Meeting Patient Expectations

ByMark Packer, MD, FACS

Mark Packer

Patient demand is driving innovations in IOLs, and business competition and surgeon demand are driving advancements in phaco system technology. These developments are increasing demand for more precise refractive outcomes. Patients expect tailored results from refractive lens exchange (RLE) and cataract surgery, and surgeons need high- performing phaco machines and premium intraocular lenses (IOLs) to meet those expectations. By using the latest technology and working with patient demands, surgeons can ensure consistent outcomes and manage patient expectations.

Age factors

Patient expectations vary among age groups. In general, younger patients have higher expectations for surgical outcomes. For example, a 20-year-old patient who undergoes an iLASIK or phakic lens procedure often expects a perfect surgery. Patients in this age group tend to be bright, aware, and very knowledgeable about technology. Even so, some have unrealistic expectations about surgery, and I find it necessary to explain the risks and educate them on complications such as dry eye syndrome, the possible need for an additional enhancement procedure, and other problems that can occur in any patient. As people age, especially as they have more experience with the medical system, surgery, and life in general, their expectations become more realistic. Eighty-year-old patients often wait until their vision deteriorates below the legal driving range to undergo surgery. At that point, the goal is improved vision and the patients will likely be pleased with the surgical outcome.

The intersection of patient expectations with what is technologically achievable occurs at approximately age 55. These patients often have presbyopia and want to solve their vision problems. However, every solution for presbyopia has strengths and weaknesses. For example, the ReZoom multifocal IOL (Advanced Medical Optics, Inc. [AMO]) has strengths in the intermediate- vision range, whereas the aspheric Tecnis multifocal IOL (AMO), which is available in Europe, has strengths in distance- and near-vision ranges. The technology is precise, and most of the time patients will be pleased with their outcomes. Patients with dry eyes, extreme degrees of correction, or jobs that place high demands on their eyes may experience complications. When surgery on eyes with presbyopia is performed perfectly and the multifocal IOL is implanted correctly, the patient may still experience halos. That outcome is not unexpected, but it may be a problem for patients if they were not informed that halos were a possibility prior to surgery. Patients with presbyopia pose the greatest challenge for surgeons aiming to meet patient expectations, but they are also the most interesting and exciting patients to work with. When surgery is successful, they are among the most satisfied patients.

Technological evolution

IOL technology is evolving primarily based on patient demand. IOLs awaiting FDA approval and scheduled to reach the market in the next couple of years are based on rising patient expectations. Recent FDA approvals have been focused on presbyopia-correcting, multifocal, or accommodative IOLs. Advancements in aspheric IOLs have led to the development of the Tecnis 1-piece IOL (AMO). Most patients are unaware of the differences between aspheric and spherical IOLs. The aberration-reducing technology in an aspheric IOL, such as the Tecnis 1-piece IOL, is a significant improvement over other one-piece IOLs. Surgeons can help patients decide on an appropriate IOL by educating them on the advantages and disadvantages of each latest-generation IOL.

Patients want cataract surgery to be safe and efficient and result in freedom from glasses, but they are not concerned with the precise methods by which the cataract is emulsified. Therefore, phaco technology seems to be evolving based on business competition and surgeon expectations rather than patient expectations. If a company develops a new phaco machine incorporating innovative technology that improves surgery, other manufacturers have to match or surpass it to keep the company name visible to surgeons. The patient does not know the difference between 1.5 seconds of phaco time compared with 3.5 seconds of phaco time, but surgeons do. A more effective lens removal system, such as the WhiteStar Signature system with Fusion Fluidics and Ellips transversal ultrasound technology, can increase surgeon confidence in offering RLE and early cataract surgery.

Surgeon expectations and patient expectations both influence developments in lens-removal technology. Smaller incisions have resulted in faster visual rehabilitation for patients. Sutureless incisions are popular among patients because they have minimal astigmatic effect and remain stable long term. The standard of care has evolved to the point at which induced astigmatism is minimal. New phaco technology is being designed to minimize the impact on surgeon technique, essentially requiring no change from the surgeon’s perspective. For example, new lens removal systems, such as the WhiteStar Signature system, allow for effective removal of the cataract through either two 1.4-mm microbiaxial incisions or a 2.2- to 2.4-mm microcoaxial incision. Advancements in IOL design has paralleled advancements in phaco systems. The Tecnis 1-piece IOL, for example, can be inserted through the same unenlarged incision.

Informing patients

Surgeons can help patients have realistic expectations by giving them preoperative information. The best and most cost-effective steps a surgeon can make are to prepare patients preoperatively and to educate technicians and staff about the technology. In my practice, the technicians talk to the patient about the technology during the initial work up and get a sense of the patient’s needs. Patients then watch a DVD about multifocal, accommodative, presbyopia-corrective lenses, or LASIK and implantable contact lens surgery. When patients meet with their surgeon, they already have information about surgical and IOL options and a list of questions. Informed patients will have a greater understanding of possible visual outcomes, and that will help surgeons better meet their expectations.

Mark Packer, MD, is a clinical associate professor of ophthalmology at the Oregon Health & Sciences University in Portland.

Selecting an Optimal OVD

Randall J. Olson, MD

Ocular viscoelastic devices (OVDs) are used during cataract surgery to create space in the ocular environment, move elements in the eye, and serve as a protective coating for the corneal endothelium.

Cataract surgeons use three different kinds of OVDs: cohesive, dispersive, and viscoadaptive. Cohesive OVDS are long-chain hyaluronate acids that are highly viscous, expansive, and easily removed from the eye after the case is complete. Dispersive OVDs are short-chain hyaluronate acids that remain in the anterior chamber throughout the procedure and can isolate spaces for protection. Viscoadaptive OVDs, such as Healon 5 (Advanced Medical Optics, Inc. [AMO]), are highly viscous, long-chain, and include a unique feature that allows pieces to break off during aspiration and leave the remaining OVD intact in the chamber for protection throughout phacoemulsification.

Using cohesive and dispersive OVDs

One disadvantage to using dispersive OVDs is that the layer can become irregular during the procedure, causing it to trap debris and resulting in blurred vision or other visualization problems after surgery. Many surgeons are discovering that using a dispersive OVD first, with a cohesive OVD injected inside the dispersive filling the anterior chamber, minimizes visualization problems at the end of the case (Figure).

This technique is popular with the Duovisc (Alcon Laboratories, Inc.) and once Healon D (AMO) is released, it can be used with other viscoelastics in the Healon family. Healon D is the first dispersive OVD of the Healon products. I am looking forward to using it with an expansive, cohesive OVD, such as Healon GV (AMO).

My colleagues and I conducted animal studies and showed that Healon D and Viscoat (Alcon Laboratories, Inc.) are equally protective against air bubbles, debris, and corneal endothelial damage. Our study shows that Healon D will be another dispersive option available to surgeons. (R.J. Olson, MD, unpublished data, 2008).

Ocular Viscoelastic Devices

Figure: Ocular Viscoelastic Devices
Figure. In an animal eye study, Pentacam technology was used to show the endothelial cell protection and space-creating benefi ts of using both a dispersive (Healon D) and cohesive (Healon) viscoelastics during a cataract procedure. To facilitate imaging, Healon D was stained (R.J. Olson, MD, unpublished data, 2008). The image shows that the dispersive OVD forms a consistent barrier while the cohesive OVD provides space for the surgeon to work in.

Source: Advanced Medical Optics, Inc.