Patient Selection – IOLs
October 8, 2011DrHovanesian No Comments »Selecting patients for accommodating vs. multifocal vs. advanced monovision IOLs.
Frequently, I’m asked by colleagues how to choose patients for different presbyopia-correcting lens implant options including multifocal, accommodative and advanced monovision using monofocal lenses. There seem to be as many methods for making this choice as there are surgeons making them. Here is a reasonable approach shared by many surgeons.
The first factor to consider is age. Older patients are more likely to do well with a multifocal IOL because their cataract is already advancing enough that some dysphotopsias are already happening, and if they are even somewhat tolerant of these dysphotopsias, they are not likely to be bothered by the glare or halos from a multifocal implant. Also, these older patients, if they still have normal maculas, are statistically less likely to develop maculopathy in the future. Older patients tend to do less computer work than younger ones, so they may not be bothered if there are limitations of uncorrected intermediate vision. Finally, older patients usually spend less time driving after dark.
The second parameter to consider is a patient’s preoperative refractive error. Low myopes are very accustomed to uncorrected near vision and may be less tolerant of the need for reading glasses with an accommodative lens implant. Hyperopes, on the other hand, are generally happy with any type of lens. Naturally, other parameters must be considered as well, such as prior refractive surgery, presence of glaucomatous optic atrophy, or presence of even mild maculopathy. Any of these would cause us to lean heavily in the direction of an accommodating lens, where image degradation is not worsened by the implant.
Most important of all, however, are the responses patients give on a preoperative questionnaire where they indicate their visual habits and desires. A copy of this questionnaire can be downloaded here, and customized for your own practice. This questionnaire is derived from Steven Dell’s preoperative survey and has been very helpful to us in determining patients’ visual needs. Those who indicate they do a good deal of driving after dark and/or spend significant time on the computer are better suited to an accommodative lens, whereas those with hobbies that involve fine detail work, like sewing, may prefer a multifocal implant.
Finally, a word about monovision: Many surgeons routinely use “advanced monovision,” a term used to describe the full range of services (contact lens testing, topography, screening OCT, postoperative enhancements) beyond simply selecting one eye for distance and the other for near. While advanced monovision can work for cataract patients who have never previously experienced monovision, I generally reserve this option for those who have had some experience with monovision contact lenses, or those who are otherwise highly motivated to use monovision.
Further detail on Jay McDonald’s approach to advanced monovision can be found here.
Naturally, many individual factors can alter our decision making in lens implant selection. No single article can fully describe this process, and we all have our own biases as surgeons. I encourage readers to comment on their own approach to choosing lenses for surgical patients.
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