Seven Habits of Successful High-tech Lens Users
A comprehensive approach to patient management.

BY JOHNNY L . GAYTON, M.D. , AND J. CHRISTOPHER GAYTON, M.D.

The new tools and techniques available to cataract surgeons continue to multiply. Each new technology or advance we encounter presents an opportunity for us to reevaluate our methods and to investigate more thoroughly additional ways to improve our surgical outcomes.
Despite the many advances we incorporate into our practices today, there is no one tool, no one process or procedure, no one new product or device that delivers it all. Cataract surgeons must manage a broad array of clinical factors to ensure that these new technologies are leveraged in ways that help us achieve consistently successful results for our patients.
Today’s new multifocal IOLs serve as a prime example. These high-tech lenses represent one of the most important advances in cataract surgery that we have seen in recent years. At the same time, however, they create new challenges. For example, patient expectations in cataract surgery are higher than they have ever been before, and the management of these expectations now takes on an increasingly important role.
The best outcomes that we can achieve with these new lenses depend largely on careful and consistent patient management. We should expect patient management to become even more important as newer technologies emerge and expectations continue to trend upward. In managing my cataract cases, I have come to rely on what I refer to as the “Seven Habits of Successful High-tech IOL Users.” These habits cover the spectrum of factors that should be addressed to realize optimal outcomes when multifocal lenses are integrated into your practice. This article will discuss these seven habits and offer examples of how they work successfully in our practice.

1 HABIT Preoperative Counseling
I believe that all cataract patients, regardless of whether they are actually multifocal candidates, should be told about the availability and attributes of these IOLs. My reason for suggesting this is twofold: First, our patients today have unprecedented access to healthcare information. Whether through the Internet, advertisements, news programs or word-of-mouth, they are going to hear about the new multifocal lenses and, in most cases, will be intrigued. Second, if we fail to include these IOLs in our discussion of cataract lens replacement options, our patients could feel betrayed or, at best, shortchanged, if they think this information has been withheld from them.
Clearly, patients for whom the lenses are not considered appropriate must be told why multifocal IOLs are not their best option. It is equally important to be completely clear about the advantages presented by the other options available to them.
I would suggest that surgeons use the following four primary principles as a guide in offering the multifocal option to patients who are deemed suitable candidates:
• Manage expectations. In counseling good candidates for multifocal IOLs, I first explain that they have a choice for their eyes to be focused near or far, or for them to be focused with a combination of near and far vision. Similarly, it is important for patients to understand that the potential tradeoff for combined near and far vision might be a slight decrease in distance vision and a small increase in night glare or halos. Many patients are used to wearing progressive lenses or trifocals. They need to understand that the IOL is primarily a bifocal lens and will not give the exact same visual range as spectacles.
In an effort to underpromise and overdeliver, I typically point out that, while these lenses do offer a good chance for spectacle freedom, there are no guarantees. One of the most important things multifocal patients must understand is that our best results are seen with bilateral procedures, and that over time and with adaptation, the results can actually improve further. About 90% of the bilateral multifocal patients in my practice enjoy spectacle freedom, but about 10% wear glasses at least part-time.
• Explain postop procedures. I also explain that about one in 10 multifocal patients will need some type of enhancement procedure postoperatively to achieve their absolute best vision. Patients need to understand that the cornea and the lens are different anatomical entities and that both may require treatment to maximize visual outcomes. It is also important to address astigmatism and the probability of additional procedures for these cases.
• Discuss multifocal choices. I primarily use the AcrySof ReSTOR multifocal lens (Alcon, Fort Worth, Texas). In my opinion, it provides better near acuity and fewer night visual disturbances than other multifocal options. In addition, its single-piece platform allows for easy insertion, as well as easy explants when power issues occur. My preference for the ReSTOR lens rests squarely with the results my patients realize with this IOL: The vast majority of my bilateral ReSTOR patients are quite happy with their vision postoperatively. If a patient with one ReSTOR lens has complained bitterly about poor intermediate vision, I have on occasion implanted a ReZoom multifocal lens (Advanced Medical Optics, Santa Ana, Calif.) in the second eye.
In about 2% of my cases, I use the ReZoom multifocal lens as the primary implant. In my opinion, it provides better intermediate acuity. If a patient with the ReZoom lens has complained about near acuity, I consider implanting a ReSTOR lens in the second eye. In my practice, however, I am not necessarily inclined to “mix and match.” I prefer to simply match for several reasons. First, with mixing, you are forced to deal with different optics, materials and A-constants.
You also have to take into account the blue-light filtering ability of one lens when the mixed lens does not provide that same feature, and you also have to consider the cost of an exchange when a patient is disappointed with one of the lenses. John Blaylock, M.D., of Abbotsford, British Columbia, has reported making the nondominant eye a little myopic in ReSTOR patients who want improved intermediate vision. I have had success with this method as well. An advantage of monovision established in this way is that it truly allows you to match and match, as opposed to mix and match.
• Discuss cost considerations. Finally, with regard to the management of expectations, we address costs by comparing the multifocal vs. monofocal implant with the regular vs. deluxe wheelchair — insurance covers the expense of a regular wheelchair, but not the total cost of a deluxe wheelchair with extra features. We should help patients understand the added advantages of high-tech IOLs as they make their own cost assessments.

2 HABIT Accurate Biometry
There is much in the literature regarding the importance of accurate biometry. The essential role biometry plays in cataract surgery justifies an unyielding emphasis on the importance of determining IOL power with the highest degree of accuracy. With this in mind, I recommend that surgeons develop a personalized A-constant and use either the IOLMaster (Carl Zeiss Meditec, Dublin, Calif.) or immersion A-scan biometry.
The IOLMaster allows you to improve refractive results through personalized IOL constants computed by the integrated optimization algorithm on the basis of your postoperative data. In addition, you can have multiple operators work with this device and achieve the same measurement results, as the device guarantees user-independent outcomes.
I have found that immersion A-scan biometry is more accurate than the contact method because corneal compression is avoided. The immersion technique also is faster than contact biometry and reduces technician dependency.

3 HABIT Accurate Corneal Power
Corneal power is, of course, the other main component of IOL calculations. The Pentacam tomographer (Oculus, Dutenhofen, Germany) is used by some surgeons to determine corneal power. The Pentacam is the newest tomographer to be introduced to the market. It enables a mathematical reconstruction of the element studied, whereas other topographers study its surface exclusively.
Currently, in our practice we use corneal topography, IOLMaster, keratometry (K) readings and manual Ks. In the ideal case, we believe that all of these methods should agree. When they do not agree, further analysis is always necessary. Commonly, if two of the three methods agree, we will go with those Ks. Otherwise, we tend to place more emphasis on corneal topography.

4 HABIT Corneal Protection Pre- and Postop
It is well known that dry eye markedly reduces a person’s quality of vision. If a patient presents with an obvious dry eye preoperatively, I strongly recommend the use of artificial tears and/or cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan).
Frequently, I insert collagen plugs preoperatively. I will consider punctal cautery at the time of surgery, assuming there is no epiphora secondary to the collagen plugs. Postoperatively, I place every patient on artificial tears at least four times daily. Should keratitis be significant and punctal occlusion has not been performed, I consider insertion of either 6-month or permanent punctal plugs.
In managing dry eye, it is important that a high-quality artificial tear product be used. I prefer Systane (Alcon) or Refresh (Allergan). Given the potential for the occurrence of dry eye, I do not believe that LASIK should be combined with multifocal lens implants in most cases. Dry eye is much more likely postop if a LASIK flap is created preoperatively, whereas a LASIK flap created in the postop period will frequently result in at least temporary dryness.

5 HABIT Protection of the Eye Pre- and Postop
• Prevent infection. Infection remains a major consideration. Our preferred ocular anti-infective is moxifloxacin HCI ophthalmic solution 0.5% (Vigamox, Alcon), a fourth-generation fluoroquinolone that is highly soluble and demonstrates excellent penetration into ocular tissues. It is a self-preserved, benzalkonium chloride (BAK)-free drop. It is formulated at a physiologic pH of 6.8, has a broad spectrum of activity1,2 and, as studies have shown, it is less likely to select for resistance than previous generations.^3,4
• Eliminate inflammation. Another major consideration is the use of a potent steroid to rapidly eliminate inflammation and decrease the risk of cystoid macular edema (CME). In our practice, we conducted a study to evaluate the efficacy of Econopred Plus (Alcon) vs. the gold standard Pred-Forte (Allergan). In this study, we compared 51 patients receiving Econopred Plus to 49 patients receiving Pred-Forte. In all of these patients, I performed phacoemulsification at the same facility, using the Infiniti Vision System (Alcon) and implanted the same model acrylic lens. The results showed no difference in anterior chamber cell or in keratitis. Observations of anterior chamber flare also were the same, except at the 2-week period, when Econopred Plus performed slightly better. Based on these findings, I see no significant difference between these two steroid drops.
• Prevent CME. The most frequent cause of vision loss after cataract surgery can be attributed to CME, with late onset at about 4 to 6 weeks postoperatively.5 CME is estimated to occur in up to 12% of low-risk cataract cases,⁶ and its development is due in part to prostaglandin-mediated breach of the blood-retinal barrier.⁷ Risk factors for CME include pre-existing ocular inflammation, epiretinal or vitreoretinal interface membrane problems, diabetic retinopathy, a history of ocular vascular or cardiovascular disease, a history of retinitis pigmentosa and/or contralateral CME.⁸
Clinical CME is usually described as vessel leakage associated with visual acuity of 20/40 or worse, but today’s definition is becoming stricter, at about 20/25 or worse, due to higher patient expectations and designer IOLs. What used to be termed clinically insignificant fluorescein angiographic CME is no longer clinically insignificant. It can cause hyperopic astigmatism and some loss of best uncorrected vision, especially with multifocal IOL’s.⁹
Thus any CME can be significant in our multifocal patients, as a small amount of macular edema can degrade visual quality. Given today’s higher standard for macula protection in our multifocal patients, I believe that topical NSAID use takes on an increasingly important role. NSAIDs used preoperatively and postoperatively minimize the incidence of patient treatment due to CME. However, conventional NSAID therapies are frequently associated with unwanted corneal effects, such as burning and irritation, superficial punctuate keratitis and delayed wound healing.¹⁰
Severe corneal events, such as thinning and perforation due to melts, also have been reported with some conventional NSAIDs.¹¹ These safety and tolerability issues underscore the importance of newer, novel NSAID therapies, such as nepafenac ophthalmic suspension 0.1% (Nevanac, Alcon).
This novel new compound rapidly delivers analgesia (not anesthesia) to the corneal surface upon administration. As it penetrates intraocular tissues, intraocular hydrolases convert the nepafenac molecule into the highly effective cyclooxygenase inhibitor, amfenac. This mechanism of action gives nepafenac target-specific activity that maximizes its efficacy at the ocular sites where pain and inflammation reside, and greatly reduces toxicity. Pivotal multi-center clinical trials demonstrated that this new topical NSAID provides excellent pain and inflammation control with no burning or stinging, and that it leads to significant suppression of prostaglandin synthesis. These same studies demonstrated a cure rate of more than 80% among patients treated with this NSAID and no steroids.¹² The recommended dosing for nepafenac is one drop applied to the affected eye(s) three times daily, beginning 1 day prior to cataract surgery, continued on the day of surgery and through at least the first 2 weeks of the postoperative period. I start it earlier and use it significantly longer in high-risk patients.

6 HABIT Excellent Surgical Technique
Multifocal patients need efficient, safe, consistent surgery that induces as little inflammation as possible. For example, dense cataracts should be removed very efficiently, the surgery should be done uniformly among patients to maintain consistent A-constants, the capsulorrhexis should be between 5 and 5.5 mm, the implant should be centered and the viscoelastic needs to be removed from behind the implant.
Another new advance — torsional ultrasound — can further increase phaco safety. Torsional ultrasound performed using a new handpiece and software upgrade to the Infiniti Vision System enhances safety and efficacy. The minimal tip movement associated with torsional ultrasound significantly reduces heat production at the incision site, and, because there is no intrinsic repulsion of the nuclear material as there is with longitudinal ultrasound, the effectiveness of emulsification is greatly improved, making dense cataracts easier to remove.

7 HABIT A Proactive Approach to Astigmatism
I take a highly proactive approach to astigmatism and typically create a plan to deal with astigmatism. This plan is discussed with patients prior to surgery, ensuring that expectations are in line with what we hope to achieve.
I feel that the best way to eliminate astigmatism is to perform surface laser ablation. I aim for a myopic result following the multifocal implant so patients can receive a myopic ablation postoperatively. This ablation clearly stabilizes faster and appears to give a higher quality of vision than a hyperopic ablation. It is advisable to plan for myopia so hyperopic or mixed ablation is not necessary. Surface treatment results in an eye that is biomechanically stronger and definitely not as dry.
Limbal relaxing incisions (LRIs) are another option, and can easily be performed intraoperatively or postop. They have a low complication rate. LRIs offer several advantages in combination with a temporal cataract wound: They can be combined with other surgical procedures, stabilize quickly, help avoid the blebs in patients with previous glaucoma surgery and spare the superior conjunctiva for future glaucoma procedures. Another option is astigmatic keratotomy, which can be utilized to reduce astigmatic error postoperatively.

A Comprehensive Approach
These “Seven Habits of Successful High-Tech IOL Users” combine to offer a truly comprehensive approach to the management of our multifocal patients. With such an approach, one new surgical imperative becomes quite clear: To keep pace with both new technologies and growing patient expectations, we can no longer do just good procedures, we now must perform great procedures.

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