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5 by Kerry Assil, MD Expanding the scope of presbyopia-correcting IOLs with low add power Low add multifocal IOL options enable surgeons to deliver personalized visual results M ultifocal intraocular lenses (IOLs) with low adds now allow clinicians to provide a full range of outstanding vision, with en- hanced performance at distances tailored to each patient's lifestyle. Multifocal options Although the +4.0 D add is excellent for near work such as reading or knitting, we need to encourage these patients to be a bit tolerant and to experiment with different mechanics to help with intermediate work (Figure 1). The +3.25 D add, which is ideal for activities at longer reading distances, such as with multimedia work, solves this to a great degree and reduces halos. These symptoms further decrease with the +2.75 D add, which is geared for intermediate activities such as using a desktop computer or shopping and makes it very comfortable for people to work at arm's length or closer. Figure 1. New multifocal IOL options Least halos +4.0 D Near vision related activities such as reading or knitting +3.25 D Activities at longer reading distances such as multimedia work Less halos +2.75 D Intermediate activities; table top computer or grocery shopping A full range of vision, personalized to each patient's lifestyle Enhancement options include IOL rota- tion, laser vision correction, IOL exchange, or limbal relaxing incisions. "The first and foremost thing that you need to do with these patients is rule out organic or iatrogenic disease," he said. Surgeons should check for ocular surface disease, subtle basement mem- brane dystrophies, other irregular astigma- tism, surgically induced astigmatism, posterior corneal astigmatism, extremes of axial length, and IOL tilt (Figure 2). If surgery was performed more than 2 years ago, Dr. Kieval chooses laser vision correction. When it has been less than 2 weeks, however, he monitors the patient. If the capsule is open, he performs laser vision correction. He also examines whether the IOL is at the intended axis or an unintended axis and recommended the Toric Results Analyzer developed by John Berdahl, MD, and David Hardten, MD (astigmatismfix.com) for guidance. He rotates the lens if the postrotation spherical equivalent will be less than 0.5 D. If not, surgeons may consider laser vision correction or IOL exchange, he said. If final cylinder is not less than 0.5 D, surgeons need to find out why, ruling out iatrogenic disease, and consider laser vision correction or IOL exchange. "If you follow a systematic approach, you can really enhance patients' satisfaction and your success with toric lenses," Dr. Kieval said. Dr. Mah can be contacted at Mah.Francis@ scrippshealth.org, and Dr. Kieval can be contacted at jkieval@lexeye.com. continued from page 4 When you look at U.S. Food and Drug Administration data for +4.0 D, +3.25 D, and +2.75 D add multifocal IOLs, more than 80% of patients reported they could read at near, intermediate, and distance (irrespective of spe- cific near add power) without glasses (Figure 2). These results are all the more impressive when considering that the studies didn't allow for enhancement. High patient satisfaction was reported with multifocal +3.25 D and +2.75 D add IOLs, which are referred to as the lower adds. More than 93% of patients said they would opt for the same lens again. These IOLs delivered excellent visual outcomes at near and binocular distance, with a J1 mean uncorrected near visual acuity and 20/20 mean uncorrected distance visual acuity. With the multifocal +3.25 D add IOL in particular, at least 96% reported that they were comfortable without glasses at interme- diate and far distances. Furthermore, 94% said they would choose the same technology again, despite the fact that astigmatism was not corrected and A constants were not yet optimized. Therefore, one can most likely view these as baseline results. Ninety-nine percent of patients had 20/40 or better near vision without glasses. continued on page 7

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