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Presbyopia correction after previous refractive laser and cataract surgery
1230
CONSULTATION SECTION: REFRACTIVE
Presbyopia correction after previous refractive laser and cataract surgery Edited by Rudy M.M.A. Nuijts, MD, PhD An-Katrien de Brauwer, MD
A 70-year-old woman had laser in situ keratomileusis (LASIK) for hyperopia in the right eye in 2004, after which there was regression of the refractive effect. Because of this, the patient refused to have hyperopic LASIK in the left eye. In 2011, she had cataract surgery in the right eye with implantation of a monofocal intraocular lens (IOL). The patient was referred to us in December 2012 with reading difficulties and dissatisfaction with the LASIK result in the right eye, which bothers her when playing golf and the piano. She requested further surgery in the right eye and to have a multifocal IOL implanted in the left eye. The uncorrected (UDVA) and corrected (CDVA) distance visual acuities in the right eye were 20/30 and 20/16 with +1.25 1.00 95, respectively. The UDVA and the CDVA in the left eye were 20/50 and 20/20 with +2.75 0.50 95, respectively. Examination showed a plate-haptic IOL with a neodymium:YAG (Nd:YAG) capsulotomy in the right eye and nuclear sclerosis in the left eye. There was some punctate staining in both inferior corneas for which the patient used artificial tears. On fundoscopy, the right eye had a posterior vitreous detachment and the left eye was unremarkable. The patient uses a daily-wear disposable contact lens in the left eye in combination with reading glasses of +3.0 diopters (D). The right eye is the dominant eye, and the patient prefers to use no distance correction for this eye. After extensive counseling, we advised the patient to try monovision first and prescribed a daily-wear disposable contact lens of +4.25 D for the left eye. The patient is satisfied with the reading vision but still reports suboptimum distance vision in the right eye. The patient asked to exchange the monofocal IOL for a multifocal IOL. We recommended implantation of a multifocal IOL in the sulcus (a reproducible procedure) that would be eventually followed by multifocal IOL implantation in the left eye.
Michael Amon, MD, PhD Vienna, Austria Initially, if the patient insisted on being spectacle free, I would have recommended an IOL. Depending on the true refractive error in the right eye, I would have calculated the supplementary IOL to achieve emmetropia and would have chosen a multifocal add-on IOL. I would then implant an IOL in the fellow eye using a duet technique.1 Usually, the calculation of a supplementary IOL is straightforward and mainly depends on the patient’s refraction. One might use the R-vergence formula, calculation software, or simply multiply the SE by 1.5 in eyes with
Corneal Scheimpflug topography (Pentacam, Oculus €te GmbH) of the right eye shows keratometry (K) Optikgera values of 44.4 @ 34 and 43.9 @ 124 and a corneal thickness of 503 mm (Figure 1). The K values of a partial coherence interferometry (PCI) device (IOLMaster, Carl Zeiss Meditec AG) were 44.4 @ 30 and 44.2 @ 122, and the anterior chamber depth (ACD) was 4.38 mm. A calculation was made based on the Scheimpflug topography device’s K values and the PCI device’s ACD for implantation of a Sulcoflex 653F multifocal IOL (Rayner Intraocular Lenses Ltd.) using the company’s proprietary Raytrace software. A multifocal +1.00 D IOL would result in an estimated postoperative spherical equivalent (SE) of emmetropia. On May 18, 2017, the patient had a +1.00 D multifocal IOL implanted through a temporal incision. One month postoperatively, the patient was dissatisfied with distance vision because of a myopic surprise; the UDVA and CDVA in the right eye are 20/80 and 20/20 with 1.25, respectively. However, the patient is happy with the near vision, which allows fluent reading of newspapers. Figure 2 shows an anterior segment optical coherence tomography (AS-OCT) image of the multifocal IOL position. Figure 3 shows corneal Scheimpflug tomography of the left eye. What would have been your initial treatment advice to this patient? What is the explanation for the myopic surprise after the implantation of the supplementary multifocal IOL, and could this have been prevented? What would be your current treatment proposal to the patient for the right eye? If you were successful in correcting the refractive error in the right eye, which IOL would you implant in the left eye?
hyperopia or by 1.2 in eyes with myopia. Therefore, the choice of a +1.00 D IOL was appropriate. One explanation for the myopic surprise is that the patient had disease-related intermittent refractive changes (eg, diabetes mellitus); however, if the refraction was stable during all visits, this cause can be excluded. Another explanation is that the myopic surprise could be a result of mislabeling on the IOL packaging, although this would be an exceptionally rare case. Even if I had reservations that this caused the myopic surprise, it would be interesting to check the defocus curve to determine which part of the optic was used for the 1.25 D correction and to determine whether a 1.00 D or a +1.00 D IOL was used. Because the corneal topography was unremarkable, another cause for the myopic surprise might be an 0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.09.005
CONSULTATION SECTION: REFRACTIVE
Presbyopia correction after previous refractive laser and cataract surgery Edited by Rudy M.M.A. Nuijts, MD, PhD An-Katrien de Brauwer, MD
A 70-year-old woman had laser in situ keratomileusis (LASIK) for hyperopia in the right eye in 2004, after which there was regression of the refractive effect. Because of this, the patient refused to have hyperopic LASIK in the left eye. In 2011, she had cataract surgery in the right eye with implantation of a monofocal intraocular lens (IOL). The patient was referred to us in December 2012 with reading difficulties and dissatisfaction with the LASIK result in the right eye, which bothers her when playing golf and the piano. She requested further surgery in the right eye and to have a multifocal IOL implanted in the left eye. The uncorrected (UDVA) and corrected (CDVA) distance visual acuities in the right eye were 20/30 and 20/16 with +1.25 1.00 95, respectively. The UDVA and the CDVA in the left eye were 20/50 and 20/20 with +2.75 0.50 95, respectively. Examination showed a plate-haptic IOL with a neodymium:YAG (Nd:YAG) capsulotomy in the right eye and nuclear sclerosis in the left eye. There was some punctate staining in both inferior corneas for which the patient used artificial tears. On fundoscopy, the right eye had a posterior vitreous detachment and the left eye was unremarkable. The patient uses a daily-wear disposable contact lens in the left eye in combination with reading glasses of +3.0 diopters (D). The right eye is the dominant eye, and the patient prefers to use no distance correction for this eye. After extensive counseling, we advised the patient to try monovision first and prescribed a daily-wear disposable contact lens of +4.25 D for the left eye. The patient is satisfied with the reading vision but still reports suboptimum distance vision in the right eye. The patient asked to exchange the monofocal IOL for a multifocal IOL. We recommended implantation of a multifocal IOL in the sulcus (a reproducible procedure) that would be eventually followed by multifocal IOL implantation in the left eye.
Michael Amon, MD, PhD Vienna, Austria Initially, if the patient insisted on being spectacle free, I would have recommended an IOL. Depending on the true refractive error in the right eye, I would have calculated the supplementary IOL to achieve emmetropia and would have chosen a multifocal add-on IOL. I would then implant an IOL in the fellow eye using a duet technique.1 Usually, the calculation of a supplementary IOL is straightforward and mainly depends on the patient’s refraction. One might use the R-vergence formula, calculation software, or simply multiply the SE by 1.5 in eyes with
Corneal Scheimpflug topography (Pentacam, Oculus €te GmbH) of the right eye shows keratometry (K) Optikgera values of 44.4 @ 34 and 43.9 @ 124 and a corneal thickness of 503 mm (Figure 1). The K values of a partial coherence interferometry (PCI) device (IOLMaster, Carl Zeiss Meditec AG) were 44.4 @ 30 and 44.2 @ 122, and the anterior chamber depth (ACD) was 4.38 mm. A calculation was made based on the Scheimpflug topography device’s K values and the PCI device’s ACD for implantation of a Sulcoflex 653F multifocal IOL (Rayner Intraocular Lenses Ltd.) using the company’s proprietary Raytrace software. A multifocal +1.00 D IOL would result in an estimated postoperative spherical equivalent (SE) of emmetropia. On May 18, 2017, the patient had a +1.00 D multifocal IOL implanted through a temporal incision. One month postoperatively, the patient was dissatisfied with distance vision because of a myopic surprise; the UDVA and CDVA in the right eye are 20/80 and 20/20 with 1.25, respectively. However, the patient is happy with the near vision, which allows fluent reading of newspapers. Figure 2 shows an anterior segment optical coherence tomography (AS-OCT) image of the multifocal IOL position. Figure 3 shows corneal Scheimpflug tomography of the left eye. What would have been your initial treatment advice to this patient? What is the explanation for the myopic surprise after the implantation of the supplementary multifocal IOL, and could this have been prevented? What would be your current treatment proposal to the patient for the right eye? If you were successful in correcting the refractive error in the right eye, which IOL would you implant in the left eye?
hyperopia or by 1.2 in eyes with myopia. Therefore, the choice of a +1.00 D IOL was appropriate. One explanation for the myopic surprise is that the patient had disease-related intermittent refractive changes (eg, diabetes mellitus); however, if the refraction was stable during all visits, this cause can be excluded. Another explanation is that the myopic surprise could be a result of mislabeling on the IOL packaging, although this would be an exceptionally rare case. Even if I had reservations that this caused the myopic surprise, it would be interesting to check the defocus curve to determine which part of the optic was used for the 1.25 D correction and to determine whether a 1.00 D or a +1.00 D IOL was used. Because the corneal topography was unremarkable, another cause for the myopic surprise might be an 0886-3350/$ - see frontmatter http://dx.doi.org/10.1016/j.jcrs.2017.09.005