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Presbyopia-Correcting Intraocular Lenses: Too Great to Be True?

There is no best intraocular lens, but matching a patient with the lens that best satisfies their requirements can help in reducing postoperative dissatisfaction.

Two brand-new researches on presbyopia-correcting intraocular lenses (PC-IOLs) highlight the demand for individualized patient management, consisting of careful patient selection and excellent physician/patient communication.

Cataract surgical treatment has evolved into lens-based refractive surgery, with the choice of lens that is transplanted being an important attribute of the surgery, as well as individuals who go with premium lenses (usually multi-focal) agree to pay more – generally about $2000 to $3500 extra per eye – to attain their best spectacle-free vision,” stated an ophthalmologist.
Make note:
– A study researching patient dissatisfaction with presbyopia-correcting intraocular lenses (PC-IOLs) revealed that one of the most typical complaints were blurred or unclear vision, usually triggered by residual refractive error and dry eye.
– Patient satisfaction with PC-IOLs might be enhanced by careful patient selection, identification as well as pre-treatment of ocular surface problems, and also patient/physician communication, especially about the benefits as well as disadvantages of different lenses.
– A brand-new toric PC-IOL, the very first choice in mono-focal toric IOLs for patients with astigmatism, might be an alternative for selected patients looking for a broader range of spectacle-free vision without night-time glare, according to a current study.
“Although the technology for these lenses is constantly advancing, currently diffractive lens technology provides a range of vision at the price of contrast/focus,” clarified the doctor.
So what takes place when a patient with a premium lens is not pleased with the results?

Client dissatisfaction with PC-IOLs: reasons as well as solutions
The ophthalmologist and her team took on a retrospective review of patient documentation (49 individuals; 74 eyes) of patients who consulted them with vision complaints after undertaking PC-IOL implantation. The most usual grievance was blurred or cloudy vision, for both distance as well as near, occurring in 68% of eyes; residual refractive error (57%) as well as dry eye (35%) were the other most usual reasons for these concerns.

“The majority of patients were inevitably dealt with through a range of conventional procedures as opposed to complex surgeries, in conjunction with excellent communication between the doctor and patient and also reassurance from the entire team of the treating doctor,” discussed the doctor. In 46% of patients, refractive error was resolved with glasses or contact lenses; 24% were treated for dry eye; 8% went through corneal laser vision correction; and also 7% had an IOL exchange procedure. These interventions resulted in complete resolution of symptoms in 45% of patients, however 23% were just partly satisfied and 32% remained entirely disappointed.
“When patients are disgruntled, it is helpful to seek a consultation in order to provide the patient with reassurance, as to the outcomes and if possible, re-treatment surgery alternatives. Ultimately, any kind of disgruntled client can be helped most successfully through interaction as well as providing peace of mind,” claimed the doctor.
So what can the clinician do to ward off or manage suboptimal results? The ophthalmologist noted, “Patient dissatisfaction is still rather uncommon, however preoperative screening and precise measurements paired with efficient communication is crucial.” She suggested the following guidelines:
Select patients carefully: “In our series, 20% of eyes had pre-existing pathology that might have made the surgeon reconsider implanting a PC-IOL, and look for other treatment alternatives which could be more beneficial, and also 8% had intraoperative complications with similar thought processes about alternatives that need to have made the specialist rather consider a mono-focal lens,” stated the doctor. Individual preferences are additionally crucial. “With many alternatives for IOLs with different focal-point as well as side-effect accounts, we require to understand our patients as well as lead them or cajole them or gently guide them through the procedure of themselves making the choice (with our help and assistance of course) which is most ideal for their lifestyle as well as concerns.”
Identify and also pre-treat ocular surface problems: “Dealing with ocular surface condition and also detecting other pre-existing conditions that might influence outcomes is crucial. Detecting and also dealing with dry eye preoperatively protects against ocular surface disease from being viewed as a complication of surgery,” described the doctor.
Establish reasonable expectations: “Have an honest discussion about the risks as well as advantages of various lens options.”

Selecting a lens for astigmatism
“There is no single best implant for every single patient,” said another ophthalmologist, noting the relevance of picking a lens that matches each patient’s individual objectives and expectations.
Another doctor recently reported on a toric PC-IOL, the very first option to mono-focal toric IOLs for patients with astigmatism that have a need for a broader range of vision.

“The toric PC-IOL allows decreased dependence on corrective lenses or eye glasses, and additionally as icing on the cake, without the night-time glare typically related to multifocal lenses,” she said.
In a retrospective research of 40 eyes (31 individuals) utilizing intraoperative wave front aberrometry guidance, 1 month after implanting the IOL properly counteracted astigmatism (refractive cylinder minimized <0.50 D in 97.5% of eyes) as well as offered exceptional uncorrected distance (20/25 or far better in 95%) and also uncorrected intermediate vision (20/25 or better in 95%), without the need for glasses, and functional uncorrected near vision (20/40 or better in 92.5%).

The ophthalmologist stated that this real-world research consisted of individuals that would certainly have been ineligible for the U.S. Food and Drug Administration (FDA) clinical trial of this lens, and yet end results of the patients in her research study were “comparable if not better” than that of the people in the FDA test. Around one-quarter of the ophthalmologist’s patients had a problematic ocular background, including a history of irregular corneal astigmatism, previous refractive surgical treatment, macular pathology, or previous vitrectomy.

The ophthalmologist connected the excellent end results in these more complex patients to reliable biometry, topography, as well as wave front guidance measurements as well as the preoperative treatment of ocular surface condition.

“Assisting the patient with astigmatism, decide between a mono-focal toric or non-toric IOL and a toric-correcting presbyopic lens needs full disclosure of the benefits and also downsides of each,” discussed the doctor.
“The risk of glare is marginal with the toric-correcting presbyopic lens, and this is a huge benefit for patients who drive around a lot in night-time,” she claimed. “It is also ideal for patients that want excellent distance and also intermediate vision and also want to use glasses for their reading vision. She adds that the toric presbyopic lens can be implanted if the patient has a mono-focal lens or a natural lens in the other eye. “It likewise has advantages for patients who may have difficulty adjusting to multifocal lenses, which is a single pair of lenses for near, intermediate and far vision and also patients with macular pathology. (Age-related macular degeneration (AMD) is an eye disease that may get worse over time and is the leading cause of severe, permanent vision loss in people over age 60. It happens when the small central portion of your retina, called the macula, wears down in some individuals with age.)”
On the other hand, the doctor cautioned, “The toric-correcting presbyopic lens does not provide as great near vision as some of the multifocal lenses as well as there might be a propensity to develop fibrosis that might cause a Z pattern, where the lens can move in its position. This is a relatively rare event as well as there are numerous things the doctor can do intraoperatively and also postoperatively to reduce risk of this fibrosis.” She included that,” Since the toric-correcting presbyopic lens is a silicone lens, I would most likely avoid it in someone with a background of detachment, as it may cause unwelcome injury and unintended damage.”
“I typically ask the patient to finish a survey regarding their vision objectives which gives me a good idea of what they are expecting, and then I have an honest discussion with the patient regarding the advantages as well as negative or adverse aspects or disadvantages of each lens”, the doctor noted.
“The success with cataract surgery relies on an extensive and precise preoperative analysis, to figure out any pre-existing issues likely to affect the surgery, biometry, reviewing as well as dealing with pre-existing conditions preoperatively (which we had found out earlier), patient education as to expectations and reality as well as treatment (which of course is paramount), and also establishing practical assumptions about the various lens choices available,” she ended.

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