Lead Your Premium IOL Patients to Complete Satisfaction

BY JOHNNY L. GAYTON, M.D.

When I opened my practice 25 years ago, I set one simple goal — to take the best possible care of each and every patient. This has worked extremely well for my patients and practice, especially when it comes to premium IOLs. True success with these lenses requires a hands-on, patient-centered approach. In our practice, this means taking steps to prevent potential problems. It also means troubleshooting and addressing any concerns patients have with their postoperative vision so their satisfaction is ensured.

If you are new to premium IOLs, or your efforts are not producing the results you are looking for, you may find it helpful to read about the following strategies that work for us.

Setting the Stage for Success

As noted above, we take steps to prevent any potential problems that could interfere with patient satisfaction. We refer to these steps as "7 Habits of Highly Successful High-Tech Lens Users."

(1) The most important habit is thorough and honest preoperative counseling. We educate patients so that their expectations about postoperative vision are realistic. We try to under-promise and over-deliver. We explain the role of astigmatism and the probable need for additional procedures to minimize it. We make sure patients understand that the cornea and lens are different anatomic entities and may both require treatment to maximize vision.

We also explain to patients that they tend to do better if they have bilateral surgery. For example, the results of a recent study performed by Richard J. MacKool, M.D., indicate that patients with an apodized diffractive IOL (AcrySof ReSTOR IOL, Alcon, Fort Worth, Texas) in one eye have an approximately 60% chance of being able to read without correction, but when the lens is implanted in both eyes that number approaches 90%. Given this information, most of our presbyopic patients end up having surgery on both eyes, whether it is cataract surgery or refractive lens exchange. We have also found that unless we tell patients that IOL marketing materials and advertisements tend to overstate the abilities of the lenses, their expectations are too high.

(2) Accurate biometry and corneal power.

(3) Appropriate patient selection. It is important to pick patients who would do well with premium lens technology. It is easier to list some types of patients that I would not consider for presbyopic lens correction. Do not insert the lenses in patients who are expecting perfect vision. Many of the unhappy referrals to our practice have been long-term smokers who frequently have dry eye and some macular dysfunction. There is no way to deal with every situation, but you should try to marry lens characteristics to the patients desires and needs.

(4) Pre- and postop protection of the corneal surface with artificial tears, punctal plugs, topical cyclosporine and/or nutritional supplements, as well as discussion of environmental irritants to avoid. Dry eyes can adversely affect the success rate by decreasing the accuracy of preop measurements, blurring vision, decreasing contrast sensitivity and by contributing to glare and halos.¹

(5) Pre- and postop protection of the eye with steroid, antibiotic and NSAIDs is also key. The NSAID is necessary to prevent cystoid macular edema (CME), the most frequent cause of diminished vision following uncomplicated cataract surgery.² Even low-level CME can cause hyperopia or hyperopic astigmatism. The peak onset of CME is usually 4 to 6 weeks after surgery.³ Steroids alone do not effectively prevent or treat CME², and adding a topical NSAID is very effective and has been shown to have a beneficial effect on visual function.³ It is important to achieve therapeutic concentrations in the posterior chamber to maximize the effects.⁴ I personally prefer bromfenac ophthalmic solution 0.09% (Xibrom, ISTA Pharmaceuticals) because it is dosed b.i.d., half as frequently as other NSAIDs. It has also been shown to be effective when dosed once per day.

(6) Excellent, consistent surgical technique, including protection of the cornea and capsule, is also necessary for optimum results.

(7) Proactive management of astigmatism and residual refractive error. The surgeon must have a plan and discuss it with the patient. Generally, if a patient with astigmatism wants to achieve his or her absolute BCVA, I recommend a toric IOL. If a patient wants a presbyopia-correcting option, I counsel him or her thoroughly about astigmatism.

If preop cylinder is less than 2 D, I try to correct it with limbal-relaxing incisions (LRIs) during the lens procedure. If preop cylinder is 2 D or greater, I take a bioptic approach. I intentionally aim for postop myopia, which I then correct with laser surface ablation. Myopic surface ablations tend to stabilize quicker than hyperopic ablations. We enhance ReSTOR IOLs with surface laser at about 6 weeks. Crystalens (Bausch & Lomb Surgical, Aliso Viejo, Calif.) patients are advised to wait 6 months.

In our practice, we've added a bonus eighth habit to the list: Have everyone on the same sheet of music. The practice has to work as a team and deliver the same message to the patient. When this doesn't happen, problems do occur. For instance, I implanted a toric lens for one of my patients, who was -11 D +2 D preop. After surgery, his VA was 20/25 uncorrected. Instead of congratulating him, the referring doctor pointed out that he "still had three quarters of a diopter of astigmatism." I had to spend 45 minutes calming down a patient who otherwise would have been ecstatic. In another case, a technician told a satisfied ReSTOR IOL patient that her distance vision was not good enough. The patient then insisted on a YAG laser procedure. As Murphy's Law would dictate, she suffered a post-YAG retinal detachment.

Following Through is Crucial

In spite of our best efforts to prevent problems, we still have been faced with a few unhappy postop patients. What has helped us most in making them happy is listening earnestly to their complaints. As J. Lawton Smith, M.D., Bascom Palmer Eye Institute professor emeritus of ophthalmology, said, "listen to your patient and he will tell you what is wrong." If a patient is having a problem, we run to them rather than away from them.

The four most common reasons for postop dissatisfaction are:

(1) Not knowing how to use the lens. Often, presbyopic patients had been used to having reading material in their laps. Postoperatively, it most likely needs to be held at 11 to 14 inches. I have patients who are struggling with this "find the sweet spot" by placing reading material at their nose and gradually moving it away until they find their clearest vision.

(2) Dry eye. All our advances in cataract and refractive technology are diminished by persistent ocular surface disease. Patients who complain of burning eyes, mattering eyes and/or fluctuating vision after surgery should be considered to have ocular surface disease until proven otherwise. This needs to be managed aggressively, as it was preoperatively.

(3) CME. Cystoid macular edema is much less likely to occur when an appropriate course of NSAID is used. However, it can still occur. Be sure to check for it by performing optical coherence tomography on patients with diminished BCVA, hyperopia or hyperopic astigmatism. It would be a shame to do a laser procedure for refractive error on a patient with CME only to have the CME resolve and be left with the opposite error. Aggressively treat CME with steroids, NSAIDs and vitamins. If it does not resolve quickly, consider referring to a retinal specialist.

(4) Residual refractive error. In my experience, this occurs in 10% to 20% of presbyopia-correcting lens patients. In these cases, some form of enhancement should be done. Multifocal IOL patients have very low tolerance for residual refractive error because they may already have decreased contrast sensitivity from the lens. Correcting the residual error frequently makes a huge difference in patient satisfaction. We treat most of these patients with LASEK. We prefer LASEK to LASIK because it doesn't induce dry eye like LASIK, and we can do the procedure sooner without concerns about disturbing the cataract surgery wound.

In addition, it's possible for a patient to markedly under-respond to intraoperative LRIs. In these cases, we also enhance with laser surface ablation. Postop patients who have not had an LRI and have 1.5 D or less of cylinder with a near plano spherical equivalent are treated with LRIs 1 month or more after their lens procedure.

Finally, in some cases where patients tell us they are not satisfied with their postop vision, using a -3 D lens to illustrate what their vision would have been like had we not used an apodized-diffractive IOL completely changes their minds. It allows them to see and appreciate the benefits of the IOL.

Patients are Looking for a Partnership

Once patients know that you are with them until they are satisfied, they remain willing partners in making their premium IOLs work. To keep everyone in our practice on the right track, we have this sign posted throughout: "Patients do not care how much you know until they know how much you care." This mindset is certainly working for us. OM

References

1. Rolando M, Lester M, Macri A, Calabria G. Low spatial-contrast sensitivity in dry eyes. Cornea. 1998;17:376-379.
2. McColgin AZ, Raizman MB. Efficacy of topical Voltaren in reducing the incidence of post-operative cystoid macular edema. Invest Ophthmol Vis Sci. 1999; 40 S289.
3. Samiy N, Foster CS. The role of nonsteroidal anti-inflammatory drugs in ocular inflammation. Int Ophthalmol Clin. 1996;36:195-206.
4. Gaynes BI, Fiscella R. Topical nonsteroidal anti-inflammatory drugs for ophthalmic use: a safety review. Drug Saf. 2002;25:2332-2350.

Dr. Gayton is the founder of Eyesight Associates in Warner Robins, Ga. He is on the speaker's bureau at Alcon.