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Dr. Dell: There is a perception that the Crystalens AO is more difficult to target for emmetropia than other lenses. Have you found that to be the case? Dr. Dick: Not at all. The lens is highly predictable. Dr. Ang: You need to keep using the lens to get your own technique to achieve the optimal target because we all have our own little intraoperative techniques and tricks. For instance, after I perform irrigation and aspira- tion, I tap the lens and push it toward the posterior capsule to give me an added sense that it is posteriorly vaulted. I also use atropine, whereas some of my colleagues don't. As with any surgery, the more we do it, the better we get at it. My data suggests that the lens is predictable— you just have to get your A-constants correct, as with any other IOL. Long-term stability Dr. Lindstrom: Another issue that comes up every now and then with the Crystalens is long-term stability. Dr. Dell, you have long-term follow-up, what is your experience? Dr. Dell: We've looked at our original clinical study patients for about 10 years now. There was improvement between year 1 and 3, and slight improvement between year 3 and 4, but we did not see continued improve- ment after year 4. However, we did not see degradation either. I think that a large percentage of patients wind up with capsulotomies; a physician unfamiliar with the Crystalens AO may attribute that degradation in near vision to a cessa- tion of the movement of the lens, but in actuality it is posterior capsule opacification. If I see a patient who could read 6 months ago and now can't, the first thing I do is perform a YAG laser capsulotomy, and that often resolves the issue. Dr. Ang: I think the YAG laser is our ace-in-the-hole and needs to be done at the correct time. I perform YAG laser capsulotomy to lock in a good result, for example at 1 year, when a patient can see well at distance and at near. I think Asians tend to have a lot of striae come into the capsule very early, so I tend to perform YAG capsulotomies between 3 and 12 months, and that often locks in the good result I had initially. I feel that when patients lose some near vision, it's easier to talk to them than when patients lose good uncorrected distance vision. They're unhappy, so I want to lock in the good distance vision first. That's what they enjoy, and that's what the Crystalens AO is for— to enjoy good quality distance vision with some added near. Dr. Fernandez: In order to succeed with this lens, it's critical to involve patients in the decision-making process before surgery. We have to tell them that the perfect vision they had when they were 18 years old is not going to return. Pre-operatively, we have to make them accept that idea, and we have to explain dysphotopsias and what we can achieve with each type of lens. Dr. Yogi: First I tell them that their near vision is going to improve in the next weeks as long as they practice some exercises for near and interme- diate vision, like crosswords. I give them exercises to do. The other thing is that I implant a lens in the non- dominant eye first, to achieve better near vision, and the next week I implant the IOL in the dominant eye, to get better distance vision. Then for special requests like reading, I make it clear to them that their vision is going to improve as weeks go by, and I make sure they understand the impor- tance of the exercises I give them. Dr. Lindstrom: The visual acuity results at near definitely get better with time, and we've had the opportunity to use a vision training program called RevitalVision [Lawrence, Kan.] that's helped some of those patients achieve better performance at near. We've 6 March 2012 Advancements in accommodating IOL technology: A global perspective

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