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7 usually aim for the predicted spherical equiv- alent that I want, even if I know there will be astigmatism. Mixed astigmatism protocols work well with current excimer lasers. Our patients have high expectations, so we need to be prepared to provide occasional enhancements. References 1. Packer M, Chu YR, Waltz KL, et al. Evaluation of the aspheric Tecnis multifocal intraocular lens: one-year results from the first cohort of the Food and Drug Administration clinical trial. Am J Ophthalmol. 2010; 149(4):577–584. 2. Hoffmann PC, Hütz WW. Analysis of biometry and prevalence data for corneal astigmatism in 23,239 eyes. J Cataract Refract Surg. 2010; 36(9):1479–1485. Dr. Hardten practices with Minnesota Eye Consultants, Minneapolis. He can be contacted at drhardten@mneye.com. surgeon. We must have a backup plan for the 15 to 20% of patients with residual refractive error. Conclusion Laser vision correction improves visual out- comes after implantation of presbyopic IOLs when patients have residual refractive errors. I able to obtain an accurate wavefront and use wavefront-guided LASIK or PRK. As a cataract surgeon, you must decide whether you will implant presbyopic or toric IOLs. If you provide this option, you will need to manage astigmatism and residual refractive error with relaxing incisions, laser vision cor- rection, or co-management with a refractive Among those who received the multifo- cal +2.75 D add IOL, 98% of patients reported that they could function comfortably without glasses at intermediate and far distances, and 95% had 20/40 or better near vision with- out glasses. Ninety-seven percent said they would have the same IOL again, though—as before—no enhancements were performed for astigmatism or residual spherical error and A constants were not yet optimized. Customizing lens selection Practice demographics, geographic differences, and patient lifestyles influence IOL powers. I have now implanted several hundred of these IOLs; approximately three-quarters have the +2.75 D add; approximately 20% have the +3.25 D add; and approximately 5% have the +4.0 D add. After I have ruled out ocular pathology and determined that patients are good can- didates for the technology, I ask if they wish to see well without glasses, and most respond that they do. I ask them a few visual demand lifestyle-related questions (e.g., computer use, night driving, preferred reading distance), which guide my IOL choice. I review the ben- efits expectations and I share the anticipated side effects and safety information. I also emphasize bilateral procedures. In addition, I stress what to expect afterward, which is very important. Even with the +2.75 D add, I explain that they should expect halos and glare, even though I find that with that lens, the amount of halos and glare is only slightly higher than with a monofocal lens. To achieve success, it is important to under promise so that you can over deliver. Dr. Assil is medical director and chief executive officer of the Assil Eye Institute, Beverly Hills and Santa Monica, Calif. He can be contacted at info@assileye.com. Figure 2. Patients' ability to function comfortably without glasses 6 months after bilateral implantation of multifocal IOLs >80% of patients reported an ability to function comfortably without glasses at all distances 81 85.9 94 97.9 97.3 85 97.9 96 90 ZKB +2.75 D N=142 ZLB +3.25 D N=149 ZM900 +4.0 D N=292 Near Intermediate Distance Percent 100 90 80 70 60 50 40 30 20 10 0 " The most common reason for patient dissatisfaction after implantation of presbyopic IOLs is residual refractive error. " continued from page 5 Clinical outcomes

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