or less 70 to 80 cm—at this distance, the Crystalens AO is superior. Dr. Ang determined that Crystalens AO fulfills most, if not all, of these criteria

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