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Achieving success with your cataract patients and presbyopia-correcting IOLs
Patient education and careful preoperative management are the keys to success.
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 Gary Foster |
Many patients have the misconception that they must accept deteriorating vision as they age. Although that may have been true in the past, modern technology allows ophthalmologists to offer new options to restore their vision. Among these are multifocal IOLs such as the AcrySof ReSTOR IOL (Alcon, Inc.).
Although proper surgical technique and device selection are central to success, patient education and preoperative management are also crucial.
Many patients vastly underestimate the importance of near vision. Even if they do not read often for leisure or work, they still use near vision for many different activities throughout their day, like examining prescription labels, reading recipe ingredients or reading a watch. Educating patients includes helping them understand the negative effect of presbyopia. When given appropriate education with ample time, most patients prefer presbyopia-correcting IOLs. Spectacle freedom and increased visual performance make presbyopia-correcting IOL implantation a life-enhancing option.
Patient education
The surgeon must spend an appropriate amount of time with each patient to ensure that all of his or her questions are answered and that he or she is prepared for surgery. The patient should receive a consistent message not only from the surgeon, but also from every staff member with whom he or she comes into contact.
Patients should receive a brochure that highlights their IOL options before the first cataract evaluation. During their office appointment, patients should view an educational video about presbyopia-correcting IOLs. The ophthalmologist can then recommend the appropriate IOL during the consultation.
Patients should be briefed on the benefits and tradeoffs of the IOLs in addition to the costs of the procedure. The likelihood of success is higher for patients who undergo the procedure with a realistic idea of what a multifocal IOL can do for them. They need to understand both how the lens could benefit them and also the limitations and compromises that accompany multifocal vision. This is accomplished through an open and frank discussion with the surgeon.
Preoperative management
When a patient opts for presbyopia-correcting IOL implantation, I immediately insert a 3-month dissolvable plug in the lower puncta of each eye to increase tear film to decrease postoperative dryness. The patient should also receive an ocular lubricant, which should be administered at least twice daily until the preoperative visit in order to achieve better keratometry readings. This assists the surgeon in making a better IOL choice and decreases postoperative dryness.
When conducting preoperative examinations of the eye, a thorough evaluation of the cornea using topography is important to ensure that the eye is capable of providing good vision. In addition, a thorough evaluation of the macula is required and using optical coherence tomography may be necessary. I do not routinely perform these tests for traditional cataract surgery, but before implanting a premium IOL, extra evaluation of the cornea and macula, along with excellent biometry, is necessary to ensure that you can meet the patient’s expectations. I prefer the axial length measurements of the Zeiss IOL Master and keratometry readings of a manual keratometer.
The final preoperative step to ensure success is to administer a topical nonsteroidal anti-inflammatory drug. This improves intraoperative mydriasis and patient comfort, increasing the probability for successful surgery. Preclinical evidence suggests that NSAIDs such as nepafenac (Nevanac, Alcon) may reduce the risk of macular edema.1 The NSAID should be started at least 1 day before surgery and used for 4 to 6 weeks, postoperatively.1,2 NSAIDs are particularly important to achieve optimal outcomes, as the rising patient and surgeon demands correspondingly increase with our presbyopia-correcting IOL volume.
Intraoperative tips and techniques
To increase the chances of success during presbyopia-correcting IOL implantation, consistent capsulorrhexis size is important. In an oversized capsulorrhexis, the IOL may move forward, and in an undersized capsulorrhexis, the IOL can shift backwards. In both cases, accuracy is compromised. Using a 6.0-mm marker, the surgeon can touch the cornea at the beginning of the capsular case, leaving a faint impression on the cornea. Then, staying within the 6.0-mm marker, the surgeon can center and complete the capsulorrhexis at the appropriate size.
A unique feature of the AcrySof ReSTOR IOL is that the AcrySof material adheres to the posterior capsule so that after removing the viscoelastic, the IOL can be well centered upon placement.
If the patient has astigmatism, the surgeon should manage the astigmatism to < 0.5 D to provide patients with the opportunity for the best vision possible.
Postoperative steps to success
The postoperative period should be smooth if proper preoperative care is taken. However, complications can compromise the success of the procedure. Common side effects include postoperative dry eye and posterior capsular opacification.
Over time, cataract-surgery patients can experience PCO. Multifocal patients are more sensitive to small amounts of PCO and may require a YAG capsulotomy at an earlier stage or for lesser amounts of opacification. YAG capsulotomy can produce dramatic improvements in vision for some patients.
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As patients adapt to their vision, they may experience halos or glare, but this tends to diminish over time. I tell all patients that they will experience nighttime halos even though many do not. The great delight of my experience with the AcrySof ReSTOR IOL has been how few patients experience nighttime halos. Bilateral implantation of AcrySof ReSTOR IOLs is strongly recommended to achieve maximum success. My preference is to perform surgery for the second eye 2 to 3 weeks after the first eye. This allows patients to adapt to their multifocal vision using bilateral summation and decreases any anisometropia that they otherwise would have experienced. My experience implanting the AcrySof ReSTOR IOL bilaterally has been positive, and therefore, I recommend bilateral AcrySof ReSTOR IOL placement for most of my cataract patients. In premarket clinical trial, 80% of patients never required spectacles, implying comfort with their distance, near and intermediate vision.4 From my experience, the percentage of spectacle-independent patients is higher. Patients implanted with bilateral AcrySof ReSTOR IOLs are my most satisfied patients and undergo the smoothest postoperative course. I believe this is due to the superior reading performance and the overall quality of the vision that they receive with this IOL.
I mix and match different multifocal IOLs or do modified ReSTOR/ReSTOR monovision in about 5% of those over 65 years of age and about 20% of those under 65 years old, based on specific lifestyle needs. I approach these patients the same way I do traditional monovision patients in other parts of my practice. Most ophthalmologists use monovision in only a small percentage of contact lens, laser vision-correction and monofocal-lens patients simply because most patients find that the same correction in both eyes is more important than benefits of monovision. A mixing and matching approach is similar. If a patient is motivated for a broader range of vision, then he or she will be willing to accept the “aniso-multifocal-metropia” that comes from having different systems in each eye. If not, then they are more satisfied overall with having the same IOL in both eyes. The majority of my patients are bilaterally implanted with ReSTOR IOLs with a plano target and are extremely satisfied.
This presbyopia-correcting IOL has allowed me to help my patients turn back the hands of time to when they could see with clarity and focus. The correction of presbyopia has become the most joyous part of my practice and the area of ophthalmology where I feel I can contribute the most.
References
- McColgin AZ, Raizman MB. Efficacy of topical Voltaren in reducing the incidence of post operative cystoid macular edema. Invest Ophthalmol Vis Sci. 1999;40:S289.
- O’Brien TP. Emerging guidelines for use of NSAID therapy to optimized cataract surgery patient care. Curr Med Res Opin. 2005;21:1131-1137.
- AcrySof ReSTOR Clinical Trial Data. Alcon data on file from USFDA submission. December 2001-March 2005.
Dr. Foster is in private practice with The Eye Center of Northern Colorado, P.C., in Fort Collins, Colo. where he practices cataract and refractive surgery.