For premium IOLs, take the focus beyond the clinical

Advanced-technology devices demand a sharper view on patients’ professional and personal lives.

By Surjeet Singh, MD

I have implanted more than 300 advanced-technology or premium IOLs in the last 12 months. When I select patients for premium IOLs, I go beyond the clinical evaluation of their eyes to evaluate the entire person: What he or she does for a living or for fun, expectations — realistic and otherwise — and, in these times, love of technology. Selecting the appropriate patient not only hinges on ocular pathology, but also on the individual’s vocation, hobbies, lifestyle and personality.

The discussion about the various types of technologies to treat cataracts begins when the patient is in the exam chair.

Baby boomers are more tech savvy than their parents’ generation in their advanced years, and their expectations are higher. They are accustomed to cell phones and text messaging, as well as computers and tablets, all of which can be challenging for anyone with astigmatism and presbyopia.

Baby boomers are but one example. My parents are not baby boomers, but they are always on their cell phones, PCs and other devices. Ophthalmologists today have a responsibility to make these patients aware of the various IOL options available when they are having cataract surgery.

Demonstrating transparency about the out-of-pocket cost of the premium IOLs is another key to gaining the patient’s trust. I never hesitate to discuss the extra price for additional options, and I do this without the patient asking me. I clearly discuss the exact out-of-pocket cost associated with those options so my patients know I have nothing to hide. I welcome and answer all cost inquiries at the same time I tell them about what different IOLs provide.

THE PREMIUM IOL PRESENTATION

Gaining the patient’s trust

I personally counsel each patient rather than have a surgical coordinator do that. I delegate to her the tasks of answering questions about scheduling, obtaining medical clearances and conducting required preoperative tests.

When a patient first presents for a cataract evaluation, I act as the point person for information on various lens options. As I evaluate a cataract patient sitting in the exam chair, I discuss the various types of technologies available to treat cataracts as well as correct astigmatism and presbyopia during the same surgery. I do this before taking any preoperative measurements.

I have found this to be a useful method for engaging my patients in their plan of care from the first moment that they start considering cataract surgery. I also believe that for a patient to get information about various IOLs directly from a physician rather than ancillary staff instills more trust in the process.

Strengths, limits of IOLs discussed

In our discussions, I explain to my patients these key points:

• With the monofocal IOL option, they may still need glasses to see far, near and intermediate if they have astigmatism.

• Astigmatism and cataracts can be treated at the same time. This allows greater spectacle independence for distance activities such as driving and watching TV.

• They should consider presbyopia-correcting IOLs: These maximize the range of vision from distance to near with multifocal lenses or accommodative IOLs. Presbyopia-correctiong options may provide the greatest independence from glasses, and may also offer the best opportunity to drive, watch TV, text message, view caller-ID information on phones and read normal newspaper print without glasses.

Explaining the basics: ‘far’ and ‘near’ vision

Some patients may not know what “far vision” is or what constitutes “near vision.”

So I often elucidate that the act of watching television involves distance vision, as does driving. People should understand what specific activities they can and cannot do with certain IOLs.

They will have difficulty reading texts or numbers on their cell phones, for instance, with monofocal lenses or toric IOLs if corrected for distance, and they will need glasses for those tasks. It is my job to tell them directly about their candidacy for each given their respective expectations.

Glaring challenge for a comic’s vision

This discussion also helps me select the right IOL for any special attributes unique to the person in front of me as well as in identifying any unrealistic expectations.

For instance, one of my cataract patients is a Las Vegas comic who was interested in the multifocal IOL because his wife had an excellent outcome with it. However, I did not think he would be a good candidate for the multifocal option. The risk of glare from stage lights could pose a potential challenge to his job performance.

The additional three minutes it took for me to have this discussion allows me to understand my patients better, as things will come up that my surgery counselor may not otherwise unveil as a potential pitfall.

CHOOSING THE RIGHT IOL

Wide array available

I’ve used a wide array of IOLs. The Tecnis ZCB00 (Abbott Medical Optics, Abbott Park, Ill.) is my monofocal IOL of choice. It is an aspheric, non-blue blocking, acrylic IOL. These innate properties allow for excellent contrast sensitivity while enhancing scotopic vision.

As far as the toric IOLs are concerned, I have implanted several hundred AcrySof IQ Torics (Alcon, Fort Worth, Texas) and Tecnis Torics (AMO) IOLs, as well as a few Trulign Torics (Bausch + Lomb, Rochester, N.Y.). My IOL of choice once again is Tecnis, because this lens is built on the same platform as the monofocal IOL.

Multifocal vs. accommodative IOL

In terms of presbyopic correction, I end up using multifocal IOLs 90% of the time over accommodative IOLs. This is because I’ve found patients who have had accommodative IOLs have a greater need for spectacles more for near vision than those who have had multifocal IOLs. I prefer the Crystalens (Bausch + Lomb) accommodative technology for cases of macular or optic nerve pathology.

When it comes to multifocal options, I prefer the Tecnis as my lens of choice. Besides having the same platform as the Tecnis monofocal and toric IOLs, the Tecnis multifocal more consistently delivers excellent distance and near vision without glasses.

This is an exciting time for eye surgeons and patients alike. We can offer our patients a wide array of advanced-technology IOLs

However, none are perfect. So our work-up must combine clinical and pathologic information along with the patient’s professional and personal needs for us to select the best IOL fit for an individual. OM

About the Authors
	Surjeet Singh, MD, is a cataract and refractive surgeon at Westfield Eye Center and Nevada Eye & Ear in Las Vegas. Disclosure: Dr. Singh has no conflicts to disclose.