Viewpoint FROM THE CHIEF MEDICAL EDITOR

The Challenge of Presbyopic IOLs

Larry E. Patterson, M.D.

I've had the opportunity to talk with many of you regarding your use of presbyopic IOLs. At the last annual American Academy of Ophthalmology meeting, I was surprised to learn how many of you don't use these implants in your practices. They aren't even offered.

On further reflection, maybe I shouldn't be surprised. There are downsides. It takes a lot of chair time. Even if you delegate patient education tasks to you staff, it still involves their time. And sometimes, after a few visits and several hours of discussion, the patient still decides against these premium lenses.

There are significantly increased patient expectations. Some will be 20/20 and J1+ uncorrected, but still unhappy with night vision, intermediate vision, or visual side effects. They paid a lot of money – they want perfection. If your patient is unhappy, you may have quite a task ahead trying to determine why. Is it the IOL itself, mild CME, uncorrected astigmatism, dry eye, or something else? There are often more postop visits. If you don't have onsite LASIK and/or CK equipment, then enhancements are inconvenient at best.

One of my happiest patients received multifocal implants bilaterally elsewhere and complained bitterly about quality of vision. After many visits and lots of measurements and discussion, I explanted the lenses and gave him monovision with aspheric monofocal IOLs. He says it's exactly what he needed.

We don't have a perfect presbyopic IOL yet. I use all three that are commercially available in the United States. I don't yet have one that I prefer, as they all have pluses and minuses. I mix and match a lot. About 20% of my cataract patients choose these premium implants. I don't push them, I just explain what they do and give the option. Having said that, most of my patients who do choose presbyopic IOLs state that it's the best money they've ever spent.

Even if You Decline

If you decline to use these IOLs, that's fine and that's your choice. Believe me, I do understand. Life used to be much simpler. But in my opinion, you do not have the choice of failing to bring these up as an option. Certainly you can explain to your surgical candidates why you prefer monofocal lenses over the presbyopic variety. You can even refer them out to another surgeon if they really want the implants. But I am concerned that more and more patients are going to be upset when they find out these lenses have been available for a few years and yet were never informed about them. Even the seemingly poorest patients in my practice are given the option, even if I prejudge that they can't afford them. I've been surprised a few times. And I've already heard doctors talk about patients who were upset that they weren't offered the option because they were on Medicaid.

The issues surrounding presbyopic IOLs aren't going away anytime soon. I'd love to hear your thoughts, as well as personal experiences.