Cheryl Guttman Krader, BS, Pharm

Cheryl Guttman Krader is a contributor to Dermatology Times, Ophthalmology Times, and Urology Times.

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Strategies lead to positive outcomes in tough cases

This article was reviewed by Ken K. Nischal, MD


	
	Findings from studies investigating the efficacy and safety of corneal collagen crosslinking (CXL) for keratoconus in pediatric-age patients and developmentally delayed adults and the consequences of leaving their ocular disease untreated provide a solid base of evidence for offering CXL to these populations, according to Ken K. Nischal, MD.

“In the United States, CXL is only approved for the treatment of progressive keratoconus in patients from 14 to 65 years of age, and so it may not be offered to younger children even if indicated,” said Dr. Nischal, professor of ophthalmology and chief, Division of Pediatric Ophthalmology and Strabismus, University of Pittsburgh Medical Center, Pittsburgh, PA. 
	
	

Corneal collagen crosslinking imperative in paediatric keratoconus 

Keratoconous is not uncommon, with incidence rates reported up to 265 per 100,000 patients. 

Unfortunately, disease onset tends to be in early adolescence, and these younger patients are at risk for rapid progression and a lifelong visual disability. 

Dr. Nischal said his take on the issue is that technology should be for those who cannot advocate for themselves or who are the most vulnerable. 

“Those individuals are the children and developmentally delayed adults,” he said, “In fact, there is mounting evidence that CXL should be offered to children at presentation rather than waiting for progression.”
	
	

Keys to assessing true crosslinking outcomes 


	Several published studies demonstrate that keratoconus progresses at a rate that is much faster in children than in adults and that CXL arrests disease progression in pediatric patients, said Dr. Nischal. 

Discussing some of these papers, he cited a study by Chatzis and Hafezi that reported a progression rate of 88% after one year of follow-up in a series of 59 eyes of 42 children awaiting CXL for keratoconus.

Another study by Leon-Mesplie et al. showed that children who did not have CXL for keratoconus had a sevenfold increased risk of requiring a keratoplasty compared to adults.

“If you do not want to do CXL in a child, you certainly do not want to have to perform penetrating keratoplasty considering the extra problems that it brings in terms of operative and postoperative issues,” Dr. Nischal said.
	
	

Estimating total corneal power key in keratoconus patients 

Other papers in the peer-reviewed literature show the safety and benefit of CXL for keratoconus in pediatric patients. In what is the largest published study to date, Padmanabhan et al. analyzed data from 194 eyes of 153 children ages 8 to 18 years old that underwent CXL for documented progressive keratoconus.

Of the 194 eyes, 142 had CXL using the standard Dresden protocol and 52 were treated using hypoosmolar riboflavin.

The CXL was associated with keratometric flattening and stabilization of pachymetry during follow-up extending to 6.7 years. Of the total cohort, 59 eyes were followed for longer than 4 years, and reversal of keratometric flattening occurred in 14 (24%) of those eyes. 

“Interestingly, however, the flattening did not correlate with significant changes in vision or corneal pachymetry,” Dr. Nischal said.

Findings from a study by Mazzotta et al. suggest that regression after CXL may be more likely in patients with severe allergy who are eye rubbers.

 These investigators reported outcomes for 62 eyes of 47 patients ages 8 to 18 years who underwent CXL and represents the report with the longest post CXL follow-up for a pediatric population. 
	
	

Traversing the CXL pathway: Where do we go from here?

The outcomes were stable at 10 years in 80% of eyes. A 2 D increase in mean keratometry occurred in four eyes of two patients who had severe ocular allergy and were eye rubbers, but stability was achieved after repeat CXL. No other patients in the series needed a repeat treatment because of CXL failure.

Two papers have reported on performing CXL for keratoconus in developmentally delayed patients.

Dr. Nischal noted that the patients, who often have Down syndrome, already have challenges. 

“Not performing CXL and therefore leaving them to possibly develop hydrops from progressive corneal thinning and lose vision makes their lives and the lives of their families much worse,” he said.
	
	

Doing justice to corneal irregularities 


	Reluctance to perform CXL in children and developmentally delayed adults may be partly due to concern that they will not remain still during a procedure performed using local anesthesia. In addition, children and developmentally delayed adults may not comply with instructions to avoid eye rubbing that not only increases the risk of regression over time but also the chance for infection following the procedure. 

To overcome these problems, Dr. Nischal said that he performs CXL in most pediatric patients and developmentally delayed adults under general anesthesia with a regimen that will result in complete paralysis.

“If there is not complete paralysis, the eye may roll up during the UV light application, leaving me grabbing for forceps to try to hold the eye in place,” he said.

Dr. Nischal said he uses integrated intraoperative OCT (Carl Zeiss Meditec) to assess adequacy of the riboflavin soak. 

An OCT scan prior to the soak allows for baseline evaluation and after the soak there is a visible change in reflectivity on the OCT. The OCT is also used after UV exposure. 
	
	

OCT providing physicians with improved view of ocular surface 

“If I see a clear interface after the UV light application, I know I am going to get a good result, but I do not yet have enough follow-up to know what the outcome is in cases where I cannot see the interface,” he said.

To protect the eye in the early post-treatment period while the epithelial defect is healing, he usually places a temporary central tarsorrhaphy for two days and prescribes topical moxifloxacin six times daily to be applied at the medial canthus. 

“So far, we have not had any cases of infection, and the children seem comfortable with the tarsorrhaphy in place,” Dr. Nischal said.
	
	

Study focuses on HOA measurements in normal keratoconic eyes 

Patients who had CXL elsewhere with placement of a bandage contact lens reported much less pain and discomfort with their second eye procedure using tarsorrhaphy. 

One case involved a developmentally delayed patient whose parents were very frightened about the child tolerating the second eye procedure. 

“The parents reported that with the lids sutured shut, the child did not touch the eye and was very relaxed,” Dr. Nischal said. 

Dr. Nischal is aggressive with treatment for allergic conjunctivitis-related inflammation both pre- and post CXL as a strategy to mitigate eye rubbing. Patients are also referred for behavioral therapy to reduce eye rubbing.
	
	

CXL-LASIK pairing can enhance refractive outcomes 


	Between July 2018 and September 2019, Dr. Nischal performed CXL in 18 eyes of pediatric patients. All cases were done using the standard Dresden protocol. 

Sixteen cases were done using general anesthesia, of which 14 had a temporary tarsorrhaphy placed and two had a bandage contact lens. Eight of the cases involving temporary tarsorrhaphy were in developmentally delayed or non-verbal children. 

Topical anesthesia with post-CXL placement of a bandage contact lens was used in two eyes of healthy teenagers aged 15 years. 

This article is based on a presentation given by Dr. Nischal at the American Academy of Ophthalmology's 2019 annual meeting. He has written an editorial on this topic (Reference #7). Dr. Nischal receives honorarium from Carl Zeiss Meditec, but has no other relevant financial interests to report. 

1. Chatzis N, Hafezi F. Progression of keratoconus and efficacy of pediatric corneal collagen cross-inking in children and adolescents. 

2. Leoni-Mesplie S, Mortemousque B, Touboul D, et al. Scalability and severity of keratoconus in children. 

3. Padmanabhan P, Rachapalle Reddi S, Rajagopal R, et al. Corneal colleagen cross-linking for keratoconus in pediatric patients: log-term results. 

4. Mazzotta C, Traversi C, Baiocchi S, et al. Corneal collagen cross-linking with riboflavin and ultraviolet a light for pediatric keratoconus: ten-year results. 

5. Koppen C, Leysen I.  Riboflavin/UVA cross-linking for keratoconus in Down syndrome. 

6. S abti S, Tappeiner C, Frueh BE. Corneal cross-linking in a 4-year-old child with keratoconus and down syndrome. 

7. Lalgudi VG, Nischal KK. Pediatric corneal collagen cross-linking for keratoconus: not an experimental procedure.

Articles

CXL imperative in treatment of pediatric keratoconus 


Results of an email survey sent to the Glaucoma Research Foundation (GRF) Ambassadors when most states were poised to ease 

 restrictions showed that only three-fourths of the respondents had a plan in place for reopening their offices after stay-at-home orders were lifted.

Judging from write-in responses, whether or not the glaucoma specialists had developed strategies for returning to practice, they were interested in having colleagues share ideas for establishing safety and for optimizing practice efficiency and patient care delivery. They were also keen to receive post 

 patient education and support materials from GRF.

These topics and more were addressed in a virtual GRF Ambassador Round Table on managing a 

COVID-19 safety challenges accelerating welcome changes

​ 

Held on May 8, the discussion was moderated by Andrew Prince, MD, of Glaucoma Consultants of Greater New York & New Jersey, and Andrew Iwach, MD, of Glaucoma Center of San Francisco, and included input from several GRF Ambassadors that showed the clinicians were meeting the new challenges with different approaches; in part, these reflect variations in practice settings.

Recognizing that the pandemic situation will be evolving and that ideas about best practices are likely to change based on actual experience and changing circumstances, the group looked forward to reconvening to share their practical insights and take away new ideas.


Once stay-at-home orders were issued in California, only patients needing emergency care or a postoperative follow-up visit were being seen at the Glaucoma Center of San Francisco. 

In planning for reopening, staff had to review charts to identify patients who should be given priority for an appointment, according to Iwach.

Patients who have an upcoming visit are being contacted by phone and are being screened for 

 symptoms and informed about new processes in the office. The latter include requirements to wear a mask and enter alone unless they need to be accompanied by someone for language or other reasons.



A screening station has been set up at the entrance to the building where patients are checked for fever and 

 symptoms, asked to clean their hands with a hand sanitizer, and given a mask if they did not bring one. 

Changes were made in the office, including removal of magazines, removal and rearrangement of furniture in the waiting area to create proper social distancing, and installation of plastic shields at the front desks.

Iwach and his associate, Terri-Diann Pickering, MD, identified restaurant supply companies and neighborhood hardware stores as good sources for acquiring protective equipment, including plastic shields, hand sanitizers, gloves, and masks.

Prince mentioned that individuals with an Amazon business account can register as a health care professional; then, they will be put on the top of a queue for getting supplies. 

He also noted that in his practice, a solution containing 70% ethanol with hydrogen peroxide and glycerin that comes in large spray bottles is being used with paper towels for surface disinfection and offers a less expensive alternative to disinfectant wipes.



Transitioning back to ophthalmic care during a pandemic

Practices differed in their use of gloves for staff versus frequent hand washing and sanitizing, but all participants agreed that it was critical for patients to witness attention being given to hygiene.

Minimizing patient time in the office was a universal goal. In general, patients are undergoing necessary testing in the office. Oluwatosin Smith, MD, of Glaucoma Associates of Texas, said her practice is looking at establishing a dedicated center for glaucoma testing that would be separate from the rest of the clinic and might be opened for extended hours to meet the pent-up demand for services.

In-office physician–patient interaction is being limited. Patients are mostly being contacted following their visit once the provider has a chance to review the results from the diagnostic evaluations. 

Depending on the need for follow-up, the results may be discussed over the phone or patients may be offered a telehealth or subsequent in-office visit.



Capabilities of telemedicine for ophthalmologists during a pandemic: Part I


The participants agreed that home monitoring of IOP using a self-tonometer suffers from suboptimal accuracy. 

A few have reduced the use of Goldmann applanation tonometry except when they are not able to get an accurate or reliable measurement with other tonometers that are noncontact or involve minimal time up close with the patient.

Davinder Grover, MD, MPH, of Glaucoma Associates of Texas, said that his group is using a noncontact device to measure corneal-compensated IOP in most patients, but a Tono-Pen is used to check IOP of postsurgical patients during the first month of follow-up.

Visual field testing presents a particular concern, given the special care that needs to be taken to avoid damaging the perimeter bowl. Participants felt that guidance on disinfection from the manufacturer lacked clarity, and many were exploring alternative methods for checking visual fields.

Both Grover and Iwach mentioned that their practices are pursuing other methods of perimetry that can be performed with a low risk to the patient, such as virtual reality goggle-type visual field testing.



Putting to practice retina innovations amid a pandemic

Robert Feldman, MD, of the Robert Cizik Eye Clinic, Houston, Texas, said that visual field testing at his practice has been put on hold while the potential to use an ultraviolet (UV)-C lamp for sanitization is being investigated. He noted, however, that the perimeter manufacturer cautioned that UV-C light could damage the equipment.

Prince said that an air purifier was installed in his practice’s testing room.

“While there is no direct evidence yet that filtration works to reduce transmission of the novel coronavirus, it can be assumed from what we know of similar viruses that air purifiers might help in some situations,” he said.

Prince added that, theoretically, if an air purifier removes or reduces the viral load from the air, the potential for exposure is lessened.

“The novel coronavirus itself is 0.125 microns, but the droplets it travels in when people cough, talk, or breathe are around 1 μm,” he said. “That is a size easily captured by air purifiers with HEPA filters.”



In the GRF Ambassador survey, the majority of respondents indicated that they had been using a telemedicine approach to some extent.

Ambassadors participating in the discussion agreed that telemedicine has limitations for following patients with glaucoma.

Certain patient queries can be handled by phone, and a video visit can be helpful for reviewing medication use or for checking whether a red eye in a surgically treated patient is worrisome. 

Patients gain reassurance knowing that a physician has looked at their red eye, and the interaction itself can be a boost for patients who are socially isolated during the pandemic, Iwach said.



The eyes offer conjunctival clue to COVID-19


Steven Vold, MD, in private practice at Vold Vision in Fayetteville, Arkansas, noted that because of the conducive physical setting of his office building, his practice created a “curbside clinic” where patients could be quickly checked for possible progression of their glaucoma.

“We know that compliance with glaucoma medication is an issue, and the concern when patients are not being seen is that some who have moderate-to-advanced glaucoma could be having asymptomatic worsening,” Vold said.

In Vold’s “clinic,” patients remain in their cars and go from station to station for a “visit” that is completed within 5 to 10 minutes. 

After gathering insurance information and then a history, vision is tested with a device like that used at state motor vehicle departments, IOP is measured with a rebound tonometer, and anterior and posterior segment photographs are taken using a retinal camera through a 3-mm pupil.

Patients are contacted by a physician later in the day.

“I am not saying that it is ideal and I am not advocating this approach as a standard of care,” Vold said. “But I can say we have picked up numerous disc hemorrhages and elevated IOPs, and I think we have actually saved vision for some patients.”



Emerging opportunities — and risks — with telehealth in a pandemic



He added that the service has also been a practice builder. Patients who have seen its availability on the practice’s website have traveled as far as 1000 miles to get access to in-person care.

The encounter is charged as a telehealth visit. Before offering the service, the plan was reviewed with the Arkansas Department of Health and Arkansas State Medical Board.


The GRF Ambassadors’ focus is on patient education, and some of the write-in responses on the GRF Ambassadors survey indicated interest in materials that would give patients confidence about the safety of in-office visits and inform them about new processes.

The physicians continue to do their part.

Vold said that his practice has created some videos with those goals in mind, and Smith noted that she is currently working with the Cure Glaucoma Foundation to develop patient information.

Thomas Brunner, president and CEO of GRF, said that GRF is also collaborating with this effort to inform and educate patients.

“Starting in early April with financial support from Industry, GRF began hosting a number of patient webinars and we recently launched a new video series that includes steps doctors are taking to ensure the safety of their patients.” Brunner added. “GRF can play a unique role in supporting both doctors and patients during this extraordinary time.” 


Vold has no financial disclosures related to this content.

Glaucoma Research Foundation (GRF) Ambassadors webinar provides platform for idea-sharing by ophthalmologists

Pearls for practicing in the COVID-19 era

Results of a two-week phase III study demonstrated efficacy of loteprednol etabonate ophthalmic suspension 0.25% found the investigational treatment was well-tolerated and had a favorable safety profile. 

This article was reviewed by Elizabeth Yeu, MD


	
	Loteprednol etabonate (LE) ophthalmic suspension 0.25% (Eysuvis, Kala Pharmaceuticals) met its primary and key secondary endpoints in a third phase III clinical trial investigating the corticosteroid in a 

The LE 0.25% suspension is formulated with a proprietary mucus-penetrating particle drug delivery technology (AMPPLIFY) that improves bioavailability of the active ingredient at the target site. 

Topline results from the phase III study known as STRIDE III showed statistical superiority of LE 0.25% suspension (formerly known as KP-121) compared with vehicle for improving signs and symptoms of 

. In addition, the investigational corticosteroid was well-tolerated and had a favorable safety profile.
	
	

New techniques probed for managing dry eye disease 

Elizabeth Yeu, MD, an investigator in the LE 0.25% studies, is assistant professor of ophthalmology, Eastern Virginia Medical School, Norfolk, VA, and a partner, Virginia Eye Consultants, Norfolk, VA. 

“The results from STRIDE III showing benefit of LE 0.25% suspension for improving both signs and symptoms of 

are quite positive and replicate what was seen in STRIDE I and II,” Dr. Ueu said. “Collectively, these studies enrolled almost 3000 patients, making STRIDE the largest DED clinical trial program to date, and the results indicate that LE 0.25% suspension is a rapid-acting, safe, and effective anti-inflammatory therapy.”

Dr. Yeu added that if approved, LE 0.25% suspension will be an important therapeutic addition for the temporary relief of the signs and symptoms of 

“It is estimated that more than 17 million people in the US suffer from DED and 80% to 90% of those individuals experience flares for which a steroid can be appropriate treatment,” she said. “While eye care providers have used topical steroids to quiesce acute DED flares, we are always cautious about the potential for IOP elevations. It is noteworthy that no patients treated with LE 0.25% suspension in STRIDE III had an IOP increase >5 mmHg leading to IOP >21 mmHg.”

STRIDE III was a multicenter, double-masked study that randomly selected 901 patients 1:1 to treatment four times a day for two weeks with LE 0.25% or vehicle. 

Patients were eligible for study enrollment if they had a documented clinical diagnosis of DED in both eyes and were only randomized to treatment if they still met the study’s eligibility criteria after a two-week run-in period during which they used the investigational product’s vehicle four times a day. 
	
	

Lab tear tests aid reimbursements, clinical application of dry eye 

Using a 0 to 100 mm visual analog rating scale, patients were instructed to record Ocular Discomfort Severity (ODS) daily in a diary. Patients returned for follow-up visits on days eight and 15 after randomization for evaluations that included conjunctival hyperemia, corneal staining, and safety.

The primary endpoint looked at change in ODS score at day 15 in the overall intent-to-treat (ITT) population and in the subgroup of ITT patients with more severe baseline discomfort (ODS ≥ 68 mm). 

STRIDE III achieved both of its independent primary endpoints, demonstrating a statistically significant difference in the LE 0.25% group compared to vehicle in the overall ITT population (

 = .0002) and the subgroup (n = 602) with more severe baseline ocular discomfort (

In analyses of secondary endpoints, LE 0.25% suspension demonstrated statistical superiority for improving conjunctival hyperemia at day 15 (

=.0282), and total corneal staining at day 15 (

Instillation site pain was the most common adverse event in both the LE 0.25% suspension and vehicle groups (2.9% and 1.5%, respectively). No patients in either group experienced an IOP increase >5 mmHg that resulted in an IOP ≥21 mmHg nor did any patient have an IOP increase >10 mmHg.
	
	


	In STRIDE I, LE 0.25% suspension achieved the sign and symptom endpoints and demonstrated rapid and sustained improvement in the ODS score.  In STRIDE II, LE 0.25%  suspension achieved its sign endpoint and showed a significant benefit for reducing corneal staining and for improving the ODS score at day eight.

Kala Pharmaceuticals is working on finalizing resubmission of the NDA for LE 0.25% suspension as a treatment for the temporary relief of the signs and symptoms of DED utilizing a two-week course of therapy. 
	
	

Dr. Yeu is a consultant to and investigator for Kala Pharmaceuticals and is a consultant to and does research for other companies that market or are developing products for the treatment of dry eye.

Investigational topical corticosteroid demonstrates efficacy for dry eye 

The AcrySof IQ PanOptix trifocal IOL delivers a full range of good uncorrected vision, leads to high rates of patient satisfaction, and simplifies surgical counseling and planning. 

This article was reviewed by Cathleen M. McCabe, MD

In August, the FDA granted approval for Alcon to market the AcrySof IQ PanOptix trifocal IOL. Surgeons who are using the lens, which is available in spherical and toric versions, agree that it is an important advance in presbyopia-correcting technology.

Cathleen M. McCabe, MD, chief medical officer, Eye Health America, and medical director, The Eye Associates, Bradenton, FL, said she began using the PanOptix IOL as soon as it became available and estimates that she had already implanted it in several hundred eyes within the first six months. 

“I think PanOptix is the lens we have been waiting for in the United States,” she said. “With the PanOptix, we can actually meet patient expectations for independence from glasses at all distances.”

Dr. McCabe noted that the patients she has implanted with the PanOptix have been very enthusiastic about their outcomes, and they are sharing their experience with family and friends. 
	
	

 Changing focus of accommodating IOLs now reaching a new level

“Happy and satisfied patients build the market and practices too,” she said. “Although the PanOptix has been available for a relatively short time, I am already seeing patients asking for it through word-of-mouth referral.”

In Canada, ophthalmologists have had access to the PanOptix IOL for more than three years. 

Rosa Braga-Mele, MD, MEd, professor of ophthalmology, University of Toronto, Toronto, Ontario, Canada, has been using the lens since it came onto the market in her country and echoed the idea that the lens has benefits for patients and practices.

“Unless we did some mixing and matching or mini-monovision, traditional multifocal 

 and extended depth of focus (EDOF) IOLs had a weakness at some focal point,” Dr. Braga-Mele said. “In contrast, the PanOptix IOL delivers a blended range of vision with good vision at distance, intermediate, and near without glasses.”

Dr. Braga-Mele noted that with the toric version, ophthalmologists can correct a good range of astigmatism.

“Appropriate patient selection and education are still critical, but given that is done, patients are very, very satisfied with their outcome,” she said. “Happy patients are a source for more patient referrals.”
	
	

Performance of trifocal toric IOL highlight in tests 


	Dr. Braga-Mele said that the PanOptix has become her go-to lens for patients wanting presbyopia correction. It is her lens of choice for patients who in the past she would have offered a bifocal multifocal IOL or an EDOF IOL, and she is offering the PanOptix to a broader pool of patients because of its superior range of vision.

Dr. McCabe pointed out that she has years of experience with various multifocal and accommodating presbyopia-correcting lenses, dating back to the days of the ReZoom and first ReSTOR IOLs. 

“I have always tried to find the best solution to match each patient’s needs with the fewest side effects,” she said. “PanOptix is the first lens that gives a useable, functional range of vision.”

With the PanOptix IOL, preoperative counseling conversations with patients have changed for the better. Dr. McCabe observed that in the past she spent a lot of time explaining a variety of options to patients.

“I used to have to say that I could provide technology that would give good uncorrected vision at distance and intermediate and functional vision for near,” she said. “Or, I could offer better near vision with excellent distance vision and ‘okay’ intermediate vision.”
	
	

Light-adjustable IOL technology creates novel treatment window 

As a third choice, Dr. McCabe said she could try to mix and match technologies to achieve a full range of uncorrected vision.

“It’s a different situation now that I can use one lens that predictably gives excellent vision at distance, intermediate, and near,” she said. 

Dr. McCabe also pointed out that in her discussion, she no longer has to distinguish between the intermediate and near focal points or offer surgery with different lenses in fellow eyes. 

“I tell patients that I have a lens that will allow them to see up close without glasses and that gives them independence from glasses for their distance vision too,” she noted. 

Surgical planning is also easier with the PanOptix because it eliminates mixing and matching and adjusting refractive targets. Both Dr. Braga-Mele and Dr. McCabe say they plan for emmetropia bilaterally when using the PanOptix IOL.
	
	

Advanced toric IOL improves refractive outcomes


	Dr. McCabe tells patients that 99% of patients in the FDA trial were so satisfied after surgery with the PanOptix IOL that they would want the same lens implanted again. In her practice, the few exceptions involve cases with a small refractive miss, and those can be solved with a touchup procedure.

“We have excellent technology for accurate biometry and advanced formulas for IOL power calculation, including for toricity. Refractive predictability with the PanOptix IOL has been excellent overall,” she said. 

Dr. Braga-Mele also observed that the refractive outcomes with the PanOptix IOL are predictable. She attributed its performance, in part, to the fact that it is built on the tried-and-true AcrySof IQ platform. 
	
	

Accurate data key for planning toric IOL surgery 

Although Dr. Braga-Mele said that is almost consistently achieving her target of emmetropia, vision outcomes with the PanOptix IOL seem to have some tolerance to residual sphere and cylinder. 

There are some conditions that can impact the results of the

“Patients seem to do well with this lens if they have up to 0.5 D of hyperopia or myopia and up to 0.6 D of astigmatism,” she observed.
	 


	Because the PanOptix IOL is diffractive technology, some patients can still experience dysphotopsias. 

Dr. McCabe says she explains that because the lens has a target-like design, some patients see rings around point sources of light following surgery. She goes on to say that the symptoms are relatively common early after surgery, but by six months, most patients are not bothered by them if they notice them at all. 

“I acknowledge that a very small percentage of patients still consider this issue a problem,” Dr. McCabe pointed out. “Then, patients can decide for themselves if this is a potential compromise they are willing to accept for the benefit of having great vision at distance and near.”

Dr. Braga-Mele said that she also discusses dysphotopsias with patients, but that the PanOptix IOL seems to be associated with a little better profile than bifocal lenses when it comes to halo and glare. 
	
	

Physicians on quest to end dysphotopsias in premium IOLs

Because it splits light to different foci, reduced contrast sensitivity is another issue to consider. Consequently, Dr. Braga-Mele and Dr. McCabe exclude patients as candidates for the lens if they have glaucoma or macular pathology affecting vision now or if there is a real risk for progression.

“If a patient has early diabetic retinopathy, age-related macular degeneration, or glaucoma, I consider the potential for it to worsen over time and reach a level where I think this technology would not have been the best choice,” Dr. McCabe explained. “In that setting, I would not implant the PanOptix IOL or any diffractive presbyopia-correcting lens.”
	 


	Dr. Braga-Mele and McCabe both emphasized the importance of identifying preexisting 

“Like all multifocal IOLs, outcomes with the PanOptix are sensitive to the condition of the ocular surface,” Dr McCabe said. “I look carefully for dry eye and treat it preoperatively because dry eye affects the accuracy of surgical planning as well as quality of vision.”

SHE added that some patients may need additional encouragement and more intensive education postoperatively to maintain management for 

so that the quality of their vision is good. 
	
	

Dr. McCabe explained that when patients express some dissatisfaction postoperatively, which is rare, she has found it helpful to ask if they notice fluctuation of their vision and if it seems better sometimes during the day than others. 

“If patients report fluctuating vision, I use the information to help them understand why a healthy ocular surface is important for good quality vision,” she said.

Dr. McCabe also noted that she explains that the only thing that fluctuates during the day is the condition of their ocular surface. 

“Their observation about fluctuation helps me understand their complaint about their vision and is a sign that if they follow the recommendations for treating their dry eye, their vision will stabilize at its better level,” she said. 

Beyond dry eye, Dr. McCabe and Dr. Braga-Mele look for other ocular surface conditions/corneal pathology and determine whether they can be adequately treated preoperatively or are a reason for not recommending any multifocal 

Dr. Braga-Mele is a consultant to Alcon and Johnson & Johnson Surgical Vision.

Dr. McCabe is a consultant to Alcon, Bausch +  Lomb, Johnson & Johnson Surgical Vision, and Carl Zeiss Meditec.

Author | Cheryl Guttman Krader, BS, Pharm

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CXL imperative in treatment of pediatric keratoconus