IOL matchmaking

Know your patients’ visual expectations before surgery to achieve success.

By Lisa B. Samalonis, Contributing Editor

Selecting the optimal IOL for each patient requires making a concerted effort to define and manage postoperative expectations — as well as making keen observations about patient personalities. But in a busy practice, those things are often easier said than done. Successful surgeons spoke with Ophthalmology Management about the methods they’ve found that can help surgeons select the optimal lens for each patient.

EXPECTATIONS AND PERSONALITY

Compromise is essential

In recent years, the category of premium lenses has grown to include toric, accommodating and multifocal IOLs. For all the new alternatives, there’s still one qualification they all share: they require some flexibility on the patient’s part.

The technology of many of these lenses requires a degree of optical compromise, says Steven Dell, MD, in practice in Austin, Texas — and that is in addition to the patient’s “substantial financial contribution.”

Patients who do well with any given technology truly understand their likely outcome and their actual outcome. “Even a perfect optical result of spectacular distance vision will be viewed as a spectacular failure by a patient expecting good near vision postoperatively. Accurately elucidating the patient’s visual goals preoperatively is critical to success,” he says.

Straight from the horse’s mouth

Dr. Dell uses a cataract and refractive lens exchange questionnaire that his practice developed 10 years ago to help with the patient screening process. Since its inception, he has distributed it to more than 1,000 physicians and countless patients. (See sidebar). The questionnaire reviews seven specific situations in which the patient would like to see well without glasses after surgery; the patient’s feelings and requirements about night vision; and distance vision preferences during the day and night (See sidebar). The questionnaire also asks the patient to indicate on a sliding scale their personality from “easy going” to “perfectionist.” Thus the surgeon has a document of the patient’s stated preferences, instead of basing surgical decisions on his impressions from conversations with the patient — which could turn out to be inaccurate or misunderstood. And the questionnaire plants some important ideas in the patient’s mind.

“While the IOL questionnaire does specifically ask patients to rate their own personalities on a ‘perfectionist scale,’ the real secret to [its] success is that it forces patients to prioritize their visual goals and it leaves patients with the clear impression that optical compromise may be required with even premium lens choices,” he explains.

Not that the questionnaire will eliminate the problem of dissatisfied patients. In an unpublished study Dr. Dell performed several years ago, patients who rated their personality exactly midway on a linear scale between “easy going” and “perfectionist” tended to be slightly less happy postoperatively even with a result the surgeons judged to be optically perfect.

Dr. Dell says his many years of experience with premium lenses have taught him that there are some patients who are simply difficult to please — they present to the clinic unhappy, and also exit the clinic unhappy, regardless of what he and his staff do in between to help them achieve quality vision. The good news, though, he adds, is that given the excellence of the technologies available, the vast majority of his patients are delighted with their results.

LENS SELECTION AND SCREENING

Goals first

According to David Hardten, MD, in practice in Minneapolis, Minn., it is the patient’s goals that determine IOL selection. The lens only becomes “premium” if it helps the patient achieve the sight goal. “If the patient is made to think that somehow the [premium] IOL ... can achieve whatever goal they have, then the terminology can be misleading to how to best achieve the patient’s goals,” he cautions. He interviews patients about their lifestyle habits to help them attain their desired vision.

Cataract and Refractive Lens Exchange Questionnaire

Dr. Dell and his staff have developed this questionnaire, which they use to help screen patients. The questionnaire allows patients to prioritize their vision goals, and explains to them that they might have to settle for less than perfect vision, even if they opt for a premium lens.

Practices are invited to use it in its entirety, or modify it.

Dr. Hardten provides several examples based on patients’ individual visual needs. For a patient without astigmatism who wants the best possible distance vision, he says the premium choice is a monofocal IOL with careful biometry. As for the patient who has the same distance-vision goal, some astigmatism and reader toleration capability — “The premium choice … may be a monofocal IOL and astigmatic keratotomy. “However, if the patient has moderate astigmatism, wants the best distance vision and is OK with readers, then the premium choice for that patient is a toric IOL.” For someone with serious astigmatism who can live with readers, Dr. Hardten says the premium choice may be a toric IOL and astigmatic keratotomy.

Dr. Hardten notes that if a patient wore monovision contact lenses before and without problems, then the premium choice may be monovision. For those patients who want a broad range of focus in each eye, a multifocal IOL is the likely option.

In patients considering a presbyopic IOL, the main criteria are otherwise healthy eyes and the strong desire to be primarily spectacle free, plus to possess the willingness to work hard to achieve that. Patients must be adaptable to arrive at this goal, pay extra in time, money, visits and visual quality, and possibly other surgical procedures if necessary, says Dr. Hardten.

Patient education

Many surgeons tout patient education as a key to success with premium lenses. “It is very easy to say this, but it is quite another matter to implement it,” says Dr. Dell. “If you properly educate 95% of your patients, the 5% whom you overlook can make your life very difficult. This can be particularly maddening when a frustrated patient has achieved exactly what you … expected and extensively discussed with the patient as the surgical goal.”

Surgeons should be prepared to consider declining to operate on patients who never reach a level of appropriate expectations, Dr. Dell says. And, surgeons also can become the victims of their own good outcomes. “As results improve, more patients assume that flawless vision is routine and expected.”

The education for all visual goals with cataract surgery is important, Dr. Hardten says. For example, patients who want the best distance vision but are in the range of no astigmatism correction, astigmatic keratotomy or toric IOLs, need to realize that even IOLs with one targeted point of vision have some optical trade-offs compared to their eyes before their cataracts developed. “These patients will also have poor uncorrected intermediate and near vision, and they often don’t realize this intuitively.”

Jay Pepose, MD, PhD, in practice in St. Louis, Mo., agrees. “Patients who succeed with premium IOLs [know] the different compromises ... inherent to the expanded depth of field with each specific IOL technology.”

With regard to multifocal IOLs, successful patients generally do not have highly aberrated or asymmetrical corneas or a large angle kappa, all of which can affect a multifocal’s performance, he says.

Dr. Pepose’s added pearls for optimal lens selection: Surgeons should optimize the patient’s ocular surfaces before measurement and surgery. “There should be caution in implanting multifocals in patients with epiretinal membranes or other causes of decreased contrast sensitivity, [like] advanced glaucoma.”

For example, “Patients considering Crystalens [Bausch + Lomb] need to understand that the IOL can give excellent distance and intermediate vision, but they may not achieve as good a reading vision as a multifocal unless the non-dominant eye is offset to a mini-monovision.”

Trust your staff

Dr. Dell says if staff tells you a patient is difficult, listen. Often, patients tend to be on their best behavior in the surgeon’s presence.

“On more than one occasion, I have declined to operate on someone on the basis of antagonistic or bizarre behavior exhibited toward staff members,” he says.

Surgeons and staff can work with patients to achieve each patient’s best visual outcome by considering patient preoperative vision and specific patient postoperative visual goals, as well as available lens options. OM