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Practicing in a busy cataract and refractive surgery center, I have seen thousands of patients just before and after cataract surgery. This has given me excellent perspective on how we optometrists can help our patients achieve the best possible cataract surgery experience. Today more than ever, presbyopia correction at the time of cataract surgery is something we should be proactively talking about with our patients (Figure 1).
First, however, there are several myths about premium, presbyopia-correcting IOLs that need debunking.
Myth No. 1:“My patients aren’t interested in paying a premium for cataract surgery.”
In fact, when patients understand that paying a little more at the time of cataract surgery can enhance their quality of life postoperatively, many readily see the value in choosing a presbyopia-correcting IOL technology. Do not be afraid of the price discussion. You want to be the one to share this opportunity with your patients. In the accompanying video (see Watch It Now), I share how easy and quick this conversation can be.
Myth No. 2:“Patients just aren’t as satisfied with presbyopia-correcting IOLs.”
We are all guilty sometimes of making decisions based on an “N of 1.” A dissatisfied patient can be quite memorable, but data suggest that satisfaction rates with presbyopia-correcting IOLs are high. In trials for the Tecnis Symfony IOL (Abbott), the most recently approved presbyopia-correcting IOL, 92% of US participants said they would choose to have the same IOL implanted again, and 94% to 97% said they would recommend it to a friend.1
Myth No. 3:“There is too much extra work involved to provide collaborative care for these cases.”
Look again at the IOLs that have become available in the past couple of years. With modern technologies and the way procedures are now performed, collaborative care of premium IOL patients need not take a lot of chair time or hand-holding. In fact, it can be a very pleasant process.
PREPARING PATIENTS FOR SURGERY
When your patient needs cataract surgery, it helps to have a flow chart in your head to help you guide the patient about his or her options. No single IOL technology is the perfect answer for everyone.
Questions I ask myself include the following:
•Is the patient interested in spectacle independence?
•Do I need to worry about correcting significant astigmatism?
•Are there other ocular conditions that will affect postoperative visual potential or lens stability?
The answers to these questions can help in choosing the best lens for each patient. For example, someone who has a family history of macular degeneration might be a better candidate for an extended depth of focus lens, an accommodating IOL, or a monofocal IOL, rather than a multifocal IOL. The amount of astigmatism present may also limit options. The optometrist can begin this discussion so that the patient understands that he may not be eligible for the same lens his wife or his friend got last year.
Once it is determined that a presbyopia-correcting lens is a possibility for a particular patient, there are still decisions to make. Suppose, for example, you refer to a surgeon who primarily uses the Tecnis IOL platform (Abbott). There are four Tecnis options for presbyopia correction, each with advantages and disadvantages (Table). Other manufacturers’ IOL platforms also include more than one IOL choice.
This is where the optometrist’s understanding of the patient’s visual needs and expectations is so important to the final outcome. If you know that a particular patient enjoys needlework at a very close working distance, she might be a good candidate for the traditional, Tecnis Multifocal IOL +4.0.
On the other hand, for a patient who wants the best possible distance vision with a range of functional intermediate and near vision, you might recommend Tecnis Symfony lens, which provides what the company calls an extended range of vision. The Symfony’s correction of chromatic aberration improves the optical quality enough (Figure 2) that there is little impact on distance vision or contrast sensitivity from extending the range. Night vision symptoms have also been minimal with the Symfony lens (Figure 3).
If even better near vision is desired, the surgeon might target micromonovision or put a low-add multifocal in the patient’s nondominant eye.
This is not to say that we need to discuss each of these technologies in detail with each patient. Patients care about achieving their desired outcome, so the job of the surgeon and collaborating optometrist should be to identify the patient’s goals and determine whether we can accomplish them with the refractive tools available, including toric and presbyopia-correcting IOLs, femtosecond, and excimer lasers.
Finally, we must consider what is the optimal interval between surgery dates for the patient’s two eyes. Ideally, both eyes should undergo cataract surgery within weeks of each other. If the cataract in a patient’s second eye is not advanced enough to warrant surgery, it is important to educate the patient about where his or her vision will ultimately be. You can also discuss options to help the patient with daily function in the interim. That might mean wearing a contact lens in one eye or spectacles with one plano lens. If the patient is eager to have both eyes resolved, it may even be worth considering refractive lens exchange in the second eye to speed up the process.
Using these processes, we can help patients who are interested in presbyopia correction have a satisfying cataract surgery experience that provides the best possible visual outcomes to meet their goals and expectations. n
1. Loden J, Auffarth G, Cochener B, et al. Visual symptoms reported for the extended range of vision IOL across multiple large clinical trials. Presented at: ASCRS/ASOA Annual Symposium & Congress; May, 2016; New Orleans, LA.
Marc Bloomenstein, OD, FAAO
• Director of Optometric Services at Schwartz Laser Eye Center in Scottsdale, Arizona
• Adjunct Assistant Professor at New England College of Optometry and Southern California College of Optometry
• Cofounder of the Optometric Council on Refractive Technology