) - - 79 - - 2,4 (Continued on page on (Continued Analysis of axial power maps and the front:back cor front:back the and maps power axial of Analysis measurements, cylinder analyze to important also is It Figure 1. Corneal tomography maps showing regular (left) and irregular (right) astigmatism. Figure 1. Corneal tomography maps showing regular (left) and Patients with severe irregular corneal astigmatism are not are astigmatism corneal irregular severe with Patients of reproducibility The implantation. IOL toric for eligible by confirmed be can measurements cylinder tomographic astigmatism regular of axis and magnitude the comparing wavefront-derived the and keratometry manual between poste of effect the shown have studies Several value. these making outcomes, visual on curvature corneal rior planning. IOL toric for important measurements neal surface ratio in the sagittal plane allow detection ofdetection allow plane sagittal the in ratio surface neal pertinentespecially is This shape. corneal in abnormalities proceduressurgical refractive of history a with patients in calculation.power IOL influences significantly it because aberrationspherical corneal of measurements Moreover, selec IOL for essential are tomography corneal by provided helpcan measurementsThese counseling. patient and tion extendedan and monofocal a between choice the make andsize pupil on depending IOL, (EDOF) focus of depth aberration.spherical considered. being is IOLs toric of use the if especially or manual a with astigmatism corneal regular Measuring mandato now is It enough. not is keratometer automated decision. right the make to order in HOAs total assess to ry - - - - - This 2,3 column, we discussed we column, | JULY/AUGUST 2018
BY FLORIAN T.A. KRETZ, MD, FEBO; AND IMANE TARIB, MD MD, FEBO; AND IMANE TARIB, MD BY FLORIAN T.A. KRETZ, Five fundamentals to match the right IOL technology to the right patient. technology fundamentals to match the right IOL Five These images help to documentto help images These 1 IN FIVE Corneal tomography is an effective tool totool effective an is tomography Corneal CORNEAL EVALUATION CORNEAL EVALUATION assess corneal optical quality. It provides anprovides It quality. optical assesscorneal Fundamentals in Five in Fundamentals
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ecent advances in premium cataract surgery allow sur allow surgery cataract premium in advances ecent than patients for outcomes visual better achieve to geons forindications expanding to Due past. the in possible was preoperativepatients, of expectations rising and surgery determiningof process the in step crucial a is screening FUNDAMENTALS FUNDAMENTALS Irregular astigmatism greatly affects visual outcomes and outcomes visual affects astigmatismgreatly Irregular In the June the In
FUNDAMENTAL irregular astigmatism and 0.4 µm in moderate irregular moderate in µm 0.4 and astigmatism irregular experience to likely pupil—are 4-mm a for astigmatism postoperatively. quality visual in decrease major a presbyopia-correcting with vision of quality for matters pro optical aspheric the and asphericity for also but IOLs IOLs. monofocal of file screening for this condition is important. Corneal tomogra Corneal important. is condition this for screening astigma irregular of assessment quantitative provides phy (HOAs), aberrations higher-order total of analysis with tism power refractive a with assessment qualitative with along moderate with patients that found have Studies map. mild in µm 0.3 than greater HOAs—values of amounts anterior segment structures. segment anterior patientsto explain to easier it make and opacification lens includegathered data The intervention. surgical for need the astigmatismirregular of presence the as such information cylinder.and aberration, spherical shape, corneal 1), (Figure preoperative Therefore, surgery. after treat to challenging is exhaustive examination of the corneal surface and thickness,and surface corneal the of examination exhaustive ofvisualization for images Scheimpflug display can it and five important factors in choosing the right IOL. In this In IOL. right the choosing in factors important five and surgeon every that factors key five discuss we issue, screen patient preoperative in master must member staff are patients that ensure to counseling and evaluation, ing, surgery. presbyopia-correcting in decisions our with happy the right IOL for the right patient.right the for IOL right the PREOPERATIVE STEPS IN PRESBYOPIC PRESBYOPIC IN STEPS PREOPERATIVE SURGERY CATARACT s R CATARACT & REFRACTIVE SURGERY TODAY EUROPE
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(Continued from page 82) FUNDAMENTAL OCT EVALUATION FUNDAMENTAL SETTING PATIENT Cataract patients EXPECTATIONS 3 generally belong to 2 To determine the the senior population, which means best IOL technology for patients who that they have a relatively high rate desire presbyopic cataract surgery, of associated pathologies, some of it is key to focus on each patient’s which can compromise the outcomes individual lifestyle and needs. Patient of presbyopia-correcting IOL surgery.7 education and counseling helps the Chronic pathologies such as diabetic surgeon to decide which approach retinopathy and glaucoma are well would be best. During this chair time, documented on OCT. Other disor- patients are informed about potential ders that are not clinically visible can outcomes with an emphasis on the also be observed with OCT, such as degree of spectacle independence mild macular edema or a transparent that may be expected, the possibil- epiretinal membrane—either of which ity of dysphotopic phenomena, and can negatively impact the outcomes of the potential need for postoperative presbyopia-correcting surgery. refinements. Additionally, early stages of age- It is important to impress upon related macular degeneration (AMD) patients that presbyopia-correcting can be detected on OCT. When early IOLs offer a wider range of vision com- AMD is detected, patients should be pared to monofocal IOLs because they counseled about possible chronic loss provide multiple foci.5 It is important of vision in their later years after IOL to discuss with patients how their lens implantation (Figure 4). choices will affect their reading habits and the visual tasks required in their FUNDAMENTAL DEALING WITH Figure 2. Halo and glare strength analysis with the profession and daily activities. DYSPHOTOPIC AT LARA 829 EDOF IOL (Carl Zeiss Meditec). Photic phenomena are a possible 4 PHENOMENA side effect with presbyopia-correcting Photic phenomena induced by the promising with regard to the reduction lenses, and patients must be edu- optical designs of presbyopia-correcting of dysphotopic phenomena.6 cated about this risk by showing IOLs are often the first dissatisfaction There are also so-called mix-and- them images that illustrate halos and reported by patients after premium match approaches, in which two differ- glare around light sources in differ- cataract surgery.6,8 These phenomena ent types of IOL are used. These have ent scenarios, such as driving a car at should be discussed before surgery. been reported to result in remarkable night (Figure 2). Fortunately, this side Explain to patients that each optical rates of satisfaction, with significantly effect is rare and often disappears design has a different pattern of photic reduced frequency of dysphotopsia after a period of neural adaptation. In phenomena, and show patients images complaints by patients.9 In a small case worst-case scenarios, surgery can be from simulators to gauge their tolerance series of older cataract patients, we reversed and a multifocal IOL can be in the event these phenomena occur found that the rate of photic phenom- exchanged for a monofocal. However, after surgery (Figure 2). Although it is ena in patients binocularly implanted it is important to remember that not often discussed, monofocal IOLs can with a rotationally asymmetric EDOF monofocal IOLs can also cause halos also cause dysphotopsia, depending on IOL with 1.50 D depth of focus at the and glare.6 Patients must understand their aspheric optical profiles and espe- IOL plane resulted in rates of halos and these possibilities preoperatively so cially if corneal aberrations are not taken glare comparable to those in patients that they have realistic expectations. into account.6 implanted with a monofocal IOL.10 In our practice we have learned that, In bilateral presbyopia-correcting IOL with diffractive IOLs, patients need to surgery, when patients are motivated FUNDAMENTAL TAKING ACCOUNT know that they could experience halos but undecided about their tolerance of OF ASSOCIATED as a result of the optical profile of the dysphotopsia, the surgeon can implant 5 DISORDERS lens (Figure 3). A simple explanation one IOL in the nondominant eye and In order to avoid pitfalls in pre- can result in a happy doctor with let the patient decide if he or she mium cataract surgery, it is important a functional outcome and a happy still wants the same IOL in the other to conduct an exhaustive ophthal- patient who knew what to expect. eye. The latest generation of IOLs is mic examination to determine the
JULY/AUGUST 2018 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 79 - Asia Pac J Arq Bras J Cataract J Cataract . 2015;8(2):92-96. n US Ophthalmic Review 2018;9(5):248-256. 2014;28(3):164-167. EC Ophthalmology. . 2014;40:313-322. Saudi J Ophthalmol. 2017;6(4):339-349. J Cataract Refract Surg 2012;38(12):2080-2087. . 2009;35(6):992-997. . 2015;78(4):241-245. Finally, a history of previous infection or inflammationor infection previous of history a Finally, correc presbyopia especially and surgery, IOL Premium screeningwhen mindful be must we goal, this achieve To Researcher, Augenärzte Gerl, Kretz & Kollegen, Rheine, Germany [email protected] Financial disclosure: Research grant (Carl Zeiss Meditec) CEO and Shareholder, Augenärzte Gerl, Kretz & Kollegen, Ahaus, Germany Lead Surgeon, Augentagesklinik, Rheine and Greven, Germany Research Coordinator, IVCRC.net, Department of Ophthalmology, University of [email protected] Financial disclosure: Consultant (Alimera, Carl Zeiss Meditec, Glaukos, MicroSurgical Bausch + Lomb, Carl Zeiss Meditec, Glaukos, Johnson & Johnson Vision, Oculentis, Bausch + Lomb, Carl Zeiss Meditec, Glaukos, Johnson & Johnson Vision, Oculentis, Polytech, Teleon, Vision Ophthalmology Group); Research (AcuFocus, Advanced Vision Science, Carl Zeiss Meditec, Glaukos, Hoya, Johnson & Johnson Vision, Lensar, Mediphacos, Oculentis, PhysIOL, Polytech, Santen, Teleon) Heidelberg, Germany Technology, Oculentis, Polytech, Vision Ophthalmology Group); Honoraria (Alimera, IMANE TARIB, MD n n n parameter is only one step in finding the right solution forsolution right the finding in step one only is parameter dailyand habits patients’ our of aspect subjective The them. role. important more even an plays routine 1. Loh J. Importance of performing corneal topography before cataract surgery. indications and contraindications for 2. Braga-Mele R, Chang D, Dewey S, et al. Multifocal intraocular lenses: relative implantation. with multifocal IOLs. Paper presented 3. Michelson MA, Myers RA. Corneal higher order aberrations and visual dysfunction 2012; Chicago. at: American Society of Cataract & Refractive Surgery Annual Meeting; April 20-24, to total corneal astigmatism. 4. Koch D, Ali S, Weikert MP, et al. Contribution of posterior corneal astigmatism Refract Surg. depth of focus intraocular lenses. 5. Breyer DRH, Kaymak H, Ax T, et al. Multifocal intraocular lenses and extended Ophthalmol (Phila). with different IOL models and phakic 6. Tarib I, Al-kadhi R, Abdassalm S. Comparisson of visual side-effects in patients Conference of the DGII; February 15-17, patients using the halo & glare simulator. Paper presented at: The 32nd Annual 2018; Leipzig, Germany. undergoing cataract surgery. 7. Moreira CA, Moreira CA, Moreira AT. Optical coherence tomography in patients Oftalmol lens implantation. 8. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after multifocal intraocular Refract Surg satisfaction by combining an enhanced 9. Kretz F, Breyer D, Abdassalam S, et al. Enhancing intermediate vision and patient Meeting of the Asia-Pacific Association of depth of focus IOL and a trifocal IOL model. Paper presented at: The 31st Annual Cataract & Refractive Surgeons; July 19-21, 2018; Chiang Mai, Thailand. bifocal segment intraocular lens in an 10. Tarib I, Kretz F. Benefits of a rotationally asymmetric enhanced depth of focus, older cataract population ranging from 74 to 82 years. with ocular surface disease: an update 11. Afsharkhamseh N, Movahedan A, Motahari H, et al. Cataract surgery in patients in clinical diagnosis and treatment. FLORIAN T.A. KRETZ, MD, FEBO n n n n n to strengthen the cornea and making the incision on theon incision the making and cornea the strengthen to astigmatism.reduce help to axis steep patientsexample, For measures. prophylactic for call may takemust infection virus simplex herpes of history a with preventto order in postoperatively and pre- valaciclovir the compromise would which infection, the of recurrence outcomes.surgical CONCLUSION ourin opportunities amazing most the of one truly is tion, glasseson dependence their of patients Relieving profession. alsoit but vision, their changes only not lenses contact and life.of quality better a them offers potentialon out miss to not order in preoperatively patients objectivean as vision patients’ our of Awareness problems. ------| JULY/AUGUST 2018
In severe forms, DED can cause serious ocular sur ocular serious cause can DED forms, severe In 11 Patients with keratoconus should be examined closelyexamined be should keratoconus with Patients A history of previous refractive surgery may require adapta require may surgery refractive previous of history A Dry eye disease (DED) is one of the most frequently most the of one is (DED) disease eye Dry Figure 4. Chronic loss of vision is possible due to AMD in a patient’s later years Figure 4. Chronic loss of vision is possible due to AMD in a patient’s later years after IOL implantation. Notice the difference in these OCT images of a regular foveal depression (top) and AMD (bottom). Figure 3. Patients can experience halos as a result of the optical profile of diffractive IOLs. lation. Certain procedures may be helpful for patients withpatients for helpful be may procedures Certain lation. surgerycataract before CXL performing as such keratoconus, preoperative measurements only after several weeks of not of weeks several after only measurements preoperative thatmeasurements false avoid to order in lenses, their wearing orthokera use who Patients results. postoperative affect can discontinuedof period longer even an require lenses tology performed. are measurements diagnostic before wear lens calcu power IOL complicates deformation corneal because DED is mandatory prior to surgery to ensure patients’ post patients’ ensure to surgery to prior mandatory is DED outcomes. good and satisfaction operative steps,andsurgical methods, calculation power IOL of tion Additionally, results. optimal achieve to treatment follow-up undergomustlenses contact rigid or soft wear who patients preoperative measurements. measurements. preoperative cataractpremium for candidates in conditions encountered surgery. wellnot if and, errors, topographic significant damage, face on blamed falsely be can that outcomes visual poor treated, ofmanagement and diagnosis proper Therefore, surgery. the right candidates for presbyopia-correcting surgery, elimi surgery, presbyopia-correcting for candidates right fine-tune and contraindications, have who those nate CATARACT & REFRACTIVE SURGERY TODAY EUROPE
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