Letters

Paradigm Shift for Premium IOLs

To the editor:

I totally agree with the message conveyed in the "Viewpoint" article ("The Challenge of Presbyopic IOLs," OM, March 2008). For many ophthalmologists, integrating premium IOLs into their practice requires a paradigm shift from a "disease oriented" practice to a refractive surgery "experience." Success or failure goes beyond the technical aspect of flawless cataract surgery and accurate biometry. It may rely on ethereal factors, such as doctor-patient relationships and patient expectations.

Variables, such as patients with personality disorders, morbid depression or overall pessimistic outlook, may not be easily changed in the short term. Doctors may screen these patients out as suboptimal premium IOL candidates if these traits present in the initial screening. A second visit for biometry sometimes allows the surgeon and staff a second bite at the apple in terms of preoperative personality assessment and further patient education. Questionnaires can help in screening some patients, such as those who feel that glasses are part of their persona (e.g. Harry Caray).

Portions of patient education and screening can be delegated to technicians, but only after the surgeon has trained them. (Training must include mock screenings.) For the screening process to succeed, one highly skilled technician should be designated to the task of coordinating the refractive lens program. This technician should be held accountable for the program and not be assigned so many other tasks that they are, in effect, doomed to fail. The surgeon must ultimately decide if he wants to perform premium IOL implantation as a hobby or as a main thrust of the practice, and then allot resources accordingly.

In making the transition, the non-refractive cataract surgeon faces obstacles, such as obtaining access for possible laser vision enhancement. For many practices, one or two unhappy premium IOL patients have tainted the surgeon's initial view of premium IOLs and also significantly dampened the staff's enthusiasm. Many times, the most difficult patient complaints focus on diminished quality of vision, which may be more prominent with multifocal than accommodating IOLs. Here, sometimes explantation becomes part of the treatment algorithm, but only after eliminating other possible sources of decreased image quality, such as dry eye or ocular surface disease, a decentered IOL with respect to the pupil, residual refractive error, capsular opacity or cystoid macular edema.

If all patients are told preoperatively that they will likely need to wear glasses for some tasks, and that the goal of the surgery is to diminish (but not necessarily eliminate) the need for glasses, that may go a long way in limiting preoperative expectations. Note that the patient's reaction to this information is important in preoperative selection. I explain that today's premium lenses are better than those offered in the past, but they are man-made lenses. We have not yet achieved the elegant fusion of form and function that our Creator has in giving us the crystalline lens that we were born with. While we may be able to set the clock back to age 40 or 45, we cannot yet set it back to age 20 for all patients. For some dissatisfied patients, showing them their near and intermediate vision with -2.5 D or -3.0 D spectacles gives them a better understanding of accommodating and multifocal lenses, and a better appreciation of what they did obtain for an additional fee.

Your final point about discussing the premium IOL option with every patient (even if you do not offer it or recommend it) is so important as part of the informed consent process. I have already seen very upset patients in my office that had a monofocal IOL implanted elsewhere, where a premium IOL was not offered and they later heard about this option from happy friends or neighbors. Early in my practice, my technician told me that the next patient, who had a 3-day beard and a disheveled appearance, was not going to be a premium IOL candidate. I laughed when I discovered that he was the retired CEO of a Fortune 500 company.

We live in interesting times and with challenge comes opportunity. We will have increasingly better premium IOLs to offer the baby boomers. Ophthalmologists must decide for themselves if this represents an opportunity to provide a service that their patients can afford to miss.

Jay S. Pepose, M.D., Ph.D.
St. Louis, Missouri