With the development of multifocal, accommodating, and toric intraocular lenses, we are now able to deliver a wide range of vision enhancements with cataract surgery. While many surgeons feel comfortable implanting these lenses in patients that may have minor contraindications (ie mild fuchs dystrophy, moderate dry age related macular degeneration), I feel that there is one group of patients who should not have these lenses implanted: those with pseudoexfoliation.
While many videos can be found online of surgeons deftly inserting hooks or rings to stabilize a capsular bag with loose zonules and implanting a multifocal lens, this does not tell the whole story. It may even be the case that over a year the patient maintains 20/20 distance and J1+ uncorrected vision. My concern is regarding the late term followup outcomes; 10, 20, and 30 years down the road.
Working in Palm Beach, Florida, I can recall one physician stating that in our area we "redefine elderly". In truth, many of my octogenarian patients are living vibrant lifestyles with travel, exercise, golf, hunting, and all other activities one could think of. With this older population, which includes many patients in their 80s, and 90s, I am referred many patients with dislocated lens/bag complexes. While many of these patients can be safely observed, still others have such gross decentration that surgery is the only option for visual recovery.
While observation may be successful for minor decentrations with these older lenses, this will not be the case for the "premium" lenses today. Should a toric lens rotate 1 degree, it loses 3% of its efficacy. Imagine now if a toric lens not only rotated but decentered. The induced higher order aberrations would be immense, not to mention the spherocylindrical change that would unlikely be correctable with spectacles or contact lenses. With a multifocal lens even minor decentration may cause such disabling visual compromise that lens exchange is required.
Lens exchange, and not lens reposition, will likely be the required surgery for these patients. While suturing the lens/bag complex to the eye to improve centration may be effective with a monofocal lens, to obtain the perfect centration required for a premium lens is much more unlikely and most surgeons would be unwilling to attempt it. That said, the majority of these patients will have already had a YAG capsulotomy, greatly increasing the need for vitrectomy at the time of lens exchange. Finally, these patients are going to be older, and have more comorbidities than they had at the time of their original cataract surgery. Even with "perfect surgery", they may still develop corneal decompensation or recalcitrant cystoid macular edema. Ultimately, when they are living their last decades their vision may be worse than had they originally selected a monofocal lens.
That said, I believe that premium lenses should be contraindicated for those patients with pseudoexfoliation syndrome, in spite of the fact they exhibit no phacodenesis at the time of exam or surgery. Should a patient really desire one, they should be counseled or their elevated risk of late-onset dislocation. If a premium lens is placed in one of these patients, I believe it would be advisable to place a ring and suture fixate the bag to the sclera at the time of surgery for further minimize the risk of late onset problems. In the interim, I anticipate there to be an epidemic in two decades of premium lens patients requiring IOL exchange.