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Transitioning From Cataract to Refractive IOL Surgery: Pearls for transitioning
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While good surgical technique is important, making presbyopia-correcting IOLs a successful part of your practice requires a team effort. My technicians attended the training course from Eyeonics so that they would have a strong understanding of the mechanism of the lens. Each delighted patient (and we have many) added to their confidence and enthusiasm.
We also use visual aids. Patients who qualify are shown an educational DVD provided by Eyeonics in a portable DVD player and the technicians introduce it. By the time I enter the room, the patient generally knows what the Crystalens is and how it works. After explaining cataract surgery, I am usually very direct with my approach to the IOL options. I tell the patient that there are 3 different distances in life: far, intermediate, and near. I explain that the traditional lens gets them only one out of 3; usually the patient opts for distance and will require glasses for intermediate and near. With the dominant eye I target far and intermediate and with the nondominant eye I target intermediate and near.
I explain that in this way, they will be able to see all 3 different distances with 2 eyes. The patients seem to understand this very well. I ask them point blank whether they “love” their glasses or whether they would like to read again without their glasses on. In those who really want this freedom, you will see an instant spark of interest. Once they have decided on this lens, it is important to limit their expectations by saying that at this time, there is no lens that can guarantee that they will never wear glasses under any circumstances. They may require some glasses for night driving and they may have to use eyeglasses for the very small near vision items, such as threading a needle or reading the stock quotes in the paper. Reasonable patients are always accepting of this; unreasonable patients who do not accept this should be noted and probably avoided.
I remember when refractive surgery first began and I was trying to decide whether to get into this new and exciting area. I took numerous RK courses in which instructors talked about equipment, financing, and technique, and I found this to be terribly monotonous. One day, I had the great fortune of taking a course by Dr. Spencer Thornton, who is also an amateur magician. Unlike everyone else, he spoke about the “magic” of refractive surgery. He talked about the joy, the excitement, the sheer exhilaration of restoring sight to those who have never been able to see the world clearly with their own eyes. This is why I became a refractive surgeon … this is why we all became surgeons.
Ophthalmology is on the verge of an exciting new era; the technology is changing, the world is changing, and we must change with it. We now have the power to not only improve our patients’ sight but to change their lives. I truly believe this new technology will continue to improve and should be made available to all patients requiring cataract surgery. Our patients should be able to choose how they see and how they live.
Pearls for transitioning
Sandra Yeh, MD, has to date implanted more than 1,000 multifocal and accommodating IOLs. Premier Surgeon recently spoke with Dr. Yeh and asked about her experience with premium IOLs.
Premier Surgeon: What has changed since you first wrote this chapter?
Dr. Yeh: So much has changed since I first wrote this chapter, and I really want to share with your readers some of the pearls I have learned. I really feel that surgeons need to keep current in this rapidly changing field.
I live in a middle class midwestern town called Springfield, Ill., and I am currently up to almost a 50% conversion rate. I use all three premium lenses — ReSTOR (Alcon), Tecnis (Abbott Medical Optics) and Crystalens (Bausch + Lomb) — on a regular basis. Each lens has strengths and weaknesses. I think one problem a lot of surgeons have is they use just one lens. Surgeons shouldn’t do this because then they try to cram every one of their patients’ lifestyles into one tiny little box. Because I have been using all three types of IOLs, I now know what lifestyles and which activities are best suited to each lens. I think that this is how you end up with the happiest patients. I use a five-question questionnaire, which is one of the easiest questionnaires you will ever see.
Based on those five easy questions you give them in the waiting room, you have a diagram with which to talk. You have a profile of what this person is like. For example, there is a huge difference between “light readers” and “avid readers.” There’s a huge difference between a little old lady who knits and does quilt work and someone who does computer work with four different screens. Unless you know which lens is best suited to each lifestyle, you are going to stumble because what you are trying to do is cram the wrong patient with the wrong lens. We hear so much about patient selection, but we hear virtually nothing about lens selection.
The ReSTOR +3.0 D is the most utilized with excellent bilateral vision and great range. The Tecnis multifocal provides great low light reading and is especially good with patients with small pupils. The Crystalens AO has the crispest far and intermediate vision and is very forgiving for residual astigmatism.
PS: Why aren’t more surgeons implanting premium lenses?
Dr. Yeh: I think there’s a high fear factor simply because it is new. There’s a misconception by both doctors and patients about what constitutes a side effect and what is a complication. As a result, we frequently have mistaken a patient observation for a complaint. For example, I fully expect a patient to come in and say, “I see rings at night.” I tell 100% of my multifocal IOL patients they are going to see rings at night and that is how they will know they have a multifocal implant. I also point out to them that when they are wearing bifocals or trifocals, they always see a line in their field of gaze both day and night. I tell my patients instead of a line, they’ll see a ring and only at night. I once met a fellow surgeon who said that he stopped implanting multifocal lenses just because a single patient complained of glare at night (despite numerous other happy patients). I asked whether he would stop doing LASIK just because a single patient complained of glare and he said “of course not” because he expected that as a side effect. It is when the surgeons themselves misunderstand and show fear and anxiety over a simple observation that now in the patient’s mind it has become a complication. Sometimes we create our own worst-case scenario.
PS: Aside from clinically exclusive factors, are there patient groups you will not implant?
Dr. Yeh: I try to shy away from occupational nighttime drivers with multifocals, but I use a lot of ReSTOR or Tecnis multifocal in the nondominant eye and an aspheric monofocal in the dominant eye. It does extremely well. Now, for someone who does a lot of nighttime driving and needs to see the dashboard and instrument panel, I would put a Crystalens in their nondominant eye. But I would tell them that they will get some great far and intermediate but for the near they’ll need to wear some “cheaters” and ask them if they are OK with that. But they get their choice.
PS: What do you find satisfying about implanting premium IOLs?
Dr. Yeh: There are certainly psychological factors aside from physical factors. I added to my patients’ review of systems list whether they have had depression or psychiatric illnesses. Depression frequently causes even the slightest adverse effects to be greatly magnified in the patient’s perspective. I would avoid multifocal lenses in occupational nighttime drivers just because I am cautious about the nighttime glare. Also, patients who have been on Flomax (tamsulosin, Boehringer Ingelheim) or any of the intraoperative floppy iris syndrome drugs, I tend to avoid Crystalens as these seem to affect their accommodative ability. I also avoid Crystalens in avid readers as it is difficult for some patients to sustain a prolonged accommodation.
PS: Why not just keep implanting monovision IOLs?
Dr. Yeh: I think it is a terrible mistake to assume everyone will like monovision, especially 70- to 80-year-old patients who have never tried it. I have had to explant numerous monofocal lenses in the past to reverse monovision in patients who cannot tolerate it. Monovision is limited to two single points of focus in space, one far and one near. There is only one sweet spot and the patient must find and hold their reading material in that one distance. There is absolutely no range, no depth of focus and no stereopsis, a real hazard in the elderly. Premium lenses offer tremendous range at all distances and at a much greater depth of vision.
PS: What other factors are helping you convert so many patients to premium IOLs?
Dr. Yeh: Really, this is an educational process. We are finding that the earlier you educate the patients, the better it is. I start telling them, “Great news, you don’t need cataract surgery yet, but when you are ready, there is an advanced technology implant I want you to know about.” (We don’t call them premium lenses; we call them advanced technology implants.) I tell them they will be able to read without their glasses again. Then I tell them it’s going to cost them more than their insurance will pay: “So, start saving your pennies because this is the one I want you to have when it’s your time to have it.” The educated patient returns with a virtually 100% conversion rate as they are now psychologically and financially prepared for the new lenses. They understand, and understanding is the first step.
I also tell them that as they age, reading will likely become a more significant part of their lives, probably more than night driving. Also I have been told by numerous happy premium IOL patients about how much safer they feel going down steps and escalators since their depth perception is no longer hampered by bifocals and trifocals. I suppose the most important factor in my conversions is that I truly believe in the technology behind these lenses. I genuinely believe that we can make patients see better after the cataract surgery and we can actually make their lives better.
Sandra Yeh, MD, can be reached at The Prairie Eye Center, 2020 West Iles Ave., Springfield, IL 62704; 217-698-3030; e-mail: syeh2020@aol.com.