Premium IOLs in Practice

My Positive Experience with the crystalens

This IOL’s accommodative action comes closest to a natural lens.

BY ALAN SHILLER, M.D.

We ophthalmic surgeons live in an incredibly exciting time because we have more choices than ever before to obtain the best possible outcomes for our patients, whether they are primarily refractive patients or cataract patients who want to achieve a greater level of spectacle independence. Our practice has had a good deal of experience when it comes to refractive lensectomy as well as cataract patients who opt for a presbyopic premium IOL. My primary choice has landed squarely on bilateral implantation of the crystalens 5-O IOL (eyeonics, Aliso Viejo, Calif.).

In this article, I will provide several reasons for this choice, not the least of which is that the crystalens is the only FDA-approved accommodating IOL. This technology works well because the anatomy of the human eye is designed to accommodate.

Patient Selection

The issue of patient selection is becoming a major topic of interest in regard to presbyopic IOLs. Certainly, patient selection is an important process, but I believe we make it much more complicated than it really should be. Surgeons basically agree that if we perform a cataract procedure or clear lensectomy on a patient, then we are almost always going to place an IOL in that eye.

If you stop and think about it in its most basic terms, the main difference between a traditional monofocal IOL and the crystalens is that the crystalens flexes and accommodates. Therefore, it is my strong belief that if we agree that a patient is a candidate for a traditional monofocal IOL, then that same patient is certainly a candidate for a crystalens accommodating IOL, assuming that there is an intact capsular bag with intact zonules. The only difference is that the crystalens will provide a greater range of vision than the traditional lens.

I do not have a financial stake in the presbyopic premium IOL marketplace, but some patients are imply not good candidates for a multifocal ReZoom (Advanced Medical Optics, Santa Ana, Calif.) or ReSTOR IOL (Alcon, Fort Worth, Texas) because of the induced aberrations that occur with these lenses inherent to their design. Such patients could include those with prior RK, LASIK or even corneal scars. I have implanted the crystalens in several patients after previous LASIK and RK, as well as one patient who had an old hexagonal keratotomy, without fear of inducing more aberrations over what they already had. These patients have so far been extremely happy.

Even in light of macular pathology, when there is potential improvement of vision with a cataract procedure it would be a benefit to have a broader range of vision than not. There is obviously a spectrum of achievable vision that some patients can obtain, and it is my strong belief that it should be the patient’s decision if a broader visual range at their acuity level warrants the extra cost of this premium IOL. I find that if we educate our patients on what to expect and then deliver the highest quality results, the crystalens is a fantastic choice for the majority of our patients.

Offer the Option

I find it imperative to not prejudge patients on whether or not they can afford a premium IOL. It is absolutely my job to let patients know what technology is available and then let them make an informed decision.

I’ll offer a couple of examples from my own experience as to why I believe this is of utmost importance. About a year ago, I performed cataract surgery on a woman and implanted a traditional monofocal IOL. She did very well and was happy with her improved vision. However, at her 1-month visit she was a bit miffed at me. Upon questioning her, she let me know that I had implanted a crystalens IOL in a good friend of hers and this friend was enjoying more spectacle independence than she was able to achieve. She was upset that I had not offered her the same option. After I reviewed my traditional monofocal patient’s records, it was very clear to me that I had prejudged her ability to pay for the crystalens upgrade even though she informed me later that money was not an issue. Did she forgive me? Yes. Did I learn a lesson? Absolutely.

The crystalens 5-O is an improved version of the crystalens. Two major changes that mark the crystalens 5-O are in loop design (shown at far left) and haptic design (at near left). The new loop design creates a 27% wider arc than the original crystalens, enabling better centration and greater torsional fixation in the bag. The new haptic design features a rectangular rather than trapezoidal plate, enabling greater accommodative movement.

A second example of my potential prejudgment occurred about 2 months ago. It involved an active 87-year-old man who lives a lifestyle that I hope to have at that age. He needed cataract surgery but I was not planning to offer the crystalens option to him based upon his age. However, during his examination the thought came to me that my own father is almost 86 years old and active, and if I were about to do cataract surgery on him, he would definitely get the crystalens IOL.

How beneficial it would be to someone like my own father to be less dependent on glasses? Then, the humbling thought occurred to me that this nice, active 87-year-old’s lifestyle is no less valuable than my own dad’s. I offered the crystalens upgrade to him, thinking that he surely would not opt for it because of his age. Right? Wrong. He is now enjoying spectacle independence because he chose the crystalens upgrade and not regretting it one bit.

Therefore, my belief is that we should never prejudge a patient’s desire for a premium IOL or the willingness to pay for it. Simply give patients the option and let them decide. The primary reason I would not offer crystalens is if a patient does not have adequate zonules preoperatively.

Also, never underestimate the importance of a superb refractive coordinator. Our refractive coordinator treats all of our refractive lensectomy patients and cataract patients with the same importance that she does our LASIK patients. After all, our cataract patients have now become potential refractive patients. She counsels the patient by discussing options, expectations and costs. A patient does not leave our office without being offered financing — and then going through the approval process if the patient elects to finance the procedure.

The effectiveness of my refractive coordinator means that extra chair time with these patients is kept to a minimum. When I consider the added profit that these lenses provide to our practice, it is easy for me to see that the monetary math is clearly on my side.

Surgical Technique

My surgical technique is fairly straightforward, as I perform routine phaco through a 2.75-mm incision. I perform limbal relaxing incisions (LRIs) on patients with greater than 1 D of astigmatism, which I believe decreases the need for enhancements postoperatively. I rotate the lens with a cystatome so that the haptics are oriented at 90°, so that the haptics will not be affected by any potential subincisional cortex that could be left behind. Moreover, the incision, as well as the paracentesis, is always hydrated. We should never underestimate the paracentesis as the possible site of aqueous leakage after the patient leaves the facility. Any aqueous leakage can decompress the anterior chamber and cause the crystalens to vault forward. To date, we have had absolutely zero anterior vaults of the crystalens. I credit this to the hydration of both the primary incision as well as the paracentesis.

Postop Targets

Getting good results and happy patients depends on starting with superb preoperative keratometry (K) readings and axial length measurements.

I am fortunate to have a staff who understand the importance of making precise preop measurements. We always obtain three sets of manual K readings and use the best one for our IOL calculation. We also use the IOLMaster (Carl Zeiss Meditec, Dublin, Calif.) for our axial lengths (but never use the K reading that the IOLMaster provides). We’ve also used immersion A-scan axial lengths if an IOLMaster measurement cannot be done. We simply never, ever, stray from this methodology.

Alan Shiller, M.D., is founder of the Shiller Vision & Laser Center, with offices in Palestine and Waco, Texas. Dr. Shiller has no financial relationship with any company mentioned in this article. He can be reached via e-mail at ashiller@shillervision.com

I prefer to do the non-dominant eye first with a postop target of -0.37 D to -0.62 D. The dominant eye is typically done 2 weeks later with a postop target of plano to -0.25 D. These targets give us slightly overlapping visual ranges, which is quite unlike the monovision achieved with traditional IOLs. These slightly overlapping visual ranges provide a binocular functional range of around plano to -2 D. This refractive range gives most patients the ability to go about most of their activities spectacle free.

Postop Counseling

Our patients are aware from their preop consultation that it is okay to use weak readers of about +1 D as a crutch for reading anything that is too small. We strongly encourage our patients to go without the readers as much as possible, and we have definitely seen their reading ability improve over time. I believe this improvement is due to the strengthening of the muscles of accommodation as well as the fact that patients have the ability to neuoroadapt to the new visual system they now have.

To obtain the greatest amount of patient satisfaction, we must be able to perform refractive procedures for any undesired refractive error we find after crystalens implantation. For purely mixed astigmatism, I tend to do astigmatic conductive keratoplasty (Refractec, Irvine, Calif.) as early as 3 weeks postop. If a patient needs spherical correction, I typically use LASIK as my tool of choice. So far, using these adjunctive procedures has not caused any problems and has created much happiness for the patients who needed it. Our enhancement rate after crystalens is about 6%. I credit this low rate to my staff because of the accuracy of their preop measurements.

Finally, we must take into account that each of our patients has unique vocational demands as well as lifestyle desires. It is our job as physicians to provide our patients with the technology that will give them the greatest chance of meeting these needs and desires. In my experience, the crystalens IOL fits the bill. OM