Delivering the Premium Package

Surgeon combines B-MICS and the Crystalens AO for the ultimate in patient satisfaction.

By Robert J. Weinstock, MD

As an early adopter of presbyopia-correcting IOLs, I've had a close-up view of their evolution and improvement over the years. We've reached the point where we can deliver increased freedom from spectacles and spectacle-free quality vision at all distances to nearly every patient who wants it. For example, 90% of the cataract patients I see in my practice are good candidates for the Crystalens accommodating IOL, a lens I frequently implant. I was also an early adopter of bimanual microincision cataract surgery (B-MICS). I use B-MICS for all of my cases, including procedures with the Crystalens. In my opinion, B-MICS allows me to perform the safest and most efficient surgery possible, which makes it a must for premium IOL cases. I have to enlarge my incision to implant the IOL, but my patients and I derive major benefits from the smaller wounds of B-MICS at every other stage of the procedure.

In this article, I explain the benefits of using B-MICS and the Crystalens, and discuss other facets of surgery that are necessary to achieve premium outcomes.

B-MICS Helps Satisfy Patient Expectations

Patients who opt for a presbyopia-correcting IOL do so because they're interested in, and willing to pay for, the best we have to offer. This includes the expectation of a smooth and uneventful surgery. For me, B-MICS is crucial for meeting that expectation because it maximizes the safety and effectiveness of removing the nucleus and cortex. These stages of surgery are the most delicate and where we're most vulnerable to potential complications.

In B-MICS, irrigation is separated from phacoemulsification and aspiration, which fosters superior control of fluid dynamics. A steady flow of irrigation into the anterior chamber allows highly controlled manipulation of the phaco handpiece and nuclear particles. The sleeveless irrigating chopper acts as an additional instrument inside the eye by pushing particles in the desired direction, leading them to the phaco handpiece. This contrasts with coaxial surgery, where irrigation tends to repel lens material away from the phaco needle.The efficiency of B-MICS results in quicker procedures, less phaco energy used, less endothelial cell loss, less postoperative inflammation and faster healing and visual recovery. Also, because less fluid escapes through the smaller wounds, the risk of iris prolapse and chamber collapse, which can lead to capsular tears, is reduced.

Crystalens: My Preferred Presbyopia-Correcting IOL

The Crystalens is my presbyopia-correcting lens of choice because, in my experience, it gives patients the best overall quality of vision of any of the currently available presbyopia-correcting IOLs. It doesn't rely on multifocality to provide a range of vision, so patients are not susceptible to the visual disturbances and reduced contrast sensitivity that can be associated with a multifocal lens design. Three models of the Crystalens are available to surgeons, the Crystalens Five-0, the Crystalens HD and the Crystalens AO. I participated in the post-approval field observation evaluation for the Crystalens AO and was so impressed with its performance that I now implant that model exclusively.

The combination of the Crystalens monofocal accommodating platform and the AO optics work together to provide better retinal image quality than a multifocal lens and therefore excellent intermediate and distance vision. The optic is aspheric, specifically designed to add zero spherical aberration to the visual system. As a result, contrast sensitivity is enhanced. The Crystalens AO leaves the eye with its existing amount of corneal positive spherical aberration, which serves to add depth of field to the IOL's accommodative effect.

Another advantage of the Crystalens AO compared with the multifocal lenses is that it's not as dependent on pupil size. Its aspheric design with slight power changes center to edge means it is very rare that a patient is not a candidate for the Crystalens AO based on pupil size.

I have never had to explant a Crystalens AO because a patient is dissatisfied with his or her post-op vision. That has not been the case when it comes to the multifocal IOLs. That alone tells me that patient satisfaction and quality of vision with the aspheric accommodating design are superior to a multifocal design. Well over 90% of my Crystalens AO patients not only have excellent distance vision, but also can use a computer and perform other intermediate tasks without correction.

Figure 1. Dr. Weinstock implants a Crystalens IOL, placing the tip of the injector far and deep into the capsular bag. When the bag is filled with viscoelastic, the leading haptics fold, bend and slide safely into place.

Additional Premium Components In addition to the B-MICS procedure and the Crystalens AO, other aspects of care are key for providing the best possible experience and outcomes for cataract surgery patients. Patient selection: The quality of today's presbyopiacorrecting IOLs has simplified patient selection for this category, but it's still important to ensure expectations are realistic. For perfectionists or patients who fail to understand that 100% spectacle independence can't be guaranteed, I usually do not recommend a presbyopia-correcting lens. Even when we obtain excellent results, these patients tend to find things to complain about. When this category of lenses was first introduced, it also made sense not to implant them in patients with intraoperative floppy iris syndrome or pseudoexfoliation. Now that we've developed more sophisticated techniques for handling these conditions, they're not always an absolute contraindication for a Crystalens as long as the surgery itself goes well. If I suspect one of these conditions could interfere with surgery or post-op results, I decide in the OR whether to proceed with Crystalens implantation based on capsular stability. Patients who have epiretinal membranes, severe glaucoma, previous vitrectomy or other posterior segment problem that would limit potential postoperative vision are not good candidates for presbyopia-correcting IOLs. The investment in a premium IOL is simply not worth it for them. I examine the retinas of all cataract patients with a 90D lens to check for pathology and evaluate the foveal reflex. If I see a dulling of the reflex, I order an OCT scan to determine macular thickness. I may also send the patient for a vitreoretinal consultation. All patients also undergo a thorough corneal evaluation, which, like the retinal evaluation, takes on added importance for patients considering a premium IOL. It would be impossible to meet visual expectations in the presence of conditions such as Fuchs' endothelial or map-dot dystrophy. Patients also should be screened for dry eye, although typically it can be treated so it doesn't interfere with post-op vision. Pre-op and intraoperative ocular measurements: Precise eye measurements are also crucial for maximizing the performance of presbyopia-correcting IOLs. I use the IOL Master (Carl Zeiss Meditec) for axial length and keratometry measurements. However, I also obtain manual keratometry readings, direct axial length measurements with A-scan ultrasound biometry, topography with the Orbscan (Bausch + Lomb) and a wavefront analysis with the OPD-Scan (Nidek). If manual and IOL Master Ks don't match, I retest. Increasingly, I use the ORange Intraoperative Wavefront Aberrometer (WaveTec Vision) for additional guidance on IOL power and the refractive status of the eye. This device is designed to be used intraoperatively, so real-time measurements are possible at any stage of surgery. As such, it's very useful in the management of corneal astigmatism, which should be .5D or less postoperatively for premium IOL patients. With the ORange, I can titrate IOL power as well as the number and location of limbal-relaxing incisions in the OR, fine-tuning the preoperative plan if necessary. Post-op medications: To prevent inflammation, including cystoid macular edema, and capsular contraction, I'm a strong proponent of prescribing anti-inflammatory medications for 6 weeks after surgery. I have patients use a topical steroid 4 times a day for a month and then 2 times a day for an additional 2 weeks. I also have them use a topical nonsteroidal anti-inflammatory agent twice a day for 6 weeks. In-office experience: When it comes to premium IOLs such as the Crystalens, patients are expecting a premium experience from start to finish. Two ways to ensure patients come away feeling their choice was one of value are to create an efficient yet inviting, spa-like environment at the practice and ensure that all staff members are focused on providing high-quality customer service in a pleasant manner.

Strategies for Patient Satisfaction

As with any technology, I'm careful not to overpromise results for my Crystalens AO patients. I let them know not everyone responds to the lens the same way and their spectacle-free range of vision depends on how well their eye can make the lens move.

The patients most likely to require reading glasses postoperatively in at least some situations are those for whom I target both eyes for the best possible distance vision. This is the best strategy for patients whose top priority is clear distance vision, such as pilots, police officers and those who drive a lot.

However, most patients don't need both eyes to be emmetropic. I've learned that I can use a small amount of anisometropia to provide more functionality for near tasks. In these cases, I operate on the dominant eye first. I target as closely as possible to plano on the minus side. If I've achieved that goal at 1 week post-op, I target minus 0.35D to 0.37D for the second, nondominant eye. If the first eye refracts more minus than I had expected, and uncorrected visual acuity is 20/30 or worse, I target the second eye closer to plano. With this approach, the vast majority of patients achieve complete spectacle independence with no need for glasses for daily activities or reading in good lighting.

I will, on rare occasions, implant a multifocal IOL. I reserve this strategy for patients who are very motivated to have spectacle-free near vision for fine tasks, such as sewing, in just about any lighting condition. Using a Crystalens AO in the dominant eye and an apodized diffractive multifocal in the nondominant eye can work well as long as the patient understands the different optics may take some getting used to.

Based on my experience to date, the Crystalens AO — along with B-MICS phaco to maximize safety and efficiency — is the best way to provide the widest range of quality vision to the largest number of patients.

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Dr. Weinstock is director of Cataract and Refractive Services at the Eye Institute of West Florida and The Weinstock Laser Eye Center. He's also surgical director of the Largo Ambulatory Surgery Center and an associate clinical professor of Ophthalmology at the University of South Florida. Dr. Weinstock is a consultant to Bausch + Lomb.