When it comes to implanting a premium intraocular lens (IOL), there are two groups of patients that surgeons are typically wary of — those with preexisting ocular disease and those with the potential for developing an ocular disease down the road. As we all know, it's generally impossible to predict which patients are going to go on to develop a problem. In this article, we'll look at the contraindications for some presbyopiacorrecting IOLs, as well as the alternatives that are available.

Contraindications

When it comes to some types of premium IOLs, primarily multifocal lenses, the list of patients that are not good candidates is lengthy and includes:

Patients with significant macular degeneration, epiretinal membrane, macular pucker, macular holes, significant diabetic retinopathy, history of severe retinal detachment, retinal dystrophies or degenerations, retinal vascular occlusions, advanced glaucoma affecting central vision, irregular corneal astigmatism, corneal scarring, keratoconus, corneal dystrophies or optic neuropathy.

Our pre-op screening approach

All of these conditions can preclude a patient from having a multifocal IOL. But, this is the easy part as these patients present to us with distinct signs and symptoms of their diseases. The more challenging part is knowing which patients will go on to develop problems.

What we do know is that agerelated macular degeneration (AMD) causes a substantial portion of visual impairment. According to statistics from the National Eye Institute, the overall prevalence of neovascular AMD and/or geographic atrophy in those 40 years and older is estimated to be 1.47% (95% confidence interval, 1.38–1.55%), with 1.75 million people with AMD. In addition, given that the population is getting older, the number of people with AMD will increase by 50% to 2.95 million by 2020. The Beaver Dam Eye Study calculated that drusen were present in 2% of all adults between the ages of 43 and 54 and in 24% of those 75 and older. Meanwhile, the Agerelated Eye Disease Study (AREDs study) estimated that more than 20% of patients with earlystage AMD progressed to latestage disease over a 5yearperiod. Lastly, consider that by 2050, the population of Americans over the age of 80 is expected to outgrow the current population of 65yearolds.

Glaucoma has a similar impact with the prevalence increasing with age, going from an annual rate of 0.9% in those 43 to 54 to 4.7% in those 75 and older.¹

The point is that we know a substantial portion of our patients will not only be living longer, but may also go on to develop an eye disease during the last decades of their lives. As we currently don't have easy-to-use genetic testing to screen patients, it's difficult to predict who will be affected. As we can't really do more than guess in this respect, a better option may be to use an accommodative IOL or monofocal IOL in patients we consider higher risk for developing these ocular conditions.