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Patients with challenging presbyopia may do well with accommodating lens


Las Vegas-Some candidates for cataract and refractive surgery are easygoing about their visual expectations, whereas others can be demanding. For those individuals who desire a full range of vision-distance, intermediate, and near, but who are likely to be highly intolerant of reduced visual quality or night-vision disturbances-an accommodating IOL (crysta-lens, eyeonics inc.) may be the best option, explained D. Michael Colvard, MD, FACS, during the American Academy of Ophthalmology annual meeting here.

Dr. Colvard, assistant clinical professor, University of Southern California, provided an example of a 72-year-old patient who was referred for presbyopic correction. The optometrist who made the referral warned that this retired mechanical engineer was "a difficult customer" who was never satisfied with his glasses and required numerous remakes. During his preoperative meeting with Dr. Colvard, this patient took extensive notes. He had moderate hyperopia with mild astigmatism.

"This is the type of fellow who would be likely to be happy with a multifocal IOL," Dr. Colvard explained, "but, based on my positive experiences with the [accommodating lens], I didn't hesitate to perform bilateral . . . procedures with mini-monovision, and the result was an entirely happy individual."

In addition, multifocal IOLs are associated with a higher incidence of halos and glare during night-time. According to FDA submission data, 23.2% of patients receiving an apodized diffractive lens (AcrySof ReSTOR, Alcon Laboratories) reported moderate halos versus only 5.7% of accommodating IOL recipients. In addition, 7.2% of the patients in the apodized-lens group complained of severe halos versus only 3.4% of the group receiving the accommodating lens. Glare was also a problem in the apodized-lens patient population, with 23.3% experiencing moderate symptoms and 4.3% having severe symptoms, compared with only 5.7% and 1.1% in the accommodating lens group, respectively.

Numerous advantages

Implantation of the crytalens has many advantages, Dr. Colvard said, including:

"The [accommodating lens] is much more forgiving of small residual refractive errors," Dr. Colvard said. "This is not always the case with multifocal lenses."

A drawback of the accommodating IOL is that the full accommodative effect takes time to develop. Some patients do not experience the "wow" factor immediately after implantation. Patients may take several months after the procedure to experience the full accommodative effect, but they tend to be quite satisfied long-term, he said.

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