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- In general, I consider patients with exfoliation syn-

drome or exfoliative glaucoma to be poor candidatesfor multifocal IOLs. Patients with glaucoma are poorcandidates for multiple reasons including reducedcontrast sensitivity, risk for progressive visual fieldloss limiting acuity, ocular surface disease due tomedication use, and a possible need for eventualfiltering surgery and subsequent change in cylinderor axial length. This patient carries a risk for glaucomadevelopment; however, with no evidence of disease atage 78 years, I would not consider glaucoma as thelimiting factor in IOL selection.

Concerns regarding zonular stability and pupil sizearemore significant issues for this patient. Both IOL tiltand decentration have a marked impact on opticalquality with multifocal IOLs. With an average lifeexpectancy of approximately 10 years, a 78-year-oldpatient with exfoliation syndrome who currently hasno evidence of phacodonesis has an increased lifetimerisk for IOL decentration and tilt. Less than 1.0 mm ofdecentration can have a marked impact on opticalquality with refractive IOLs and diffractive IOLs.If the patient's optical biometry results from the firstsurgery are accessible, the anterior chamber depth(ACD) could be evaluated, looking for comparisonsbetween the ACD between eyes before the firsteye surgery and relative to current measurements.Unequal ACD measurements before surgery or analtered ACD in the phakic eye after the first set of mea-surements might indicate zonular laxity and be acontraindication to placement of a multifocal IOL atthis time.

Reduced pupil size and function can affect the sur-gery, making it more difficult to make an adequatelysized capsulorhexis and may require mechanical dila-tion, leading to reduced pupil motility after surgery. Asurgically dilated pupil may lead to poorer visualfunction with multifocal IOLs.

For the above-mentioned reasons, I would discussthe long-term concerns of multifocal IOLswith this pa-tient. If she has been fairly independent of spectacleswith her current situation, I would recommend thatshe consider a mildly myopic refractive outcomewith a standard IOL in her left eye, similar to hercurrent refraction. Implantation of multifocal IOLshas been shown to provide good outcomes in patientswho have unilateral cataract. Longer-term risks aside,the patient is likely to have a satisfactory outcomewitha multifocal IOL in the left eye initially based on hercurrent satisfaction with the IOL in the right eye. Ifafter discussion of the risks the patient still desires amultifocal IOL, I would implant the same type ofIOL in her second eye, taking care to make a generouscapsulorhexis and carefully polish the posteriorsurface of the anterior capsule in hopes of reducing

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the risk for capsule phimosis and strain on thezonular fibers. I would not implant a CTR unlessI encountered evidence of poor zonular fibers intra-operatively. Theoretically, a 3-piece IOL design mayprovide better resistance to zonule stretching withcapsule contraction than a 1-piece IOL. I would not,however, change IOL designs for a patient who hasbeen satisfied with the outcome of his or her firstmultifocal IOL.

Barbara A. Smit, MD, PhDSpokane, Washington, USA

- I very carefully consider multifocal IOLs in patientswith exfoliation syndrome; however, I typically avoidthem in patients with exfoliative glaucoma. The mainreason for not using multifocal IOLs in patients whohave existing glaucoma is because of the threat ofreduced contrast sensitivity. I prefer using a CTR inmost patients with exfoliation syndrome, especiallywhen using a 1-piece IOL, because the risk for capsulephimosis seems to be higher and in the event of IOLdislocation, I can suture the CTR to the sclera.

I frankly discuss with patients the risk for IOLdecentration or subluxation and how multifocal IOLsare ideally suited for anatomically pristine eyes. Giventhe lack of phacodonesis and no evidence of glaucoma,I think that it is reasonable to place a multifocal IOL inthis eye. I would use a 5.0 mm capsulorhexis in thiseye, just as I do in standard cataract surgery, with apreference for a 1-piece multifocal IOL with a CTR toallow ideal centration. A prophylactic relaxinganterior Nd:YAG capsulotomy is probably notwarranted, and I would not alter the anterior capsuleunless there were signs of capsule phimosis. If earlyphimosis started to occur, I would immediately usean Nd:YAG laser on the anterior capsule.

The heart of cataract surgery is matching a patient'svisual goals and expectations with the physiologic andanatomic capabilities of his or her eye. As such, I donot advocate implanting multifocal IOLs in patientswith visual field loss. In general, multifocal IOLs arereserved for disease-free eyes. Because this patient hadsuccessful multifocal IOL despite exfoliation, I ammore confident in placing a multifocal in this situation.

My experience has been that multifocal IOLs workbest when 1 is present in each eye. In this case, becausethe manifest refraction is �1.50 D sphere the left eye,I would cover that eye and make sure the patient istruly happy with her vision at distance and nearwith the multifocal IOL. If she is, I think it makes alot of sense to implant the multifocal IOL modelused in the right eye. If she is relying on the left eyefor intermediate vision, I would consider a monofocal

VOL 40, JANUARY 2014

EDITOR’S COMMENT

There was general agreement among our ex-perts in favor of placement of a multifocal IOLin this patient with exfoliation syndrome who ishappy with the multifocal IOL in her first eye.However, each of our consultants stated thatthey do not advocate multifocal IOLs in patientswith manifest visual field loss or in the setting ofzonular instability. There was less consensusregarding the use of a CTR. Slightly more thanhalf the experts would use a CTR in this patientto improve the chances of maintaining goodIOL centration. Each consultant would fashiona capsulorhexis of approximately 5.0 mm. Al-though our experts would use the Nd:YAG laserpostoperatively to make relaxing incisions in theanterior capsule in the event of phimosis, theywould not make primary relaxing incisions atthe time of surgery. Each consultant mentionedthat the patient should be counseled about theincreased risk for IOL decentration or tilt. Despitethese caveats, our experts would favor multifocalIOL implantation in this patient's second eye.Although there seemed to be a general reluctanceto use multifocal IOLs in the setting of exfolia-tion, our experts seemed emboldened by thefact that the patient was happy with the multi-focal IOL placed in the fellow eye by a differentsurgeon.

Thomas W. Samuelson, MDMinneapolis, Minnesota, USA

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IOL targeted at�1.50 D.My preference would bemul-tifocality in both eyes.

John Palmer Berdahl, MDDurham, North Carolina, USA

- I do implant multifocal IOLs in patients with exfoli-ation syndrome, as in this particular case. I typicallyuse multifocal IOLs with a 1-piece design. I do notuse multifocal IOLs in patients with manifest visualfield loss because I am concerned it might decreasecontrast sensitivity further in glaucoma patients. I donot mix and match multifocal IOLs and monofocalIOLs. I would place a multifocal IOL in the left eye inthis patient.

I do not routinely use a CTR in exfoliation unlessI see evidence of zonular weakness intraoperatively.I am not sure there is evidence that a CTR is necessaryin this elderly patient without phacodonesis.

When counseling patients preoperatively, I typicallydescribe a host of potential complicationswith cataractsurgery in patients with exfoliation. These includepossible difficulty dilating the pupil and that zonularsupport may be less than ideal, which could lead tovitreous loss and difficulty centering an IOL in thecapsular bag.

During surgery, I try to make the capsulorhexis abit larger than usual. At the end of the case, if I am con-cerned that the capsulorhexis is too small, thus creatinga risk for capsule phimosis, I make several radial tearsin the capsulorhexis edge with microscissors.

Leon W. Herndon Jr, MDDurham, North Carolina, USA

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VOL 40, JANUARY 2014