Premium IOL implantation presents steep challenges and ample rewards

Preop chair time, meticulous IOL centration, optimal IOL power calculations and management of the ocular surface are critical to patient satisfaction.

Eric D. Donnenfeld

Meeting or surpassing premium IOL patients’ expectations can significantly benefit a practice by generating word-of-mouth referrals, according to one clinician.

Achieving strong outcomes and high patient satisfaction requires keen patient counseling and meticulous preoperative and postoperative assessment, Eric D. Donnenfeld, MD, said at OSN New York 2009.

“The successful refractive IOL patient with good visual outcomes whose expectations have been met or exceeded is also the happiest patient in our practice and presents an enormous opportunity for all of us,” Dr. Donnenfeld said. “Exceeding expectations the day following surgery drives patient-to-patient referrals. Patients will call their friends the next day when they have a great result.”

Patient selection and evaluation

Preoperatively, “the more chair time you spend before the surgery, the less you will spend after surgery,” Dr. Donnenfeld said. Chair time before surgery helps ease patient expectations. After surgery, allowing a patient to become angry will irreparably harm the physician-patient relationship.

In addition, patient selection is critical for multifocal IOL outcomes. For example, hyperopes and moderate myopes are better candidates than low myopes and emmetropes, he said.

Preoperatively, surgeons should optimize their IOL calculations, confirm corneal topography and optimize the ocular surface.

Additionally, optical coherence tomography analysis is useful for detecting epiretinal membranes, lamellar holes and other types of maculopathy. Patients with maculopathy should not receive multifocal IOLs. Macular thickness more than 230 µm correlates with worse postoperative visual acuity, Dr. Donnenfeld said.

Intraoperatively, IOL centration is critical. The surgeon should mark the center of the pupil before dilation, center the IOL on patient fixation and Purkinje images during surgery, and decenter the IOL slightly nasally on a dilated pupil, he said.

Postoperatively, multifocal IOLs yield good results in patients with previous LASIK. Results are best following modern prolate ablations. Surgeons should avoid multifocal IOL implantation in patients with previous high myopia, oblate ablations, small ablation zones and decentered ablations, Dr. Donnenfeld said.

Premium IOL implantation requires a full array of pharmaceuticals. For example, antibiotics can protect against infection and be used to treat lid disease. NSAIDs protect against cystoid macular edema and minimize pain. Corticosteroids and cyclosporine reduce inflammation, treat dry eye and ocular surface disease, and protect the cornea, Dr. Donnenfeld said.

Lens choice and patient satisfaction

According to results of U.S. Food and Drug Administration clinical trials for the Tecnis multifocal IOL (Abbott Medical Optics), 84.8% of patients reported never wearing glasses, 13.4% of patients reported wearing glasses occasionally and 1.8% of patients reported always wearing glasses.

In addition, 94.6% of patients said they would choose the lens again.

Results of the FDA clinical trials for the AcrySof IQ ReSTOR multifocal IOL (Alcon) showed that more than 75% of patients reported never wearing glasses, fewer than 25% of patients reported wearing glasses occasionally and fewer than 5% reported always wearing glasses. Results for the +3 D and +4 D add versions of the implant were similar.

Additionally, about 95% of patients said they would receive the same implant again, Dr. Donnenfeld said.

Various lenses have different advantages. For example, the single-piece ReSTOR has a hydrophobic acrylic apodized diffractive optic with ultraviolet and high-energy blue light-filtering capability. The three-piece Tecnis has a square-edge optic and a modified prolate anterior surface and is pupil-independent, Dr. Donnenfeld said. – by Matt Hasson

• Eric D. Donnenfeld, MD, can be reached at OCLI, 2000 N. Village Ave., Rockville Centre, NY 11570, U.S.A.; +1-516-766-2519; fax: +1-516-766-3714; e-mail: eddoph@aol.com.