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Dr Assil is the Medical Director and CEO of the Assil Eye Institute in Beverly Hills, California, USA.

Having reviewed his earlier data with multifocal lenses, Dr Assil found that slightly less than 80% of his bilateral patients could hope to achieve 20/25 or better acuity, or J2 or better. During his presentation at the annual congress, he offered some pearls that have helped him achieve patient satisfaction rates of nearly 100%.

"It is imperative that you do not make your patient feel that they are getting a better lens, because the new multifocal lenses are not better, they are just different. They help people get rid of their glasses," Dr Assil insisted.

Picking the ideal candidate

He advised that paying attention to inclusion parameters for multifocal IOL implantation is absolutely critical, for example, ensuring the absence of maculopathy and making sure the lens is available in the patient's range.

According to Dr Assil, the ideal refractive lens exchange patient is over the age of 50, has more than 2 D of hyperopic spherical equivalent and has at least some colour change to their lens. Similarly with the cataract patient, the more advanced their cataract, the happier they will be with the multifocals because they have already demonstrated that they can function well with some loss of contrast acuity.

In contrast to some LASIK patients, Dr Assil insists presbyopic patients expect their surgeon to participate in the pre-and postoperative consultation process. "It is a simple encounter that takes less than 30 seconds most of the time in my practice, but it is sufficient to make the patient feel good about making a decision with you," said Dr Assil. "Equally important is to look them in the face at the end of the discussion, shake their hand and tell them that you are excited to help them. This instils trust and confidence," he added.

He also urged surgeons to tell their patients that glare and halos are a normally expected consequence of multifocal lenses. "If anybody would be able to argue that it's not natural to have glare and halos after you implant a multifocal lens, I'd like to hear about it," challenged Dr Assil. Patients should also be informed that they will perform better following the second implant. According to Dr Assil, this makes them eager rather than reluctant for the second implantation.

Once the correct patient has been selected for the procedure and they have been appropriately "counselled", the next step is to choose the right lens for them.

"The ideal multifocal lens would focus all of the pixels of light to the exact same one point on the fovea, irrespective of pupil size and distance. Unfortunately, such a lens does not currently exist. The crystalens gets you about 1 D of accommodative amplitude, but in a variable fashion," said Dr Assil.

Picking the right lens

He then went on to refer to his experience with the ReZoom lens (Advanced Medical Optics; AMO) and ReStor (Alcon). According to Dr Assil, the ReZoom lens is the most versatile and ideal in many ways apart from in patients with very small pupils, who will experience problems with the lens when trying to read in bright sunlight, for example.