IOL Choices

Guiding Your Patients Toward Their Best IOL Choice

For patients motivated to correct presbyopia, the IQ ReSTOR IOL +3.0 D is an excellent option.

By Carlos Buznego, MD

For both experienced and new cataract surgeons, when presenting IOL options to a patient, it is essential that you end the conversation by providing a solid recommendation. Realize that as physicians, we should steer patients in the right direction, if they qualify for that particular option. This will decrease confusion and reinforce to patients that we have their best interests in mind.

Opening Discussion

Before you even begin a conversation with patients, it is crucial that you feel confident in the presbyopic lens you've chosen and the results you'll achieve. To this end, I recommend that you practice your IOL presentation with a staff member or another doctor to get your speech down. These ‘test runs’ will make your patient presentations more effective and efficient. This will help portray confidence in the lens selection, which ultimately should make patients feel more comfortable following your recommendations.

Saying, “This is the most advanced technology lens available” or “If you are interested in possibly eliminating or reducing your need for eyeglasses, I recommend … ” gives the patient a clear indication of why you have chosen a particular lens. Providing too many options may lead to confusion and frustration for the patient. On the other hand, providing examples or stories about patients who have enjoyed successful outcomes will make your patients feel confident in your recommendation. You may also begin with, “If I had this surgery myself, I would … ”

If you have a busy clinic, efficiency is critical. When I talk to patients about cataracts, I have a standard discussion about what a cataract is, what a lens will do and so on. If you provide the same background information, then move on to speaking about the positive characteristics of the lens, the discussion will be simple and informative each and every time.

The bottom line? Speak calmly, confidently and clearly. Set realistic expectations and make a specific recommendation.

Present the Options

As ophthalmologists, we treat a relatively older patient population. We are highly dependent on Medicare as the primary payer for most of our services. However, over the last several years, and with the anticipated arrival of the baby boomers, we also need to address higher patient expectations. As we work to formulate a plan for the future, we should consider revenue streams that will provide quality care for our patients with higher expectations and reimburse us fairly for our time and skills.

Among these services are refractive IOL procedures, which provide a dual benefit. Patients who receive presbyopic IOLs benefit from gaining improved vision and this option gives us more satisfaction as surgeons because we can fix their presbyopia. This is a paradigm shift for cataract surgeons. For years, I had patients achieving 20/20 results, but complaining that they couldn't read without glasses.

The ability to offer presbyopic lenses to our patients helps us provide them with top-quality care and helps us sustain our practices in a period when managed care and Medicare are threatening dramatic reductions in reimbursement.

When it comes to introducing the option of presbyopic IOLs, patients who want to be rid of eyeglasses are the perfect candidates. You just need to explain the value of the presbyopic lens implantation. You should explain that it's a fraction of what one might spend on a car and is a minor expense considering that the procedure will provide lifelong benefits.

A Quality Lens

Again, when deciding which presbyopic lens to choose, I want to deliver high-quality, spectacle-free vision. In clinical studies,^1-3 the AcrySof IQ ReSTOR IOL +3.0 D add (Alcon) provides a high level of success in patients reading small print with no spectacle correction.

Current pseudo-accomodating lenses claim to deliver excellent near, intermediate and distance vision. However, studies^4-6 at the recent ASCRS meeting indicate that many patients with pseudo-accomodating lenses really don't achieve impressive levels of high-quality near vision — such as a J1 or J2. They must supplement with reading glasses. When patients are willing to spend extra for multi-focal lenses, they expect to free of spectacles.

The original version of the ReSTOR had a +4 reading add. Although this provided patients with high-quality near vision, the near focal point was 13 inches away from the patient, which left some patients having difficulty with intermediate vision. The new version of the IQ ReSTOR IOL, which now has a +3 add, has a more natural reading distance and delivers high quality vision across all distances. In contrast, the other multifocal lens on the market, the Tecnis lens (Abbott Medical Optics) has a +4 add. According to its DFU, it has a shorter focal point and does not deliver the same level of intermediate vision as compared with the IQ ReSTOR IOL +3 add. This result has been confirmed in preliminary human comparative trials presented at the recent ASCRS meeting.^2,7

With the IQ ReSTOR multi-focal IOL, in order to achieve consistent results in a more discerning patient population, attention to detail and meticulous surgical technique are required. However, from the surgeon's point of view, the implantation of the IQ ReSTOR lens is not significantly different than inserting standard IOLs, such as the AcrySof IQ IOL. This contrasts with the pseudo-accommodating lenses, which require changes in surgical technique.

With older multifocals, there was concern about the quality of vision. Many of these issues can be attributed to uncorrected refractive error, residual astigmatism and ocular surface disease. In addition, the original version of the ReSTOR lens was spherical, whereas the newer IQ ReSTOR IOL has an aspheric design that delivers higher quality vision and better contrast sensitivity. With bilateral implantation of the ReSTOR IOL +3, patients can enjoy excellent vision across the board.

Surgical Technique

For surgeons who are just beginning to implant presbyopic lenses, it is crucial to undergo appropriate training. A great resource is training provided during a major meeting, such as ASCRS or AAO.

Here are some important steps to keep in mind when inserting a lens:

■ Preoperatively, careful examination of the ocular surface is critical. If the tear film or surface of the cornea is anything short of pristine, no IOL will provide a patient with the high-quality result they desire.

■ Be alert for signs of macular disease, because patients who exhibit these signs should not be offered presbyopic lenses.

■ Always read the Directions for Use, provided with every product.

■ During the preoperative evaluation, be sure to obtain high-quality images of the cornea to determine corneal power, make careful biometry measurements and use latest generation IOL formulas to maximize visual results.

■ Determine the amount of astigmatism your current cataract procedure causes (surgically induced astigmatism). For example, if your patient has some against-the-rule astigmatism and your surgery routinely increases against-the-rule astigmatism, it is important to adjust your measurements to ensure that you do not induce additional astigmatism, which would prevent you from achieving the desired final results.

■ I recommend that you track your results at regular intervals, so you can measure your current success with IOL calculations, axial length measurement and keratometry and evaluation of the surgically induced astigmatism.

■ To eliminate reliance on eyeglasses, you need to hit refractive targets on the nose. In general, patients who pay money out of pocket will complain if they still need readers and will be more concerned about their final results.

Presbyopic lenses are a wonderful addition to our surgical armamentarium because they benefit both patients and surgeons. Once you are comfortable with your premium lens presentation and your ability to insert the lens properly, you will be on your way to having a successful cataract surgery career. nMD

References

1. Maxwell WA, Cionni RJ, Lehmann RP, Modi SS. Functional outcomes after bilateral implantation of apodized diffractive aspheric acrylic intraocular lenses with a +3.0 or +4.0 diopter addition power. J Cataract Refract Surg 2009;35:2054-2061.
2. Fisher B. Subjective visual function outcomes after bilateral implantation of diffractive presbyopia correcting IOLs. Poster presented during ASCRS annual meeting; March 2011.
3. Rivera R. Range of vision after bilateral implantation of presbyopia-correcting intraocular lenses: apodized diffractive and accommodative IOLs. Presented during ASCRS annual meeting; March 2011.
4. Cionni R. Postoperative refraction and patient satisfaction after bilateral implantation of presbyopia-correcting intraocular lenses. Poster presented during ASCRS annual meeting; March 2011.
5. Snyder M. Spectacle dependence with presbyopia-correcting IOLs: Aspheric apodized diffractive, aspheric accommodative, or spherical accommodative. Poster presented during ASCRS annual meeting; March 2011.
6. Woodhams T. Limitations with vision for near, distance, and social activities: A comparison among three models of presbyopia-correcting IOLs” Poster presented during ASCRS annual meeting; March 2011.
7. Fisher B. Reading performance of patients with bilateral implantation of aspheric apodized diffractive and full diffractive intraocular lenses. Poster presented during ASCRS annual meeting; March 2011.