Viewpoint

An Ounce of Prevention…

FROM THE CHIEF MEDICAL EDITOR
Larry E. Patterson, MD

I just returned from the ASCRS meeting in Boston, and as usual picked up a number of clinical nuggets. I want to share three common implant-related issues that are being fairly well publicized but whose message, surprisingly, has not yet completely reached our ranks. And recently, they've all affected me directly.

We have access to high-quality, single-piece acrylic IOLs that are specifically labeled for in-the-bag placement. This information has been widely disseminated. But apparently the word hasn't yet reached everybody. Last year, at a major meeting, about 40% of the eye surgeons in the audience thought sulcus placement would be OK for these lenses. I have a new patient in my practice with bilateral sulcus-placed single-piece acrylic IOLs. The right eye has UGH syndrome, with rising pressures, and chronic iritis years after implantation. The other eye has only mild iritis, but in both eyes the haptics can be seen easily through the iris from contact erosion. I'm scheduling an IOL exchange soon for the right eye and will carefully monitor the left.

We now have multifocal IOLs, with well-known presbyopic benefits. But care should be utilized with those who drive much at night. "Subjects with multifocal lenses should exercise caution when driving at night or in poor visibility conditions," reads one insert. Another company lists "occupational night drivers" as one of four subjective exclusion criteria. The manufacturers are strongly suggesting you exercise restraint in implanting multifocals in patients who drive after dark a lot.

That's a reasonable precaution but, again, not everyone got the message. I now have a young state trooper with a monocular multifocal implant after a traumatic cataract. He says the only time his vision doesn't bother him is when he is asleep. And neither he nor his wife have any recollection of any discussion about night driving from the surgeon or staff that recommended and implanted this lens. State troopers work a lot at night. Especially on Highway 27 around 11 pm. Seriously.

Finally, with all premium lenses, be careful with premature YAG capsulotomies. I know you've read for some time that these patients are extremely bothered by early PCO, with some doctors recommending YAG treatment at the first sign of any opacity. But what happens when you perform a YAG capsulotomy and your patient is still unhappy? You just took a fairly simple IOL exchange procedure and turned it into a potential nightmare, vitreous included. Many doctors are now re-examining the timing of this procedure, taking great pains to eliminate surface disease and residual refractive error as culprits.

Oh, the state trooper? Yes, you're way ahead of me. This mid-40s gentleman has already had his capsulotomy as well. Fortunately for all involved, he's not the litigious type. Wish us both luck.