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Preop patient counseling, choice of lens key for those who desire spectacle independence


Bellville, Cape Town, South Africa-The Tecnis multifocal lens (Advanced Medical Optics) is effective and safe and provides excellent distance and near visual outcomes. Preoperative patient counseling is imperative as well as careful biometry, meticulous reproducible surgery, and astigmatic neutral surgery, all of which are keys to the success of the procedure, according to Johann Kruger, FRCS.

"Patients who undergo cataract surgery often desire not to have to wear reading glasses after the surgery. This is becoming more common and careful consideration of the choice of the IOL is required," Dr. Kruger said.

He pointed out that the newer generation of IOLs and improved surgical techniques have resulted in improvement in the surgical outcomes, which has renewed the interest in this technology. Dr. Kruger is in private practice in Bellville, Cape Town, South Africa.

The Tecnis IOL has a prolate anterior surface, which produces sharper vision compared with spherical IOLs, he said.

Dr. Kruger also emphasized patient selection.

"The patient is actually selected for the lens, that is, patients who desire spectacle independence and the patients with cataract or who are presbyopic with minimal cataract changes. Patients with unrealistic visual expectations were not included," he explained.

In addition, patients with macular pathologies, uncontrolled diabetes or retinopathy, abnormal pupils, keratoconus, irregular corneas, or recurrent inflammatory ocular disease were excluded, as were those with a history of a previous refractive surgery. The target refraction in these patients was 0.25 to 0.75 D.

In addition to correct patient selection, Dr. Kruger also emphasized the use of topography in the surgical planning to avoid inducing astigmatism, because multifocal IOLs perform better for astigmatism of less than 0.75 D. The Holladay II formula is used for accurate IOL power determination.

Other factors that he considers important preoperatively are a discussion of the potential for the development of glare and halos and postoperative emmetropia, with the possibility of postoperative LASIK or lens exchange.

"To receive this lens, the patient must be willing to undergo a secondary procedure," he stated.

All patients underwent the same procedure using WhiteStar technology (AMO). A 3.0-mm incision was made and standard phacoemulsification was performed followed by meticulous cortical cleanup and polishing of the posterior and anterior capsules, Dr. Kruger said.

"The anterior rhexis should be intact, the lens in the bag, and the capsulorhexis round, central, and covering the optic circumferentially. We generally use a 5-to 5.5-mm capsulorhexis," he explained.

Dr. Kruger reported the results from 50 consecutive eyes. The patients ranged in age from 48 to 79 years (average, 61.5 years).

"The preoperative uncorrected distance visual acuity was a mean of 0.38. The postoperative mean uncorrected distance vision was 0.83. The preoperative best-corrected visual acuity (BCVA) was 0.8 and the postoperative BCVA was 0.97. The preoperative uncorrected visual acuity (UCVA) at 40 cm was a mean of 0.2 and postoperatively it was a mean of 0.77. The postoperative best-corrected distance visual acuity at 40 cm was 0.20. The postoperative uncorrected unilateral intermediate visual acuity was 0.25," he reported.

Distance, near acuity

All patients achieved 20/40 uncorrected distance visual acuity, greater than 90% had 20/30, and 35% had 20/20. All patients had 20/40 uncorrected near visual acuity, 95% had 20/30, and 30% had 20/20.

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