Historically, we have said that patients needed to have perfectly healthy eyes in order to be considered candidates for diffractive presbyopia-correcting IOL implantation.
With the advent of extended depth of focus (EDOF) IOLs, we may have more opportunity to offer diffractive presbyopia technology to our patients. Given that EDOF lenses provide postoperative contrast sensitivity rivaling that of a monofocal, many surgeons will now consider implanting these IOLs in patients with mild ocular pathology who desire spectacle independence. I have personally begun to selectively implant EDOF lenses in patients with:
- parafoveal mild epiretinal membrane (ERM);
- preperimetric glaucoma (or glaucoma suspects);
- well-controlled diabetes without retinopathy;
- post-RK (eight or fewer cuts, well centered).
While I have seen patients with more advanced pathology who are doing very well with EDOF lenses, I would personally not consider them to be appropriate candidates. In short, if the pathology is not affecting best corrected visual acuity and appears to be unlikely to progress to the point of affecting visual acuity for some time, I have been offering this technology to motivated patients — with additional informed consent.
I would caution surgeons to take responsibility for these choices, however, and make clear to patients that there is a chance of loss of contrast sensitivity due to their other ocular conditions in the future. It is important to understand the natural history of concomitant eye disease and the risk factors this presents and disclose that to the patient. For example, it is possible that future ERM or diabetic retinopathy may impact the vision they enjoy postoperatively. If that happens, it will not be due to the IOL but rather to their diabetes or ERM. One also needs to actively manage any issues that arise after cataract surgery, such as residual astigmatism, dry eye or posterior capsular opacification.
It is encouraging that we have a growing pool of candidates for presbyopia-correcting IOLs, including post-refractive eyes, astigmats and some patients who would not have been candidates previously due to mild pathology.
Disclosure: Waring reports he is a consultant for Johnson & Johnson Vision and a member of the Johnson & Johnson Vision Optics Advisory Board.