**Abstract**

Presbyopia is a prevalent productivity-reducing, age-related visual disorder that results in a progressive near vision impairment. Conventional treatment modalities (ie. presbyopic spectacles or contact lenses) are associated with poor acceptance, productivity loss and negative impact on life quality. However, a variety of surgical methods are available to address presbyopia; among them, multifocal and multifocal toric intraocular lenses (IOLs) and monovision techniques. For the best possible refractive outcomes, the overall management of presbyopic patients is necessary. Specifically, patient selection according to personality and daily activities, topography, aberrometry, astigmatism, pupil and fundus assessment, ophthalmic surface, and premium lens selection should be taken into consideration. Additionally, image-guided surgery could increase the accuracy in multifocal/multifocal toric IOL implantation, and optimize the refractive outcome increasing patient satisfaction. Primary objective of this chapter is to analyze the fundamental preoperative, intraoperative and postoperative management of patients that undergo pseudophakic presbyopic corrections with conventional or digital-marking assisted techniques.

**Keywords:** presbyopia, cataract surgery, refractive lens exchange, multifocal intraocular lens, monovision, pseudophakic presbyopic correction

### **1. Introduction**

Presbyopia is probably the most prevalent productivity-reducing, age-related visual disorder that results in a progressive impairment of near vision capacity Presbyopia symptoms include blurry vision when targeting at near objects and fatigue when reading, especially in suboptimal lighting conditions. It is common for emmetropic populations above 40 years old. Almost every working person is expected to suffer from reduction of his/her near and intermediate vision capacity due to presbyopia [1, 2]. Taking into consideration the constantly increasing life-expectancy, conservative estimates suggest that by 2050, about 1.8 billion people will experience presbyopia symptoms [3]. Additionally, since computers, tablets, and smart phones have modified heavily working and social norms, presbyopia significantly limits the patient's productivity and reduces life quality [4, 5].

It is a truism that correction of presbyopia is among the most challenging unmet objectives in Ophthalmology. Conventional treatment modalities (ie. presbyopic spectacles or contact lenses) are associated with poor acceptance, productivity loss and significant negative impact on the quality of life [5]. Despite the fact that

the lens extraction surgery is the most frequent surgical operation in Medicine, [5, 6] the postoperative loss of accommodation is yet to be adequately addressed. Different surgical approaches for the correction of presbyopia have been developed targeting the cornea and/or the crystalline lens [7]. A variety of technologies have also been introduced, primarily in the ophthalmological lasers and in the intraocular lenses (IOLs) aiming to restore the pre-presbyopic functionality of the human eye [8]. The ultimate goal is a spectacle-free visual capacity that imposes no limits to the social, personal, working needs of each patient [9–12]. As regards pseudophakic presbyopic corrections, the "ideal" IOL should restore the patients' vision without complications or visual compromises at all distances [13]. Premium IOLs, such as multifocal, accommodating and extended-depth-of-focus (EDOF), as well as pseudophakic monovision techniques achieved by monofocal IOL implantation or implantation of a combination of premium IOLs, are some of the available surgical approaches. When presbyopia is combined with astigmatism, multifocal toric IOLs can be used.

However, for the best possible refractive outcomes, solid and up-to-date information on the overall management of presbyopic patients is necessary. In specific, patient selection (according to personality, daily activities, and expectations), astigmatism assessment, topography, aberrometry, pupil assessment, ophthalmic surface, fundus assessment, and premium lens selection should always be taken into consideration before a presbyopic correction. In addition, in case of implantation of multifocal or multifocal toric IOLs, image-guided surgery could increase the accuracy of IOL centration (in multifocal and multifocal toric IOLs) and alignment (in multifocal toric IOLs), and optimize the refractive outcome increasing patient satisfaction.

Primary objective of this chapter is to analyze the fundamental preoperative, intraoperative and postoperative management of patients that undergo pseudophakic presbyopic correction with conventional or digital-marking assisted techniques. In specific, this chapter aims to give an overview of the current IOL technologies for a pseudophakic presbyopic correction, patient selection criteria, benefits and limitations of each IOL technology.

### **2. Preoperative diagnostic evaluation**

Accurate preoperative diagnostic evaluation is necessary for preoperative patient counseling, the selection of the most appropriate IOL type and surgical planning. Preoperative diagnostics are also essential for determining the anatomical success rates of IOL implantation [13].

A preoperative examination for patients intending to undergo a pseudophakic presbyopic correction should include: (i) taking of the medical history, (ii) basic ophthalmological examination, and (iii) additional diagnostic procedures:

#### **2.1 Medical history**

#### *2.1.1 General medical history*

As in the routine preoperative examination for a typical cataract surgery with implantation of a monofocal IOL, the routine preoperative examination for a pseudophakic presbyopic correction should include taking a detailed history for current or past medical conditions [eg. hypertension, diabetes, ischemic heart disease, pulmonary diseases, benign prostatic hyperplasia (BPH), bleeding disorders, history

**95**

be open.

*Pseudophakic Presbyopic Corrections*

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

thyroiditis, and Sjogren syndrome].

medication [14].

*2.1.2 Ocular history*

be taken into account.

*2.1.3 Family eye history*

*2.1.4 Allergies*

of herpes libialis or autoimmune diseases, such as rheumatoid arthritis, Hashimoto's

In addition, the surgeon should be aware of the patient's former surgeries and current or prior use of systemic or topical pharmaceutical medications such as anticoagulant, alpha-blocker (tamsulosin) for BPH, steroid or immunosuppressant

Glaucoma, former incisional surgery (eg. refractive, retinal, glaucoma, muscle surgery), eye trauma, amblyopia, herpes simplex keratitis, allergic conjunctivitis, uveitis, recurrent corneal erosions and prior or current topical medications should

Family history of eye disorders responsible for blindness or visual impairment

If the patient is allergic to medications, the type of medication and the exact

The evaluation of the Uncorrected Distance Visual Acuity (UDVA), Best Corrected

Distance Visual Acuity (BCDVA), Uncorrected Near Visual Acuity (UNVA), Best Corrected Near Visual Acuity (BCNVA), Uncorrected Intermediate Visual Acuity (UIVA), Best Corrected Intermediate Visual Acuity (BCIVA) should be included in the

Eyelids, lacrimal drainage system, cornea, conjunctiva, iris, pupil, anterior chamber, and lens should be evaluated in the first preoperative examination. In detail, certain findings for each anatomical structure should be taken into account and could encourage surgeons to perform some types of presbyopic corrections or discourage them from performing other surgical techniques. In addition, some eye

• *Eyelids:* Eyelid pathology, including ectropion, entropion, and blepharitis,

• *Lacrimal drainage system:* The lacrimal drainage system is recommended to

• *Cornea:* Ocular surface and cornea should be evaluated. Ocular surface disease such as dry-eye syndrome, exposure keratitis and meibomian gland

ophthalmic examination. The contrast sensitivity should also be evaluated.

*2.2.2 Slit lamp examination of the anterior segments of the eye*

pathologies should be addressed before the surgery.

should be addressed before the surgery.

(e.g. glaucoma, retinal or corneal disease, etc) should be considered.

reaction to that medication should be clarified (rash, anaphylaxis etc).

**2.2 Basic ophthalmological examination**

*2.2.1 Visual acuity assessment*

### *Pseudophakic Presbyopic Corrections DOI: http://dx.doi.org/10.5772/intechopen.96528*

of herpes libialis or autoimmune diseases, such as rheumatoid arthritis, Hashimoto's thyroiditis, and Sjogren syndrome].

In addition, the surgeon should be aware of the patient's former surgeries and current or prior use of systemic or topical pharmaceutical medications such as anticoagulant, alpha-blocker (tamsulosin) for BPH, steroid or immunosuppressant medication [14].
