Making the Right IOL Decisions

Implantation of a multifocal intraocular lens (MFIOL) or an extended depth of focus (EDOF) IOL in cataract surgery patients having a history of a corneal refractive procedure is a controversial topic given the lack of rigorous evidence to inform the decision. Some published data show that good results are possible, but cataract surgeons should think about a number of issues when deciding if and how to proceed with using a presbyopia-correcting lens in this patient population, said Ruth Lapid-Gortzak MD, PhD.

“There are no randomised clinical trials showing which lens is better after what kind of corneal refractive procedure, and cohort studies show that results of IOL calculation accuracy in eyes with previous corneal refractive surgery lag behind those achieved in untreated eyes,” Dr Lapid-Gortzak observed.

“However, a meta-analysis and systematic review of available retrospective studies evaluating presbyopia-correcting IOLs implanted in post-corneal refractive laser surgery eyes found that the predictability outcomes were not so bad.”¹

In the absence of evidence-based guidelines, cataract surgeons must rely on expert opinion, and Dr Lapid-Gortzak provided her perspective.

Noting two strategies for approaching these cases, Dr Lapid-Gortzak said she favours performing cataract surgery within the limitations of what current practice allows and performing a touch-up when necessary. The alternative involves a staged approach in which corneal sphericity is restored before performing cataract surgery.

“Although the approach I take is not academic, it is practical, has wider applicability, and does not subject all patients to a possibly unnecessary extra procedure that certainly adds cost and risk.”

Regarding IOL selection, optical design is one of the main considerations, and data indicate diffractive IOLs offer better image quality than those with refractive or asymmetric optic technology.² Asphericity is also important as available evidence indicates visual quality is better when eyes with a history of laser vision correction surgery for myopia are implanted with a negative spherical aberration (SA) IOL; eyes with hyperopic correction likely will do better with an SA-neutral IOL.

Dr Lapid-Gortzak also outlined several ocular-related factors to consider when evaluating patient candidacy for a presbyopia-correcting IOL. Attention should be paid to tear film regularity and cornea surface, as it should for any patient wanting a presbyopia-correcting lens. With that in mind, Dr Lapid-Gortzak advised against implanting an MFIOL or EDOF IOL in eyes with a history of conductive keratoplasty or radial keratotomy, given their irregular topography. She also suggested proceeding with caution in high myopes (axial length >26 mm) and eyes ablated for >5 D myopia or >2 D hypermetropia.

Furthermore, surgeons should look for signs predicting a high likelihood of patient dissatisfaction.

“Judge how well patients understand what they are told in the informed consent, beware of men in the 40- to 50-year-old age range who have good uncorrected distance vision for far because they think everything is seen at arm’s length, and beware of patients in the midst of a stressful life event,” said Dr Lapid-Gortzak.

“Most importantly, remember that saying ‘no’ to a patient wanting a presbyopia-correcting IOL is also sound advice.”

Dr Lapid-Gortzak spoke on this topic during Cornea Day at the 2024 ESCRS Congress in Barcelona.

Ruth Lapid-Gortzak MD, PhD is a Medical Specialist in Ophthalmology at Amsterdam University Medical Centers, Amsterdam, Netherlands. r.lapid@amsterdamumc.nl

1. Sun Y, Hong Y, Rong X, Ji Y. “Presbyopia-Correcting Intraocular Lenses Implantation in Eyes After Corneal Refractive Laser Surgery: A Meta-Analysis and Systematic Review,” Front Med (Lausanne), 11 Apr 2022; 9: 834805.

2. Alio JL, D’Oria F, Toto F, et al. “Retinal image quality with multifocal, EDoF, and accommodative intraocular lenses as studied by pyramidal aberrometry,” Eye Vis (Lond), 6 Oct 2021; 8(1): 37.