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Over the past few years, we have noticed a dramatic change in the mindset of patients coming in for cataract surgery. What they are asking for is not only high-quality distance vision, but they also want to be glasses free at near and intermediate. Fundamentally, what this signals is a change from cataract surgery being a medically necessary surgical procedure to it becoming a refractive procedure.
In part, this change has been prompted by the successful introduction of advanced tools and techniques used during the perioperative period to assess the lens, better biometry, the introduction of new IOL options that extend the range of vision, improved multifocal designs, and, the ability to refine the outcome with excimer lasers, just to name a few. The sum total of innovation in cataract surgery has made it a procedure that is highly predictable and repeatable, in turn leading to improved accuracy of the refractive outcome. A natural downside is that patients have much higher expectations postoperatively. However, we see this trend as a net positive, as it eliminates much of the confusion and can serve as an entry point to discussing surgical options with patients.
20/20 Quality Vision Is the New Norm
One thing we have noticed is that our cataract patients tend to come into the clinic at a younger age. Instead of waiting until they are 70 or 80 years old and nearly blind from a progressed cataract, we are seeing patients in their 50s or 60s with mild lens changes but who are complaining about their night vision or just overall quality of vision. For many of these patients, a cataract diagnosis may be premature. In fact, the uncorrected visual acuity may be misleading as it is an issue of quality of vision not quantity of vision.
For this reason, we have found it valuable to obtain an Objective Scatter Index (OSI; HD Analyzer, Visiometrics) in these patients, as it measures the effects of optical scatter on the entire vision system, thereby accounting for all manner of higher-order aberrations. This test will essentially measure the patient’s quality of vision as it measures the effect of lens scatter due to normal aging changes. In a multicenter study of nearly 1,800 eyes, the OSI demonstrated significant correlation with cataract grade and the VF 14 Visual Function questionnaire and was shown to be an effective tool for early cataract diagnosis.1
For our purposes, if we diagnose a patient with dysfunctional lens syndrome, which can be understood loosely as a precataractous lens,2 we know that a corneal-correcting procedure will be insufficient to address the full visual problem and quality of vision issues experienced by the patient. Therefore, we are going to discuss a refractive lens exchange with such a patient as opposed to a corneal procedure. In these kinds of cases, understanding that quality vision is the desired outcome and having the ability to objectively measure it guides our clinical decision making.
Extended Range of Vision
Knowing that these patients are coming in not only to improve quality of vision that has been compromised by lens changes but also to eliminate the need for glasses postoperatively alters the way in which these patients should be treated. This is a prime reason why all patients coming into our clinic for a presumptive cataract evaluation are administered a modified questionnaire that seeks to understand what kind of vision the patient is hoping to have after surgery (distance only vs distance and near), and, perhaps more important, what he or she hopes to do with that vision. The questions are carefully worded to gauge what kind of activities the patient regularly participates in, determine the interest level in spectacle-free vision, and get a sense of the patient’s psychological profile, all to help us recommend the correct lens and procedure for that patient.
A quick example helps illustrate this point. Let us say the results from the questionnaire from Patient A indicate that he or she is not overly concerned about occasional glasses use, and then later in the consultation, he or she relays that they spend a lot of time at the computer. These are elements of a patient profile that may succeed with bilateral implantation of IOLs with an extended depth of focus (we use the Symfony from Johnson & Johnson Vision in our clinic), permitting the ability to perform intermediate tasks (ie, computer use) without sacrificing distance vision; there is a reasonable certainty that near vision will be improved, but in case it is not adequate for close work, this patient has already demonstrated a willingness to wear +1.00 D spectacles for near tasks.
An important concept to realize with the IOLs offering extended depth of focus or standard multifocal lenses is that each patient has an optimal distance for near tasks. We use a simple reading card with a string attached to it. The string has raised beads corresponding to working distances of 50, 42, or 33 cm. One trick we have learned is to hand the card to the patient upside down; when they get it in their hands, they will instinctively position it at the ideal distance they prefer to read at.
The reason we mention this caveat is that determining the individual’s reading distance preference is helpful for making lens recommendations. For instance, patients who prefer a 33 cm reading distance who also use the computer a lot will do well with a Symfony in the dominant eye and a +4.00 D add multifocal with a working distance of 33 cm in the non-dominant eye.
If there is a downside to the greater emphasis placed on quality of vision, it is that patients tend be more demanding about the accuracy of the outcome, and so managing expectations becomes more crucial. The IOLs available on the market are leaps and bounds beyond what was available just a decade ago; I would encourage any eye care provider with a previous bad experience with advanced technology lenses to seriously investigate the current array of lens offerings.
The innovation inherent in the Symfony is particularly noteworthy in this regard. The concept behind this lens is to elongate the effective focal point, which results in more light reaching the retina from various viewing distances. In modulation transfer function studies in which the performance of the Symfony was compared with aspheric and spheric IOLs, the Symfony was shown to improve simulated retinal image quality without sacrificing depth of field or tolerance to decentration, thereby implying a greater ability to improve visual performance relative to the comparators.3 This design consideration has a couple of implications. First and foremost, it means that vision is available at near, intermediate, and distance visions. However, because light is elongated and not split, the potential to induce halo, glare, and other dysphotopsias is greatly reduced. Overall, the lens provides the best conditions to restore quality vision across viewing distances, and because it is more forgiving, it is suitable for patient types that may not have been candidates for multifocal lenses in the past, such as post-LASIK eyes, mild age-related macular degeneration, or even mild amblyopia.
The thing eye care providers should be wary of, however, is to avoid creating unreasonable expectations. Careful and meticulous surgery is still required to get a good outcome, and even in the best scenario, unexpected circumstances can affect the final refraction. No matter how good the technology is, we simply cannot give patients back the vision they had when they were 20. While we work with patients through a process of understanding what they want to accomplish with their vision, there are never absolute guarantees. In all settings, we prefer to underpromise and overdeliver.
This article addresses a trend we have observed with regard to the mindset of the modern cataract patient. Overall, we have sensed that more patients are desirous of not simply achieving improved vision after cataract surgery with an IOL implantation, but rather, that they expect and sometimes demand high-quality vision that will allow them to be free of glasses at all distances. That mindset has caused us to shift how we approach the evaluation and consultation, including implementing protocols and diagnostics such as the HD Analyzer, which give us objective information about the individual’s quality of vision. It has also led us to begin the process by asking patients what they want—an approach that is only possible because we have excellent technology at our disposal that will usually allow us to give patients the vision they seek.
At the same time, we also readily acknowledge that this approach is not appropriate for every patient. Some patients may be medically contraindicated to get a premium IOL. Others may have unreasonable expectations about what the technology can deliver. Yet, this is also the beauty of modern cataract surgery. The array of excellent lens options at our disposal allows us to lead a conversation not just about refractive cataract surgery, but a truly customized approach that will provide the patient the best chance of returning to the activities he or she participated in before surgery and enjoying them without glasses.
1. Galliot F, Patel SR, Cochener B. Objective scatter index: working toward a new quantification of cataract? J Refract Surg. 2016;32(2):96-102.
2. Waring IV, GO. Diagnosis and treatment of dysfunctional lens syndrome. http://crstoday.com/2013/03/diagnosis-and-treatment-of-dysfunctional-lens-syndrome/. Published March 1, 2013. Accessed May 19, 2017.
3. Weeber HA, Piers PA. Theoretical performance of intraocular lenses correcting both spherical and chromatic aberration. J Refr Surg. 2012;28(1):48-52.
Jeffery Machat, MD
• founder and chief medical director of Crystal Clear Vision in Toronto, Canada
• (416) 928-0777; firstname.lastname@example.org
• financial interest: none acknowledged
Sondra Black, OD
• vice president and clinical director at Crystal Clear Vision Canada, Toronto
• (416) 928-0777 or (416) 988-495; email@example.com
• financial disclosure: consultant to AcuFocus, Johnson & Johnson Vision, Labtician Ophthalmics, and Valeant.