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Maximizing patient satisfaction with presbyopia-correcting IOLs

ByFrank A. Bucci Jr., MD

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Ophthalmologists can increase patient satisfaction with presbyopia-correcting IOLs by following a number of guidelines, or the “10 Ps of correcting presbyopia with IOLs” (Table). Patient selection is important, as is preoperative patient counseling and management of patient expectations. Ophthalmologists need to inform their patients that superior outcomes with presbyopia-correcting IOLs will take more time than for patients undergoing LASIK, who receive 95% of their results within 24 hours. With presbyopia-correcting IOLs, the ophthalmologist needs to implant the first IOL, and then implant another IOL and possibly correct astigmatism and perform a YAG laser capsulotomy. It is important for patients to understand that the presbyopic IOL procedure is a “work in progress.”

The preoperative examination is important to detect any reduced visual potential from corneal or retinal disease. Preoperative and postoperative topical nonsteroidals are essential for minimizing subclinical macular edema and frank cystoid macular edema (CME). Phacoemulsification and IOL implantation must be efficient and accurate. And finally, YAG laser capsulotomies should be performed earlier after surgery because patients have already lost contrast sensitivity and are sensitive to any further reduction in contrast.

Source: Bucci FA

Four essential visual elements of success

Four visual elements are needed for patient success. First, the patient needs to achieve relatively high- quality distance acuity. Second, the patient needs functional intermediate vision, which means the ability to see the computer at arm’s length. Third, the patient needs to have functional near vision in both bright light and moderate light, which means the patient has to have the ability to comfortably read the newspaper. Fourth, the patient should experience acceptable light phenomenon while driving at night.

Newer IOLs are better at helping to achieve these visual elements of success compared to their predecessors, but none of the IOLs currently available in the United States, when placed bilaterally in a lensectomy patient, will consistently meet all of these requirements. However, ophthalmologists who counsel patients preoperatively and explain what the patient can expect postoperatively will facilitate more successful patient adaptation to the new visual system.

IOL selection

IOL selection is an important component for overall patient satisfaction. The following is a personal chronology of presbyopic IOL experience. Since 2005, I have implanted 885 presbyopia-correcting IOLs, including 475 ReZoom IOLs (Advanced Medical Optics, Inc., Santa Ana, Calif.), 300 ReSTOR IOLs (Alcon, Inc., Fort Worth, Texas), 75 crystalens IOLs (Bausch & Lomb Surgical, Aliso Viejo, Calif.) and 35 Tecnis multifocal IOLs (Advanced Medical Optics, Inc.).

Data presented at the 2004 annual meeting of the European Society of Cataract and Refractive Surgeons suggested that the ReSTOR IOL gave patients better near vision, less halo effect and adequate intermediate vision compared to the Array lens (Advanced Medical Optics, Inc.).^1,2 Following these reports, I implanted bilateral ReSTOR IOLs in a cohort of 55 patients, 62% of whom were lensectomy patients and 23% of whom were young baby boomer cataract patients. Thirty-one percent of all patients reported unsolicited severe intermediate visual complaints. ³

I also had five patients return for follow-up who previously had received one Array lens years before and were waiting for an IOL with more reading power. These patients received a ReSTOR IOL in their second eye. Patients were pleased with the results, and we documented that the Array lens provided intermediate vision while the ReSTOR lens provided near vision.

The ReZoom IOL is a significant upgrade of the Array IOL, and it made sense to solve the intermediate vision problem of the ReSTOR/ReSTOR combination using a ReZoom/ReSTOR combination. Patients receiving the ReZoom/ReSTOR combination did not lose any near vision, but the intermediate vision was improved over the ReSTOR/ReSTOR combination. A study conducted in Brazil and presented at the World Corneal Congress also compared the ReSTOR/ReSTOR IOL combination and the ReZoom/ReSTOR IOL combination. ⁴ The results of this Brazilian study were essentially identical to the experience that I have had with this combination, especially regarding intermediate vision, and confirmed that the ReZoom/ReSTOR combination results in more spectacle-free patients than the ReSTOR/ReSTOR combination.⁴ Additionally, other studies indicate the ReSTOR IOL provides better near vision and the ReZoom IOL better intermediate vision, and both multifocal IOLs provide excellent distance vision.⁵

Intelligently mixing presbyopic IOLs can frequently create synergies that will optimize spectacle independence and patient satisfaction. —Frank A. Bucci Jr., MD

Another successful combination is the ReZoom/ Tecnis multifocal IOL. The Tecnis multifocal IOL is still pending approval in the United States, but worldwide the ReZoom/Tecnis combination is preferred over the ReZoom/ReSTOR combination. The Tecnis multifocal IOL has demonstrated superior reading in moderate and dim light compared to the ReSTOR IOL. ^6,7 The same Brazilian authors compared 300 ReSTOR/ReSTOR combinations to 300 ReZoom/Tecnis multifocal IOL combinations and found that the ReZoom/Tecnis combination had superior Jaeger scores for near and intermediate vision, faster reading speeds, superior distance vision, fewer halos and less glare.⁸

Another potential combination is crystalens/Tecnis IOLs. This combination is appropriate for patients who are concerned about halos. The Tecnis multifocal IOL provides excellent near vision, and the crystalens provides excellent intermediate vision, as well as a non-haloed image while driving at night. ^9-11

Conclusion

Many steps must be taken to ensure patient satisfaction with presbyopia correcting IOLs. Proper patient selection, counseling and careful pre- and postoperative planning will increase patient satisfaction. Finally, intelligently mixing presbyopic IOLs can frequently create synergies that will optimize spectacle independence and patient satisfaction.

References

1. Pelit A, Canan H, Yaycioglu O, et al. One year results of single piece hydrophilic acrylic intraoperative lenses. Presented at: Annual Meeting of the European Society of Cataract and Refractive Surgery; September 18-22, 2004; Paris, France.
2. Zacharopoulis I, Segev F, Jaeger-Roshu S, Assia E. Clinical evaluation of hydrophilic acrylic lenses after two year follow up period. Presented at: Annual Meeting of the European Society of Cataract and Refractive Surgery; September 18-22, 2004; Paris, France.
3. Bucci F. Bilateral multifocal cataract and lensectomy patients receiving ReZoom/ReSTOR – long term follow-up. Poster presented at: Annual Meeting of the Association for Research in Vision and Ophthalmology; May 8, 2007; Fort Lauderdale, Fla.
4. Akaishi L, Fabri PP. PC IOLs mix and match technologies: Brazilian experience. Paper presented at: World Ophthalmology Congress; February 2006; São Paolo, Brazil.
5. Chiam PJ, Chan JH, Haider SI, et al. Functional vision with bilateral ReZoom and ReSTOR intraocular lenses 6 months after cataract surgery. J Cataract Refract Surg. 2007;33(12):2057-2061.
6. Hütz WW, Eckhardt HB, Röhrig B, Grolmus R. Reading ability with 3 multifocal intraocular lens models. J Cataract Refract Surg. 2006;32:2015-2021.
7. Hütz WW, Eckhardt HB, Röhrig B, Grolmus R. Intermediate vision and reading speed with Array, Tecnis, and ReSTOR intraocular lenses. J Refract Surg. 2008;24:251-256.
8. Fabri PP, Akaishi L. Combining IOLs for spectacle independence. EyeWorld. 2006;March(suppl):7. Available at: http://www.eyeworld.org/ewweeksupplementarticle.php?id=105&strict=&morphologic=&query=Fabri%20PP,%20Akaishi%20L. Last accessed April 23, 2008.
9. Pepose JS, Qazi MA, Davies J, et al. Visual performance of patients with bilateral vs combination crystalens, ReZoom, and ReSTOR intraocular lens implants. Am J Ophthalmol. 2007;144(3):347-357.
10. Goes FJ. Visual results following implantation of a refractive multifocal IOL in one eye and a diffractive multifocal IOL in the contralateral eye. J Refract Surg. 2008;24(3):300-305.
11. Goes FJ. Refractive lens exchange with the diffractive multifocal Tecnis ZM900 intraocular lens. J Refract Surg. 2008;24:243-250.