Presbyopia Correction: Exploring Surgical Eyeworld January 2017 Eyeworld September 2016 Options, Expectations, and Postoperative Error

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Presbyopia 365 Curriculum Presbyopia correction: Exploring surgical EyeWorld January 2017 EyeWorld September 2016 options, expectations, and postoperative error

Describing the stages of presbyopia: Understanding its onset and progression by Daniel Durrie, MD

their colleagues and patients about the normal phases of crystalline lens change that With new diagnostic tools, occur with aging. When we “ review the stages of dysfunc- we can show patients the tional lens syndrome (DLS), we not only describe the way color, appearance, and density the lens changes but can correlate these changes with of the lens and how they treatments that are most ap- affect vision. propriate at each stage.1,2 ” –Daniel Durrie, MD Illustrative analogy During human embryon- New terminology ic development, a piece of When we explain this to ectodermal tissue splits off to DLS stages gains momentum in our patients, they understand Patients usually enter stage become the crystalline lens. ophthalmic practices it well. Previously, patients 1 of DLS at an average age of Consequently, it ages simi- knew their eyes changed 43. In stage 1, the lens is clear larly to the skin. As disulfide new three-stage during middle age and that and colorless, but the lens los- bonds accumulate inside the classification cataracts may develop later, es the ability to change power. lens through all three stages, system is helping but no one explained how the As a result, most patients have the lens loses flexibility and cataract surgeons lens was changing. density increases. A communicate with continued on page 2

Accreditation Statement Designation Statement Food and Drug Administration (FDA) or have Rosa Braga-Mele, MD, FRCSC, is a member This activity has been planned and imple- The American Society of Cataract and been approved by the FDA for specific uses of the speakers bureaus of Alcon Laborato- mented in accordance with the accreditation Refractive Surgery designates this enduring only. ries and Allergan. requirements and policies of the Accredi- materials educational activity for a maximum Daniel Chang, MD, has an investment inter- tation Council for Continuing Medical Edu- of 1.0 AMA PRA Category 1 Credits.™ Physi- ADA/Special Accommodations est in Omega Ophthalmics. He has received cation through the joint providership of the cians should claim only credit commensurate ASCRS and EyeWorld fully comply with the a retainer, ad hoc fees, or other consulting American Society of Cataract and Refractive with the extent of their participation in the legal requirements of the Americans with income from: Abbott Medical Optics, Allergan, Surgery (ASCRS) and EyeWorld. ASCRS is ac- activity. Disabilities Act (ADA) and the rules and Carl Zeiss Meditec, Mynosys Cellular Devices, credited by the ACCME to provide continuing regulations thereof. Any participant in this and Omega Ophthalmics. Dr. Chang has medical education for physicians. Claiming Credit educational program who requires special received expense reimbursement from and is To claim credit, participants must visit accommodations or services should contact a member of the speakers bureaus of Abbott Educational Objectives bit.ly/2gVjCDk to review content and down- Laura Johnson at [email protected] or Medical Optics and Carl Zeiss Meditec. He Ophthalmologists who participate in this load the post-activity test and credit claim. All 703-591-2220. has received research funding from Abbott activity will: participants must pass the post-activity test Medical Optics and Mynosys Cellular Devices. • Accurately describe the progressive with a score of 75% or higher to earn credit. Financial Interest Disclosures Daniel Durrie, MD, has an investment inter- diagnosis of presbyopia and the optical Alternatively, the post-test form included in John Berdahl, MD, has earned a royalty est in, has received expense reimbursement fundamentals of correction options, uti- this supplement may be faxed to the number or derived other financial gain from from, and has received a retainer, ad hoc fees lizing the appropriate current terminology indicated for credit to be awarded, and a Imprimis and Ocular Surgical Data. He has or other consulting income from AcuFocus, of presbyopia to describe all stages of the certificate will be mailed within 2 weeks. an investment interest in DigiSight, Omega Alphaeon, and Strathspey Crown. He has disease state When viewing online or downloading the ma- Ophthalmics, and Vision 5. Dr. Berdahl has received research funding from AcuFocus, • Compare and contrast presbyopia terial, standard internet access is required. received a retainer, ad hoc fees or other con- Alcon, Allergan, Avedro, and EyeGate Pharma. treatment options to match solutions to Adobe Acrobat Reader is needed to view the sulting income from: Abbott Medical Optics, Dr. Durrie has received expense reimburse- patients’ needs, and describe range of materials. CME credit is valid through June Alcon Laboratories, Avedro, Bausch + Lomb, ment from Avedro and Hoopes Durrie Rivera vision functions as related to patients’ 30, 2017. CME credit will not be awarded Calhoun Vision, ClarVista, DigiSight, Enviseo, Research. needs after that date. Glaukos, Imprimis, Ocular Therapeutix, Staff members: Kristen Covington and Laura • Implement a lower threshold for accept- Omega Ophthalmics, Ocular Surgical Data, Johnson have no ophthalmic-related financial able pseudophakic refractive error levels Notice of Off-Label Use Presentations Vision 5, and Vittamed. He is a member of interests. in presbyopia-corrected patients, and This activity may include presentations on the speakers bureaus of Glaukos and Ocular Supported by an unrestricted identify steps to mitigate refractive sur- drugs or devices or uses of drugs or devices Therapeutix. educational grant from Abbott prises and other key variables to increase that may not have been approved by the postoperative success Medical Optics 2 3 Presbyopia correction: Exploring surgical options, expectations, and postoperative error

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23-year-old lens 48-year-old lens 55-year-old lens Stage 1 DLS Stage 2 DLS

Figure 1. The first two stages of dysfunctional lens syndrome difficulty reading up close, significant change in corne- In stage 3, which usually Optometrists frequently while a minority may struggle al curvature from refractive occurs at an average age of 73, appreciate this tool when with distance vision, depend- surgery. patients have a cataract. The explaining lens changes to ing on which layers in the Stage 2 occurs in patients only treatment at this stage patients. lens change. in their 50s and 60s, when is lens replacement, which is Three surgical presby- the lens becomes yellow and covered by insurance once a References opia-correcting options are slightly clouded, with high- cataract has been diagnosed. 1. Durrie DS. Dysfunctional lens available during this stage. er-order aberrations. Patients syndrome. 2016 American Academy Blended vision or monovision require more light to read, Diagnostic technology of Ophthalmology annual meeting, LASIK has been the standard. and their night vision is not With new diagnostic tools, we Chicago. If a patient is a good LASIK as good. can show patients the color, 2. Waring GO IV, et al. Use of dysfunc- candidate, correcting the When I explain this stage appearance, and density of tional lens syndrome grading to guide dominant eye for plano and to patients, they often smile the lens and how they affect decision making in the surgical cor- the non-dominant eye for and nod, reassured to know vision. We take a slit lamp rection of presbyopia. 2016 ASCRS• –1.0 to –1.25 D has achieved DLS is a normal process and photograph of the lens and ASOA Symposium & Congress, New satisfactory results. Almost why it is occurring. perform a dilated examination Orleans. 100% of my presbyopic pa- In refractive practices, on a rotating Scheimpflug 3. Yılmaz OF, et al. Intracorneal inlay tients with myopia, moderate the most common stage 2 camera system for anterior to correct presbyopia: long-term hyperopia, or astigmatism treatment is RLE because segment analysis. This shows results. J Cataract Refract Surg. who plan to have LASIK to the patient’s optical quality lens density changes. 2011;37:1275–1281. achieve spectacle indepen- has decreased. We can still We also use an optical 4. Whitman J, et al. Through-fo- dence choose this option. perform LASIK monovision or quality analysis system, which cus performance with a corneal In addition, two corneal blended vision, but patients provides the optical scatter in- shape-changing inlay: one-year inlays have been approved need to know it will not last dex, demonstrating decreased results. J Cataract Refract Surg. by the U.S. Food and Drug long term and they eventually vision quality.5 2016;42:965–971. Administration to treat pres- will require lens replacement. 5. Cochener B, et al. Correlational byopia.3,4 They are designed At this stage, optical Conclusion analysis of objective and subjective for patients who still have a quality is no longer adequate Anyone can use DLS terminol- measures of cataract quantification.J clear lens. for corneal inlays. However, ogy to describe lens changes Refract Surg. 2016;32:104–109. If patients in stage 1 have we can perform RLE without and available treatment op- +3.0 D or greater hyperopia, removing inlays from patients tions. However, all clinicians Dr. Durrie is founder of Durrie most surgeons consider refrac- who have them. Following and staff in a practice need to Vision and the Durrie Vision tive lens exchange (RLE) in patients 10 years after inlay be trained about these stages Research Center, Overland Park, this age group. If we perform procedures, I have found that to ensure that everyone is Kansas, and clinical professor LASIK on a patient with +4.0 they still have good vision, using the same language. of ophthalmology, University hyperopia, years later cat- but eventually we will need to Practices should share of Kansas, Overland Park. He aract surgery may be more replace their lenses. this information with their can be contacted at Ddurrie@ complicated because of the optometric referral networks. Durrievision.com. 2 3

Supported by an unrestricted educational grant from Abbott Medical Optics

Surgical options for presbyopia correction

by John Berdahl, MD

We use accommodating IOLs for patients who do not have a pristine ocular system, such as those with mild macular degeneration, mild glaucoma, or corneal irregularities, or patients whose profession makes minimal amounts of glare intolerable (Figure 1). I explain that the accommodating IOL will reduce their need for spectacles, but they will need glasses for fine, up-close reading.3 Surgeons need to share In addition, accommodating IOLs are associated with a the complete range small amount of variability in of possibilities with spherical outcomes because Figure 1. Insertion of Crystalens accommodating IOL presbyopic patients the effective lens position is slightly less predictable.4 visual needs, based on their 2. Whitman J, et al. Treatment of Extended depth of focus profession, hobbies, and other presbyopia in emmetropes using a o make the most of IOLs are also a bit more toler- activities. shape-changing corneal inlay: one- an expanding range ant of small irregularities in Although many of us are year clinical outcomes. Ophthalmolo- of presbyopia-cor- the eye.5 I prefer to use a low uncomfortable discussing pro- gy. 2016;123:466–475. recting technologies power multifocal or extend- cedures or technologies that 3. Mesci C, et al. Visual performances and deliver the visual ed depth of focus IOL in the are not covered by insurance, with monofocal, accommodating, outcomesT patients expect, it dominant eye and a medi- we should not hesitate to cov- and multifocal intraocular lenses in is important to understand um power multifocal with er the full range of options, patients with unilateral cataract. Am J the benefits and limitations approximately a 3.0 D add in just as any physician would Ophthalmol. 2010;150:609–618. of each. the non-dominant eye. In my for a medical condition. That 4. Potvin R, et al. Toric intraocular lens experience, this approach has is our duty as physicians. Sur- orientation and residual refractive Treatment alternatives provided good distance vision geons who are uneasy discuss- astigmatism: an analysis. Clin Oph- Two intracorneal inlays have in both eyes and a good range ing costs should delegate this thalmol. 2016;10:1829–1836. been approved by the U.S. of near vision, helping most task to a staff member. 5. Cochener B, et al. Clinical outcomes Food and Drug Administra- of my patients achieve com- of a new extended range of vision 1,2 tion to correct presbyopia. plete spectacle independence. Conclusion intraocular lens: International Mul- These are generally appro- To deliver optimal out- Presbyopia correction has ticenter Concerto Study. J Cataract priate for that sweet spot of comes, it is critical to precisely evolved to a point where sur- Refract Surg. 2016;42:1268–1275. a new presbyope, who is in correct astigmatism during geons can achieve very good, 6. Abdelghany AA, et al. Surgical stage 1 of dysfunctional lens surgery and treat residual predictable outcomes, but it is options for correction of refractive syndrome (DLS), without astigmatism. Two presbyopic not yet perfect. Patients need error following cataract surgery. Eye signs of a cataract. toric IOLs are available to to know all of their options, Vis (Lond). 2014;1:2. For patients in stage 3 of treat astigmatism. Residual and surgeons need to develop DLS, I use monovision and astigmatism must be treated enhancement strategies to Dr. Berdahl is in private practice mini-monovision only in with astigmatic keratotomy or provide optimal outcomes. at Vance Thompson Vision, those who have responded an excimer laser.6 Sioux Falls, South Dakota. well to monovision contact References He can be contacted at lenses or LASIK. If patients Tailoring treatment 1. Dexl AK, et al. Long-term outcomes [email protected]. have not had monovision in To select the best treatment after monocular corneal inlay implan- the past, we cannot perform a for each patient, surgeons tation for the surgical compensation contact lens trial once a cata- need to understand patients’ of presbyopia. J Cataract Refract Surg. ract has been diagnosed. 2015;41:566–575. 4 5 Presbyopia correction: Exploring surgical options, expectations, and postoperative error

Addressing expectations for range of vision and visual quality by Daniel Chang, MD

length and where he or she prefers to hold devices and As industry continues to reading materials. Subjective- “ ly, factors such as the patient’s provide good options, surgeons personality, profession, and hobbies should be considered. are better equipped to find the These factors help create a picture of what patients hope best set of tradeoffs to satisfy to achieve with presbyopia- correcting surgery, particularly our patients. with respect to their past and ” –Daniel Chang, MD present visual experience. They also help me to counsel Refractive lenses, in- patients. This is my oppor- vision and a slight decrease in cluding the cornea and lens, tunity to make sure their intermediate vision. However, Emerging technology induce chromatic aberration. expectations are reasonable. this reduces contrast sensitiv- Since chromatic aberration is presents new I explain what the surgery ity and increases night vision additive, surgeons should se- opportunities to offers, without overpromising. symptoms. Reducing the add lect IOL materials that induce power decreases the depth of reduce aberrations as little chromatic aberration Optimizing outcomes field slightly while improv- as possible. Low- and mid-in- ing night vision symptoms. he goal of pres- Since extending depth of dex materials tend to have Even though low-add multi- byopia-correcting focus can compromise visual better chromatic aberration focal IOLs have similar visual surgery is to increase quality, it is important to opti- properties, and some IOLs quality as traditional multifo- patients’ range of mize aberrations when cor- induce less chromatic aberra- cals, they are now a popular vision while main- recting presbyopia. The cor- tion than the human lenses option. tainingT good visual quality. nea has spherical aberration, they replace, resulting in a net With monofocal and even Tradeoffs in visual quality and which is typically positive (av- reduction in the eye’s chro- multifocal IOLs, we only have night vision symptoms should erage +0.27 µm), so surgeons matic aberration after cataract one or two points of focus, always be considered when should correct that with a surgery. respectively, where vision is correcting presbyopia, but negative spherical aberration To maximize visual qual- best. Therefore, with these advances in technology have IOL, which will minimize the ity, surgeons need to choose IOLs, we must nail the target provided more and better spherical aberration of the eye an IOL that will compensate for far, and we have to choose options for patients. to maximize visual quality for corneal spherical aberra- the near focal point (if any) To achieve patient sat- (Figure 1).1 If the cornea has tion and minimize chromatic preoperatively. isfaction, surgeons not only positive spherical aberration, aberration. In contrast, an extended need to set patients’ expec- IOLs with positive spherical depth of focus IOL provides tations, but also choose lens aberration will induce greater Seeking balance continuous vision for far designs and materials that will spherical aberration overall. When correcting presbyopia, (driving and watching tele- meet patients’ needs. Furthermore, minimizing IOLs need to balance the three vision) through intermediate chromatic aberration can be areas of visual quality, depth (computer and dashboard) more important than spher- Patient selection of field, and night vision into near (reading and smart- ical aberration.2,3 Significant and counseling symptoms. Reducing spherical phones).4 There is a func- chromatic aberration in When selecting patients and chromatic aberrations tional range of vision that an IOL affects all patients, for presbyopia correction, maximizes visual quality, helps meet the range of vision preventing the colors of light surgeons should consider but increasing depth of field needs for patients whose from focusing sharply on the objective factors such as the decreases visual quality, result- modern lifestyles involve retina (Figure 2). The patient’s patient’s preoperative refrac- ing in night vision symptoms the use of computers and visual acuity may be 20/20, tive error, cataract severity such as glare, halos, and star- tablets—even if the refractive but vision will not appear and type, ocular surface qual- bursts. Traditional higher-add outcome is a little off. sharp, particularly in low-con- ity, macular health, and even multifocal IOLs provide good The currently available trast situations. the patient’s height and arm depth of field, with good near extended depth of focus IOL 4 5 Supported by an unrestricted educational grant from Abbott Medical Optics

Maximizing visual quality Until IOLs provide true Spherical Aberration accommodation, there will always be tradeoffs. Visual quality should be considered primarily, but the balance of depth of field and night vision symptoms should also be taken into account. As industry continues to + = provide good options, surgeons are better equipped to Positive Negative Zero find the best set of tradeoffs to SA SA SA satisfy our patients. With an expanding range of options, we can help more patients to Cornea Lens Eye make presbyopia a thing of the past. Spherical aberration decreases image quality References Figure 1. Minimizing spherical aberration maximizes image quality. 1. Chang DH, et al. Intraocular lens optics and aberrations. Curr Opin Ophthalmol. 2016;27:298–303. Chromatic Aberration 2. Zhao H, et al. The effect of chromatic dispersion on pseudophakic optical performance. Br J Ophthalmol. 2007;91:1225–1229. 3. Negishi K, et al. Effect of chromatic Mid Index aberration on contrast sensitivity in Low Dispersion pseudophakic eyes. Material = Arch Ophthalmol. 2001;119:1154–1158. 4. Cochener B, et al. Clinical outcomes of a new extended range of vision IOL materials affect Dispersion + Chromatic Aberration intraocular lens: International Mul- ticenter Concerto Study. J Cataract Dispersion Refract Surg. 2016;42:1268–1275.

High Index 5. Pepose JS, et al. A prospective High Dispersion randomized clinical evaluation of 3 Material = presbyopia-correcting intraocular lenses after cataract extraction. Am J Cornea IOL Eye Ophthalmol. 2014;158:436–446. 6. Jardim D, et al. Asymmetric vault of Figure 2. IOL materials affect the chromatic aberration of the pseudophakic eye. an accommodating intraocular lens. J Cataract Refract Surg. 2006;32:347– 5 uses diffractive technology Hyper-aspheric and pinhole vision is limited. It does not 350. to improve visual quality by designs are under investiga- provide spherical aberration actively correcting chromatic tion as well. correction, and its chromatic Dr. Chang is in private prac- aberration, so the depth of The current generation aberration properties are not tice with Empire Eye and Laser field can be extended while of IOLs labeled as “accom- particularly good. Additional- Center, Bakersfield, California. maintaining visual quality modating” provides far and ly, predictability and long- He can be contacted at dchang@ comparable to a monofocal. intermediate vision, but near term positional stability in the empireeyeandlaser.com. eye are concerns.6 6 7 Presbyopia correction: Exploring surgical options, expectations, and postoperative error

After the fact: Mitigating and managing postoperative error by Rosa Braga-Mele, MD, MEd, FRCSC

Time invested in preop assessment reduces risk of postop surprises

urgeons need to take a two-pronged approach to address refractive surprises after presbyopia-cor- Srecting procedures—perform- ing meticulous preoperative assessments and developing strategies to manage postoper- Figure 1. Surgeons should look for dry eye and multiple variable K readings. Dry eye or epithelial basement membrane ative errors. disease should be treated before proceeding, and measurements should be repeated to assess corneal astigmatism.

Preoperative protocols topography to help assess the variability in preoperative Furthermore, macular op- Careful patient selection is corneal surface and look for measurements and affected tical coherence tomography is key when implanting toric or ocular surface disease. Any IOL calculations.3 Epithelial recommended if there is any presbyopia-correcting IOLs.1,2 dry eye should be treated basement membrane disease question of macular health The first step is to per- before other preoperative should be treated or presby- and to rule out macular form corneal topography to measurements are performed. opia-correcting IOLs should disease, such as an epiretinal assess corneal health (Fig- Epitropoulos et al. reported be avoided in these patients. membrane or macular edema. ure 1). I prefer Placido disc hyperosmolarity increased 6 7 Supported by an unrestricted educational grant from Abbott Medical Optics

For every patient who increase dysphotopsia, halo, will receive a toric or pres- and glare. byopia-correcting IOL, it is There are a number of important to have accurate ways to correct postoperative Chair time before surgery biometry, with measurements errors.5 For large IOL-based er- “ from an immersion A-scan rors, a lens exchange may be will decrease a surgeon’s chair and an optical biometer necessary. If small astigmatic device. Also, as stated before, errors occur, surgeons can per- time after surgery. corneal topography is import- form limbal relaxing incisions –Rosa Braga-Mele,” MD, MEd, FRCSC ant to validate K readings. or astigmatic keratotomy at It is important when the slit lamp or with a fem- implanting toric IOLs to tosecond laser. Surgeons also consider the effect of posterior can perform LASIK or PRK. I If surgeons take this 4. Donnenfeld ED, et al. Cyclosporine corneal astigmatism and per- usually avoid piggyback IOLs time, fewer postoperative 0.05% to improve visual outcomes haps utilize the Barrett Toric because of risks of glaucoma surprises will develop and after multifocal intraocular lens Calculator (ascrs.org). or bleeding, although these more patients will be happy implantation. J Cataract Refract Surg. To determine each pa- risks are small.6 with their procedures because 2010;36:1095–1100. tient’s needs and expectations Surgeons also should their expectations are set and 5. Alio JL, et al. Enhancements after from surgery, we also perform consider that some patients surgeons are more likely to cataract surgery. Curr Opin Ophthal- a mini personality survey. may prefer to wear a slight meet them. mol. 2015;26:50–55. corrective lens for driving 6. Iwase T, et al. Elevated intraocular rather than having a second Managing postop error References pressure in secondary piggyback in- procedure. I usually wait at least 6 to 8 1. Braga-Mele R, et al. Multifocal traocular lens implantation. J Cataract It is important to discuss weeks before defining post- intraocular lenses: relative indi- Refract Surg. 2005;31:1821–1823. all these options and their operative error because the cations and contraindications for IOL may shift or tilt and the associated risks with your implantation. J Cataract Refract Surg. Dr. Braga-Mele is professor patients facing a postoperative cornea may be healing. Post- 2014;40:313–322. of ophthalmology, University surprise and together make an operative dry eye can change 2. Visser N, et al. Toric intraocular of Toronto, and director of informed decision. the refraction by 0.75 D, so it lenses: historical overview, patient cataract surgery, Kensington must be treated. In research selection, IOL calculation, surgical Eye Institute, Toronto. She can by Donnenfeld et al., cyclo- Conclusion techniques, clinical outcomes, and be contacted at rbragamele@ sporine 0.05% treatment in Chair time before surgery will complications. J Cataract Refract rogers.com. eyes receiving multifocal IOLs decrease a surgeon’s chair Surg. 2013;39:624–637. increased visual quality and time after surgery. Surgeons 3. Epitropoulos AT, et al. Effect of 4 decreased signs of dry eye. need to take adequate time tear osmolarity on repeatability of I tolerate 0.5 D of myo- for preop assessments, closely keratometry for cataract surgery pia, hyperopia, or astigmatism examining the cornea, identi- planning. J Cataract Refract Surg. with a presbyopia-correcting fying other ocular disease, and 2015;41:1672–1677. IOL. Errors exceeding 0.5 D setting patients’ expectations must be treated because they to a reasonable level. 8 Presbyopia correction: Exploring surgical options, expectations, and postoperative error

To take this test online and claim credit, go to bit.ly/2gVjCDk or complete the test below and fax, mail, or email it in. CME questions (circle the correct answer)

1. Which of the following is not part of dysfunctional lens syndrome? A. Disulfide bonds increasing in the lens B. Increase in higher order aberrations C. Loss of accommodation D. Increased transparency

2. A 65-year-old woman with arthritis has decreased vision and burning, itchy, and occasionally watery eyes when using the computer. She has a clinically significant cataract and desires spectacle independence postop. What is the FIRST step you should take to determine the best IOL choice? A. Perform corneal topography to assess ocular health B. Start artificial tears on the symptomatic patient C. Educate the patient on various IOL options D. Sign the patient up for a presbyopia-correcting IOL, since she wants spectacle independence

3. A 62-year-old accountant with cataracts who spends a lot of time on the computer would like to be able to use the computer without wearing glasses but does not mind wearing reading glasses occasionally for small print. Which of the following is most likely to make this patient happy? A. Monofocal IOL set for distance B. High-add multifocal IOL C. Low-add multifocal IOL D. Extended depth of focus IOL

4. Which of the following is not a good option for Stage 2 DLS? a. Refractive lens exchange (RLE) b. Blended/monovision c. Corneal inlays d. Observation without surgery

5. A 64-year-old patient presents with cataract and 1.75 D of against-the-rule astigmatism and hopes to become more independent of spectacles for distance and near after cataract surgery. Which of the following is NOT a satisfactory option? A. Low-power multifocal IOL B. Extended depth of focus IOL with toric C. Accommodating toric IOL D. Multifocal with postoperative laser vision correction

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