**4. Postoperative examination – follow-up**

Apart from the full preoperative examination and the high-precision surgery that are necessary for optimal refractive outcomes in patients undergoing a pseudophakic presbyopic correction, especially with mIOLs, the postoperative follow-up plays an equally significant role in the best possible results. The most common follow-up timepoints are 1 day, 1 week, 1 month, 3 months, 6 months, 1 year, 2 years and so forth. Examination at the first postoperative day is commonly applied by many surgeons, However, the current literature supports that first-day examination after an uneventful phacoemulsification surgery is not necessary when patients have not posterior synechiae or chronic/recurrent uveitis and they are operated by experienced cataract surgeons. Thus, healthcare costs can be decreased without an increased risk to the patients [172].

A comprehensive postoperative examination should include primarily history, VA assessment, automatic (with auto-refractor) and manifest refraction, slit lamp biomicroscopy and IOP measurement. However, some additional examinations should be performed for the best possible evaluation of the visual performance and optical quality of vision, including defocus curves, contrast sensitivity assessment, corneal topography, aberrometry, pupillometry, and halometry or retinal straylight, if halos, glare and other photic phenomena are present [173]. Finally, patient satisfaction and potential photic phenomena should be assessed by history taking or, more specifically, through special quality of vision questionnaires [174–176]. Among them, some important aspects that should be taken into consideration are the following:


As regards the surgery schedule of the fellow eye for a pseudophakic presbyopic correction, different factors described below should be taken into consideration:

• *Postoperative visual capacity (VA, reading speed, stereoscopic vision, dysphotopsia) and patient satisfaction:* After a successful lens extraction surgery, the surgeon should wait long enough for the patient's refraction to be stabilized and for the neuroadaptation process to take place, especially in case of dysphotopic phenomena. After this period of time, which can differ for each patient and each IOL design, [74] the surgeon could choose if and when the operation of

**117**

*Pseudophakic Presbyopic Corrections*

best option.

**Figure 8.**

*IOL implantation.*

**5. Conclusions**

*DOI: http://dx.doi.org/10.5772/intechopen.96528*

the fellow eye could be performed, and the IOL design, as well. In addition, in case of patient dissatisfaction, the cause of dissatisfaction should be identified. If dysphotopsia or suboptimal near vision are the most serious patient's complaints, the surgeon should consider if the implantation of a different IOL design with fewer photic phenomena or with a near focus point could be the

*Identification of the coaxially sighted IOL light reflex through slit lamp biomicroscopy following a multifocal* 

• *Crystalline lens clearance of the fellow eye:* In case of a clear crystalline lens, especially in young patients with unilateral cataract with a non-presbyopic fellow eye, the fellow eye may not require a lens extraction surgery for years or decades after the surgery of the first eye [181]. In fact, young people with a clear crystalline lens of the fellow eye seem to benefit from the avoidance of the fellow eye surgery, since the smooth transition among distant, intermediate and near vision that is provided by their clear non-presbyopic crystalline lens

Pseudophakic presbyopic correction is now established as a safe and effective surgical method for the treatment of presbyopia, especially when it is combined with cataract. Pseudophakic presbyopic correction with monovision techniques, implantation of mIOL, aIOL or a combination of IOL designs is also related with excellent visual outcomes, improvement in vision and life quality, and high patient satisfaction. Rapid technological advances have led to an increase in the number of the available IOL technologies and presbyopia correction techniques. Additionally, advances and innovation in imaging and preoperative assessment, but also the high precision that is provided pre- and intraoperatively by image-guided systems, have

• *Patient's desire or not for lens extraction surgery at the fellow eye*

could not be equally replaced by an artificial IOL.

#### **Figure 8.**

*Current Cataract Surgical Techniques*

refractometer should be used.

conditions should ideally be assessed.

A comprehensive postoperative examination should include primarily history, VA assessment, automatic (with auto-refractor) and manifest refraction, slit lamp biomicroscopy and IOP measurement. However, some additional examinations should be performed for the best possible evaluation of the visual performance and optical quality of vision, including defocus curves, contrast sensitivity assessment, corneal topography, aberrometry, pupillometry, and halometry or retinal straylight, if halos, glare and other photic phenomena are present [173]. Finally, patient satisfaction and potential photic phenomena should be assessed by history taking or, more specifically, through special quality of vision questionnaires [174–176]. Among them, some

important aspects that should be taken into consideration are the following:

• *Visual acuity and refraction:* UDVA, BCDVA, UNVA, BCNVA, UIVA, and BCIVA should be included in the postoperative examination. Near and intermediate vision should be ideally evaluated with logarithmic printed or digital reading charts that evaluate not only reading acuity (RA), but also the maximum reading speed (MRS) and the critical print size (CPS), namely the smallest print size that can be read with the MRS [177–180]. *Defocus curves* could also be obtained. Apart from the manifest refraction, an auto-kerato-

• *Contrast sensitivity*: Contrast sensitivity under photopic and mesopic light

centration has been done according to the visual axis (**Figure 8**) [131].

• *Pupillometry:* Postoperative pupil diameter at photopic and mesopic light conditions and PCS are suggested to be measured, especially after implantation of mIOLs, in order potential dysphotopic phenomena to be explained and

As regards the surgery schedule of the fellow eye for a pseudophakic presbyopic correction, different factors described below should be taken into consideration:

• *Postoperative visual capacity (VA, reading speed, stereoscopic vision, dysphotopsia) and patient satisfaction:* After a successful lens extraction surgery, the surgeon should wait long enough for the patient's refraction to be stabilized and for the neuroadaptation process to take place, especially in case of dysphotopic phenomena. After this period of time, which can differ for each patient and each IOL design, [74] the surgeon could choose if and when the operation of

dysphotopic phenomena at scotopic or mesopic light conditions.

correlated with the objective pupil measurements.

• *Corneal topography and aberrometry:* Corneal topography and aberrometry are suggested to be performed postoperatively, since they might reveal potential residual astigmatism and aberrations, especially in case of postoperative

• *Slit lamp anterior segment examination:* Apart from the evaluation of the cornea (Seidel test, clarity), the anterior chamber (depth, inflammatory activity), and the pupil (shape, reactivity), in case of mIOL implantation, the centration of the mIOL should also be checked. Specifically, the coaxially sighted IOL light reflex (CSILR) should be identified by placing the slit illuminator in a coaxial position with the microscope, adjusting the narrow slit beam to a small rectangle and asking the patient to fixate on the slit lamp light. The light reflection on the mIOL indicates the position of the CSILR, which coincides with the visual axis, and ideally should fall on the central mIOL optic zone if the mIOL

**116**

*Identification of the coaxially sighted IOL light reflex through slit lamp biomicroscopy following a multifocal IOL implantation.*

the fellow eye could be performed, and the IOL design, as well. In addition, in case of patient dissatisfaction, the cause of dissatisfaction should be identified. If dysphotopsia or suboptimal near vision are the most serious patient's complaints, the surgeon should consider if the implantation of a different IOL design with fewer photic phenomena or with a near focus point could be the best option.

