This 60 year old patient is seeing you in consultation for cataract surgery. He has a significant posterior subcapsular cataract in each eye and his vision has declined to the point where he cannot drive safely. In our city, Los Angeles, most people require a car for mobility and independence since the city is spread out over a large area and public transportation is not as good as other cities.
For as long as he can remember, he has not worn glasses for most activities. He has been prescribed glasses in the past, but found that he really didn’t wear them much except for driving at night. He is an accountant and spends 8 hours per day on the computer or reading paperwork. His hobby is woodworking.
He has a pair of glasses that are 12 years old and they measure:
- OD: -0.75 -0.25 x 45 giving 20/20 distance vision (at that time)
- OS: -1.75 spherical giving 20/20 distance vision (at that time)
In the pic above you can see that his current refraction is very similar. The printout from our biometer is below:
His surgery should be relatively straightforward and routine, but the difficulty is deciding on the best IOL power and post-op target. What are the options?
- Option A: Plano OU with monofocal IOLs would give the best distance vision, likely better than he has had in many years, but will take away the benefit of his low myopia
- Option B: Plano OU with multifocal IOLs would give good distance and near vision but would produce some level of dysphotopsias, particularly at night
- Option C: Plan OD / -1.75 OS with monofocal IOLs would give better distance vision than he has had and would maintain his near vision, but his is more anisometropia than he is used to
- Option D: -0.75 OD / -1.75 OS with monofocal IOLs would give him about the same refraction that he’s used to, but we lose the opportunity to improve his distance vision
Given these options, which would you choose? Or perhaps there is another option that you prefer? Please give your response in the comment section below.
In case you’re wondering, I have chosen option D with a plan for a +22.0 D IOL OD (-0.75 target) and +23.0 D IOL OS (-1.75 target). My thinking is that this will make him the happiest and it is what he is used to. He does not mind wearing glasses for driving, but wishes to be able to do his computer work and desk work without glasses.
Option D is probably the best choice for me.
The reason being the post op refraction matches the old glasses the patient has been using mostly for night driving for a long time. With cataract removed he probably would be driving with the same old glasses with ease. At 60,he probably will be more happy with this.
We think alike. Thanks for the input.
What if both the eyes are made myopic by 1 D.
that is also an option. It would give both eyes an optimal focus point of 1 meter which would be great for computer range (desktop computer), but it would limit the closer vision a bit more.
thanks for the input
Dr. Devgan said he is an accontant, and work with a PC 8 hours a day. And he drives home at night as many multifocal iol users.
yes, good points
Before Reading your option you chose, i would make the same choice. Because this patient is used to perform his daily activities without glasses, it would make a huge difference to wear glasses for nearly all nearby activities.
The important point of this case is listening to the daily habits of a person in order to make the right choice. It is not so important of what the doctor wants, but a good explanation of the options is mandatory. In the end was your patient happy with the outcome?
yes the patient was happy with the outcome
I would indicate a difractive Trifocal IOL for this patient. Much less disphotopia compared with the bifocal one. And he could read at computer distance without glasses. If this lens is not available or possible, I’d give the options to him, with pros and cons of them. Another interesting option is a mini-monovision. RE -0.25, and LE -0.50 or -0.75. With this lenses he could have a nice vision for far and intermediate (computers), and for near, an 80% of independence of glasses. Thanks for the possibilty to give my opinion.
thank you for the excellent points. The USA still does not have a trifocal IOL available yet. Ultimately, you are right, best to discuss in detail with the patient.
how would you usually decide on which is the dominant eye in your clinic please?
Thanks
The visual outcome and patient satisfaction with the trifocal IOLs will encourge me to advice it for this patient
sounds like a good option
Sir he is driver by profession..so multifocal is stict no..I think your option D is ok..
again, no right or wrong answers here. we just want to tailor our choices to the patient
Hi, very nice case, thank you for sharing it. I would choose a trifocal plano in both eyes. But if they are not available in your country, I have no doubt that the option D that you choose is the best choice, and the patient will be very happy with the outcame.
thanks for the input. sounds like a good plan. hopefully we will get the new trifocal IOL designs in the USA soon.
Once available, will make a world of difference for spectacle independence. Here in India, the trifocal and EDOF lenses are benefitting many like in Europe. And early yag cap by 6 months.
Bifocals still have not gone out of use. Early yag cap helps in my most difficult patients.
Talking out of a small number of 70 odd patients. But happy ones.
Combining with femto laser centration of rhexis also helps, to get the visual axis right.
thank you for the important feedback. I look forward to having these IOLs available for our patients in the USA
I am an eye surgeon who has the same problem, my right eye is -0.50 D my left eye is -1.75 D, I only wore glasses driving at night I always used microscope loops at “0” in my surgeries. 4 months ago, vivity toric iol was implanted, my right eye was emetropia my left eye was chosen -0.75, I am doing my operations without glasses, I have 100% near&mid&far vision without glasses, in this patient I would choose for near and far vision independent of glasses as much as getting a cataract, I would probably set the dominant eye for the emetrope non-dominant eye myopic. For this I would choose OD +21.00 OS+22.00