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Transitioning From Cataract to Refractive IOL Surgery: Raising the bar for improved patient outcomes
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I realized very early on that cataract surgery had the potential to be the ultimate refractive surgery if things were handled correctly. The advent of small-incision, foldable IOLs, as well as improved A-scan techniques and IOL formulas, provided the tools to bring cataract surgery closer to refractive surgery. With this in mind, I made a commitment in my practice to change the way we looked at cataract surgery and issued a challenge to my staff to provide refractive cataract surgery (RCS) for every patient.
With this new attitude, we began providing patients with excellent distance vision without glasses. We abandoned contact A-Scan biometry for immersion to increase accuracy and began using the IOL Master (Carl Zeiss, Jena, Germany) as soon as it was available. Advanced IOL calculation formulas such as the Holladay II further added to our precision.
In the mid 1990s, technology was introduced that seemed able to solve this last piece of my RCS puzzle. Allergan Surgical (Irvine, CA) introduced the Array Multifocal IOL and my group quickly became involved in the Array clinical trials. The small group of clinical investigators were excellent surgeons with a commitment to making the technology work. As a result, the data submitted to the Food and Drug Administration (FDA) were acceptably good and with great excitement, we all waited in anticipation of FDA approval, which came in late 1997.
For the first few months we enjoyed initial success and had many happy patients. As time went on, however, we began to have some negative experiences similar to what other surgeons nationwide began to report. Patients complained of poor near vision, nighttime glare and halos, and even some poor-quality distance acuity. As a consequence, I performed explantation and IOL exchange in 2 Array patients. I then reviewed similar negative experiences with other surgeons and reluctantly abandoned using the Array altogether.
In my refractive practice, I was still not satisfied with the menu of choices I was able to offer my hyperopic patients and especially my hyperopic presbyopes. Although hyperopic laser in situ keratomileusis (LASIK) worked in some, it was not accurate and predictable for higher levels of hyperopia, and I noted visual quality issues at those more aggressive levels of treatment. With LASIK, the hyperopic presbyope was still faced with monovision as the only choice for near vision. As luck and fate would have it, there was a groundswell of several like-minded surgeons nationwide who also felt there was a place for the Array lens in hyperopic refractive surgery patients. Drs. Kevin Waltz and Bruce Wallace organized this group of surgeons and coined the term PRELEX, or presbyopic lens exchange, to describe the use of the Array Multifocal IOL for refractive surgery purposes. To reintroduce the Array to my practice, I began with extensive study so that I truly understood the nuances of multifocality.
We then fast forward to 2005 and the FDA approval of 2 excellent new multifocal IOLs. The ReZoom lens was a redesign of the Array that addressed many of its shortcomings. The ReSTOR lens represented new technology with its apodized diffractive multifocal optic. I now enjoy a thriving cataract and refractive surgery practice that comfortably and confidently embraces multifocal technology. I can now say that we truly have an office that focuses on genuine refractive cataract and lens surgery. Adding these new generation multifocal IOLs has filled in the missing pieces in my practice.
The bottom line in this formula for success is that you simply have to pick the right patient and use the implant the right way. With this approach I have enjoyed steady growth in my refractive IOL practice and feel that the multifocal IOL has become an essential tool in refractive lens implant surgery.
Raising the bar for improved patient outcomes
Timothy B. Cavanaugh, MD, underwent a practice transformation to embrace the refractive cataract surgery movement and offer patients freedom from their glasses. Premier Surgeon recently spoke with Dr. Cavanaugh to discuss this transition process and the resulting benefits.
Premier Surgeon: What has changed since you initially wrote this chapter?
Dr. Cavanaugh: Since the original book, my cataract practice has changed to a complete refractive cataract practice. Every patient is given the option of premium upgrades to achieve freedom from glasses. If a patient does not have astigmatism and elects a monofocal IOL, we use meticulous IOL calculation with IOL Master and immersion ultrasound to strive for emmetropia in the dominant eye. In this group of patients, we do monovision with a –1.00 to –1.25 target refraction in the non-dominant eye. If the patient is averse to the cost of a presbyopic IOL upgrade, we try to provide intermediate near vision by using monovision. We only use aspheric optic monofocals and select the appropriate aspheric IOL based on the patient’s spherical aberration. In patients with astigmatism, they are encouraged to correct it with a toric IOL or LRI incision so that we can achieve excellent uncorrected distance vision.
We discuss the benefits of premium presbyopic IOLs with every patient who is a candidate. I personally go over the options briefly with each patient and then let my staff expand on the details. We have learned that it is essential for the surgeon to make a concise IOL recommendation for each patient. I now recommend a premium choice specifically for that patient but tell them that if they cannot afford it, we will use a monofocal IOL with an advanced optic to at least give them the best possible distance vision. Our conversion rates to premium IOLs have increased since we have become more specific regarding my recommended IOL.
PS: What benefits have resulted from implementing multifocal lenses into your practice? Any drawbacks?
Dr. Cavanaugh: There are have been far more benefits than negatives. First of all, it has made me a better cataract surgeon and my staff better at refractions and IOL calculations. We have essentially “raised the bar” on what we expect of ourselves, and this directly translates to better outcomes, happier patients, happier referring doctors and more surgical referrals. A surprising bonus has been referrals for LASIK from happy multifocal IOL patients. In some cases, I am not sure patients really understand the difference between cataract and refractive surgery. All they know is that they now see without glasses and want to tell everyone, regardless of age. The main negative I can pinpoint would be the increased expectations and demands of the premium IOL patient. This definitively slows down clinic flow, and surgical counseling sessions last twice as long in some cases compared to a standard cataract patient. We have also seen an increase in the number of non-paying LASIK enhancements on our LASIK days in order to take care of the premium patients who are off target on their final refraction.
PS: How do you choose the right patient/IOL combination?
Dr. Cavanaugh: This has evolved as technology has evolved. For instance, we initially used the ReZoom IOL for patients with more intermediate vision needs and used the +4.0 ReSTOR for those wanting small print near. With the advent of aspheric multifocals, we abandoned the ReZoom completely. In those early years, the Crystalens was approved but we elected not to implant that lens due to some concerns over safety and effectiveness of the original 4.5 version. We waited until the 5.0 came out to begin implanting the lens and did a fair amount of these. We then tried the Crystalens HD and became discouraged at the distance performance of this optic. At that point, we began implanting the 5.0 in the dominant eye and the HD in the non-dominant eye with much improved results. Now that the Crystalens AO is on the market, we implant this aspheric optic lens in both eyes with micro-monovision or a target of –0.50 D in the non-dominant eye, which has proved to be very successful.
With the advent of the +3.0 ReSTOR, this has become our premium IOL of choice as it provides patients with the widest range of visions including intermediate. I would estimate that 75% of the premium IOLs we implant now are +3.0 ReSTOR. The rest is a mixture of Crystalens AO and Tecnis multifocal. Our decision process first starts with a discussion about the patient’s work and hobby needs. We then look at age, pupil size and ocular health. If a patient with a healthy eye has a desire for small print near and has a small- to medium-sized pupil, we will select +3.0 ReSTOR in the vast majority of cases. If a similar patient has a larger pupil in room light (ie greater than 4.0-5.0 mm), then we may select the Technis multifocal. Not surprisingly, many patients that fit this category are in the older age group, as reading small print is more important than computer distance and night driving is often limited. Many younger patients like the mechanism of the Crystalens and are more concerned about seeing electronic media such as their computer, PDA, etc. I under-promise and try to over-deliver for the Crystalens patients, however. I let each patient know that this IOL requires active flexing to achieve near vision, and this can be variable depending on the patient. We discuss the fact that most patients will enjoy halo-free uncorrected distance and intermediate vision, but there is no promise of spectacle freedom at near.
PS: Are there patients you would not recommend implanting with a premium IOL?
Dr. Cavanaugh: I divide this into two categories: elimination of a patient based on psychological factors and based on medical. The patient who has unrealistic expectations for vision and is incredibly picky is not a good candidate. I would also eliminate the impatient patient. We tell everyone about our 2/90 rule, i.e. both eyes must have surgery and the patient must wait 90 days for full neuroadaptation to the new optics of the IOL. On the medical side, I would not implant a multifocal IOL in a patient with any irregular astigmatism, media opacity or retinal pathology. This eliminates patients with keratoconus, corneal scars, contact lens warpage, Fuchs’ dystrophy, macular degeneration and diabetic macular disease just to name a few. Since Crystalens AO is a monofocal apheric optic however, we have had some good success in some of the aforementioned patients with good informed consent about the limitations they will have from their pre-existing pathology.
PS: What advice do you have for practices looking to implement premium IOLs, based on your experience?
Dr. Cavanaugh: First and foremost – Don’t wait! The upsides far outweigh the downsides, and your practice will soon be perceived as “behind the times” by potential patients and referring doctors if you are not a premium IOL surgeon. You will find it both rewarding and challenging professionally, but also potentially lucrative for your bottom line in this day and age of declining Medicare re-imbursement. We are blessed in our field of ophthalmology to have elective procedures to offer to our patients that are truly a win-win for patient and doctor, alike. Patients enjoy an enhanced quality of life through rejuvenation of distance and near vision, while the surgeon enjoys both professional fulfillment and financial gain.
PS: How do you predict your practice might change as IOL technology continues to advance?
Dr. Cavanaugh: Progressive practices have to be ready to adapt rapidly to market and technology changes. We will continue to react and adapt to advancements in technology so that our patients have access to the best tools and the best outcomes. I predict that there will be increasing adaptation and conversion to premium technology as awareness increases. This will always be limited by economic factors, and we certainly have a concern for our future economy and the future of healthcare with the recent changes in Washington. I look forward to future IOL designs that fill voids that are present now, such as a Toric Multifocal and Toric Accommodative IOL. I believe that the majority of future research will focus on improved accommodative designs, and hopefully we will soon have an IOL that can provide consistent full range of focus, including small print near.
Timothy B. Cavanaugh, MD, can be reached at the Cavanaugh Eye Center, 6200 W. 135th St., Suite 300, Overland Park, KS 66209; 913-897-9200; e-mail: tbc@cavanaugheye.com