prsented at Trivandrum Ophthalmic Club Annual Meet 2019

1. Multifocal IOL
I am never going to
implant that again
Dr. Devin Prabhakar
MS, DNB, MNAMS, FRCS

4. Indication for Cataract
Surgery
 Not the numbers read on the Snellen chart
 But
 The symptoms the patient had.

5. First Unhappy Patient
 Perfect Surgery
 Perfect Refraction
 No multifocality

7. To Make him happy
 Monovision approach –dominant eye to be emmetropic
for distance vision and other eye made myopic by 2.5 to
3D for near vision
 Inherent limitation - loss of stereopsis, which is not well
accepted in most patients
 MINI MONOVISION -0.75 to -1.25

8. The unhappy multifocal
patient
 Refractive surprises
 Ocular Co Morbidities
 Astigmatism
 Amblyopia

9. Second Unhappy patient
 6/9 NIG following phaco. No preop councelling regards
to vision.
 OCT showed ERM post op. No pre op OCT done.

10. OCT
 OCT
 OCT
 OCT

11. The Final frontier
 Dry eye
 Slit lamp
 Symptoms
 Standard Councelling to all dry eye patients. Cataract is
not the reason for dryness, watering and itching. Infact
these may increase after surgery.

12. ASTIGMATISM
 87% of cataract surgery patients have preoperative
astigmatism
 64% of patients fall within 0.50 to 1.25
 36% of patients having greater than 1.26 D
 16% of all eyes had astig of 1.5D or more
 46.8% WTR (minus cyl @180) & 34.3% ATR
 Temp clear corneal incision will reduce astig in 34% of pts
but worsen for 47%
 Corneal astigmatism did not increase with age
 A small amount of myopic astigmatism i.e refractive
error of about -0.75DC to -1.25 DC would allow
uncorrected visual acuity of about 6/12 for distance and
near •

13. Other Factors affecting
postop astig-
 IOL Tilt and Shift
 Small rhexis- hyperopic shift
 Post capsule debris (viscoelastic) and fibrotic bands-
myopic shift and cyl
 Irregular rhexis
 One loop in bag only

14. My current counseling on
multifocal
 Do it for people who understand that
 It is a life style lens
 You can do most activities
 It is meant to be used with both eyes open
 Cataract is only one of the causes of defective vision.

15. I am not comfortable doing
Multifocal
 Too many questions
 Too many prior hospitals
 Prior refractive surgery

16. A little bit of history
 Hoffer in 1982 was the first to hit upon the idea of a
multifocal IOL after observing a patient who had 6/6
vision in spite of an IOL that was decentred by more
than 50% of the pupillary area •

17. Multifocal evolution
 Initially affordability was the issue
 Now offer to all.
 Say if it is suitable/not suitable after evaluation
 No complaints of not being read by monofocal patient
 Extra time for councelling for all patients

18. Final Thoughts
 An ounce of prevention is worth a pound of cure.
 An ounce of pre op counseling time is worth a pound of
post op interaction time.