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Refractive Surgery | Nov 2010

Five Pearls For Patient Selection

No. 1: When counseling patients for premium IOLs, perform corneal topography. Ensure that the patient has refrained from contact lens wear for an appropriate time before performing ocular biometry. Corneal topography alleviates the risk of implanting a premium IOL in patients with form fruste keratoconus, which is more prevalent than many surgeons think. This combination may have consequences with respect to quality of vision postoperatively. Also, use aberrometry to evaluate coma and trefoil when irregular astigmatism is suspected.

No. 2: Incorporate anterior chamber imaging techniques. Such imaging is crucial to evaluate the suitability of phakic IOL implantation. We now know that only measuring central anterior chamber depth is insufficient to warrant long-term safety of phakic anterior chamber IOLs. The distance of the IOL's peripheral edge to the endothelium is the largest determining factor of long-term endothelial safety.

No. 3: Consider using multiple measurements with various technologies. This strategy may be helpful to detect corneas at risk for ectasia after corneal laser surgery. If in doubt, do not treat and plan for sequential measurements to look for progression and/or change over time. There is no need to hurry the treatment.

No. 4: Do not push presbyopia-correcting IOLs when counseling patients. Selecting the appropriate IOL for the patient is a crucial preoperative step. The patient and the patient's family must have realistic expectations and understand the potential risks and long-term effects of each specific lens. This is still an issue in the second opinions I treat after the patient is dissatisfied with his or her multifocal IOL.

No. 5: Always examine the patient yourself before surgery. It is ill advised to perform surgery on patients who have been solely counseled by optometrists. Patient contact before surgery is absolutely necessary to establish a confident patient-doctor relationship. This may be crucial, especially in those cases where an unexpected and suboptimal postoperative outcome occurs.

Rudy M.M.A. Nuijts, MD, PhD, is an Associate Professor of Ophthalmology in the Department of Ophthalmology at Academic Hospital, Maastricht, Netherlands. He is a member of the CRST Europe Editorial Board. Dr. Nuijts states that he is a consultant to Alcon Laboratories, Inc., Ophtec GmbH, and ASICO, and receives research funding from Alcon and Ophtec. He states that he has no financial interest in the products or companies mentioned. Dr. Nuijts may be reached at e-mail: rudy.nuijts@mumc.nl.

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