A Balanced Approach to Premium IOLs

Surgical skill alone won't guarantee success. Patients must take part in the process as well. Here's how to get both working in harmony.

Premium intraocular lenses have been the toast of the town ever since their auspicious debut in the late 1990s. It's easy to see why — the latest designs represent some of the biggest breakthroughs in optics this decade. The potential to offer cataract patients refractive correction at multiple focal lengths in a presbyopic IOL, or combined spherical and astigmatic correction in a toric IOL, is indeed a game-changer. But perhaps not in the way cataract surgeons might have expected.

The 260-year history of modern cataract surgery — ever since Jacques Daviel performed the first extracapsular cataract extraction in 1748 — has been marked by a steady accumulation of advances in technology and technique such that today's procedures allow just about any patient to achieve life-changing results with spherical IOLs. From the patient's point of view, the transformation is passive: enter the OR with a lens opacification, leave with unobstructed media (and a pair of reading glasses), live happily ever after. Patients undergoing multifocal IOL implantation, however, must play a more active role than their monofocal counterparts if the surgery is to be considered a success. They must be motivated to adapt their reading behavior to find the lens's "sweet spot," tolerate occasional tradeoffs in acuity between different visual tasks, and must be warned of the potential for visual abnormalities like glare and halos in mesopic conditions. And these typically fixed-income retirees must pay more out of pocket than other patients. This leaves ophthalmologists in the delicate position of charging a premium price for a product that may not meet the patient's heightened expectations.

How, then, to achieve this higher level of patient "buy in," both psychologically and financially? Surgical prowess and patient motivation must work in harmony. Like the yin and yang of Eastern philosophy, each is dependent upon the other for success. Careful preoperative screening will identify the best candidates and suggest the right lens option for each. Thorough patient education prior to surgery is critical to make sure that expectations and outcomes achieve parity. And in another nod to duality, the postoperative phase is often as important as the preop screening and patient education, as patients learn to adapt and surgeons consider whether or not retreatment is needed.

To enlighten our readers, we asked two esteemed surgeons — Johnny Gayton, MD and Michael Vrabec, MD — to share their advice on setting patient expectations, measuring whether or not you've met them, and working to correct any deficiencies after the fact. Perhaps one day premium IOLs will be as plug-and-play as spherical lenses have become. Until then, heed the advice noted in the I Ching two millennia before the first primitive attempts at cataract surgery took place in India: "The Creative knows the great beginnings. The Receptive completes the finished things." Here's hoping the creative surgeon and the receptive patient can achieve that elusive harmony.