Multimodal strategies maximize success with multifocal IOL implantation

Rigorous preoperative evaluation and counseling, meticulous surgery, and thorough postoperative counseling are all critical elements for optimizing outcomes with presbyopia-correcting lenticular surgery. One surgeon shares his four-step approach to excellent functional results and high patient satisfaction.

Dr. Rosenthal discussed issues in multifocal IOL candidate selection and his strategies for enabling excellent functional results and high patient satisfaction using a four-step approach entailing:

Whereas lifestyle factors and patient motivation for spectacle independence traditionally are considered as the primary parameters for judging patient suitability for a multifocal implant, Dr. Rosenthal said that his philosophy expands beyond that "conventional wisdom."

"Further, I have found that socioeconomic, occupational, or age-related considerations are not good selection criteria because a surprising number of patients with limited financial resources are keen to have this technology and willing to pay," he said.

Dr. Rosenthal, therefore, offers a multifocal implant to all patients who are deemed appropriate candidates from an ophthalmic perspective, although those patients are told that the choice is theirs and then they can discuss the options further with patient counselors before reaching a final decision.

"However, I also present this option even to patients who are not candidates so that they understand they have received a full evaluation," Dr. Rosenthal said. "Further, from a medicolegal perspective, I believe surgeons may be required to let all patients know that multifocal IOLs are an available choice, even if it is not something they provide in their own practices, as part of a full informed consent that covers all the IOL options with their risks and benefits, and to make an appropriate referral should the patient express interest in this technology."

In addition to the presbyopia-correcting benefits of multifocal IOL implantation, results of a recent study suggest a novel safety advantage for their selection, he said. That investigation described difficulty adapting to new spectacles among elderly patients accompanied by increased risks for falls and fractures.

"If this study is validated, it would be easy to extrapolate from it that, with multifocal IOLs, we are giving the elderly a safer alternative to monofocal implants and spectacle dependence," he said.

Preop considerations

Part of the focus of the preoperative evaluation is to identify ocular pathology that would limit the potential for a good outcome with a multifocal IOL. In that regard, Dr. Rosenthal noted that he performs posterior segment optical coherence tomography to look for subtle macular and optic nerve pathology that may affect the visual outcome along with confocal microscopic evaluation of the cornea that can help plan the surgical strategy.