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reading glasses, an even smaller proportion don't think their vision is as good as they were hoping it would be. But they are not so unhappy that they request that something be done about it. For those who do want something done, I can usually manage those patients by making the non-dominant eye more myopic with LASIK. But no one has insisted that I remove the in- traocular lens, whereas I've explanted more than 10 multifocal IOLs over the years because with someone who has intractable halos or fuzzy vision, you have to remove the lens. Advice for beginners Dr. Lindstrom: If a surgeon tells you he/she is thinking about getting started with the Crystalens AO, what would you say to him/her? What pearls would you give to get him/her off to a good start? Dr. Dell: We talked about refractive predictability early on, and every IOL that has ever been manufactured has its effective lens position altered by the size and the regularity of the capsu- lorhexis. If you have a surgeon whose rhexis is different in every case, if it's not a round, regularly shaped, cen- tered rhexis of a constant size, then he needs to get much better at doing that before he begins with the Crystalens AO. Probably the easiest way for most surgeons is to physically mark the cornea over the visual axis with a 5.5- mm marker and trace the circle with the capsulorhexis. They also need to make sure that their surgical technique is such that they have exquisite cortical cleanup. Although capsular breakage rates have gone down in the U.S. in the last several years with better phaco machines and silicone I/A tips, if the surgeon has a substantial percentage of capsular breakage, the Crystalens AO is no longer an option; it might not be worth it for a surgeon who doesn't achieve those goals to begin working with the Crystalens AO. Dr. Lindstrom: Are you using atropine? Dr. Dell: No, I haven't used atropine in a long time. We do, however, use carbachol intraocular solution. We put a few microliters at the end of the case, effectively constricting the pupil for several days and preventing the excursions of movement that we think have to do with variable lens position in the eye. Dr. Lindstrom: I actually do the same. I do not use atropine either, my pa- tients don't seem to like it. I dilute the carbachol 3:1 so patients avoid the brow ache. I bring the pupil down, and the nice thing about it is the "wow fac- tor" because they often see 20/25 and J2 or better on day 1, although they tend to lose a bit of that with time as the miotic pupil returns to normal size. I explain that, but I like the fact that they see fabulously on the first day. Dr. Yogi: I don't use atropine anymore. Regarding the surgery, I would say that there are many variables that may affect the performance of a Crystalens AO, including the incision and the seal- ing of the incision. There have been experienced surgeons who went back to suturing the incision to make sure it doesn't leak. I usually don't suture my incisions, but I have perfected it in terms of avoiding leakage. In terms of polishing the capsule, I do some redundant cleaning with an I/A tip and an instrument to make sure that the capsular bag is as clean as I can get it. I think these key points in terms of performing the surgery are ever-evolv- ing. A surgeon who wants to get into the Crystalens AO must understand that the results, even in his first cases, might not reach his expectations, but can be improved as he gains practice with the surgery. Dr. Fernandez: We need to choose a lens for the patient instead of for the surgeon. Some lenses can provide good outcomes without requiring too much skill with technique, but then you have this lens that many ophthalmolo- gists perceive as being technically more difficult than other lenses to implant, but gives the best results in terms of quality of vision. 10 March 2012 Advancements in accommodating IOL technology: A global perspective

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