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Pearls for surgery on presbyopic IOL patients
Achieving emmetropia, selecting the right candidates and minimizing complications are key to succeeding with these patients.
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With the Centers for Medicare and Medicaid Services ruling in 2005, patients who are undergoing cataract surgery now have the option of choosing presbyopic lens implants. The primary presbyopic IOLs available in the U.S. market are the Advanced Medical Optics ReZoom, the Alcon ReSTOR and the eyeonics Crystalens, whose chief, J. Andy Corley, played a critical role in achieving the CMS ruling.
Patients who elect to pay out of pocket for a premium IOL and a premium surgery expect to achieve a premium result. These patients should be thought of as refractive surgery patients and not simply cataract patients. There are some helpful pearls to keep in mind to achieve success with these presbyopic IOL patients.
Achieving emmetropia postop
 Uday Devgan |
In a recent interview I conducted with Richard L. Lindstrom, MD, he explained that achieving emmetropia with presbyopic IOL patients is the most important factor in determining patient satisfaction (OSN Innovators Interview podcast, posted Jan. 1, 2007, on www.OSNSuperSite.com). This requires accurate lens calculations with either immersion ultrasound or the Carl Zeiss IOLMaster, my preferred technique, as well as personalization of the A-constant. This will ensure an accurate spherical correction but will not address any preoperative corneal astigmatism.
Incorporating corneal astigmatism correction through the use of limbal relaxing incisions is an effective way to reduce cylinder postoperatively and move closer to emmetropia. For patients with larger degrees of astigmatism or residual postoperative spherical refractive error, excimer laser is a useful adjunct. Excimer ablations can be done via surface ablation by the general ophthalmologist, or the patient can be referred to a corneal refractive surgeon for a flap-based ablation.
Patient selection
Understanding the patient’s expectations is the single most important part of the preoperative exam. Even the best technologies and the best surgeons are not able to satisfy patients with unrealistic expectations. It is usually my goal to under-promise and then over-deliver, as this is the sure way to achieve high patient satisfaction.
Patient personality plays a role in expectations, and often the stereotype of the low-myope perfectionist engineer is true. The difficulty with implanting presbyopic lenses is that we do not know how patients will perceive and react to their new vision. By choosing patients with easygoing personalities, we are stacking the deck in our favor.
To further temper expectations, I often tell patients that nothing beats the fountain of youth and I cannot make them see like they did when they were teenagers. I also tell them that I can likely reduce the need for glasses for most of their activities, but even with a perfect surgery there may be some tasks that will require a mild pair of glasses, such as driving at night or doing prolonged near work.
Patients who are hyperopic preop are often the most grateful because before surgery they were dependent on glasses for all distances: far, intermediate and near. Compare the difference between a patient who is +3 D preop and one who is –3 D preop, and you will immediately understand my reasoning. Similarly, choosing patients who have minimal or no corneal astigmatism makes it easier to achieve postoperative emmetropia.
Finally, patients with significant cataracts are already plagued with blurry vision, glare, halos and other dysphotopsias due to their lens opacities. Patients with posterior subcapsular and cortical cataracts have significant glare and halos before surgery, and just about anything will be a large improvement for them.
 | During cortex cleanup, the bare metal of the I&A tip may come into direct contact with the delicate posterior capsule, which is just a few microns thick. |
 | To avoid this metal-to-capsule contact, surgeons can use a silicone coated I&A tip. Images: Devgan U |
Minimizing complications
You select an easygoing hyperopic patient with no astigmatism, you do accurate lens calculations, but you get a complication and the patient ends up with chronic cystoid macular edema and 20/200 vision. All surgeons have complications from time to time, but it is particularly important in these premium presbyopic IOL patients to take all steps to minimize complications.
Producing clear corneas on postop day 1 is important for patient satisfaction. Multiple studies have shown that reducing the phaco energy placed into the eye and protecting the cornea with a good quality viscoelastic are key to achieving clear corneas.
All surgeons should be using some form of phaco power modulations, as this does not require a change in technique and it is available on most major phaco platforms. Similarly, all surgeons should use a good quality viscoelastic, and during longer or more challenging cases, surgeons should periodically recoat the endothelium.
For my senior residents, all excellent surgeons, the most common time for posterior capsule rupture in cataract surgery is during cortex removal with the irrigation and aspiration probe. During this cortex cleanup, the bare metal of the I&A tip may come into direct contact with the delicate posterior capsule, which is just a few microns thick. To avoid this metal-to-capsule contact, surgeons can use a silicone coated I&A tip, such as the one from MicroSurgical Technology. These I&A tips have changed the way that I perform cataract surgery and have decreased complication rates significantly.
Even with a technically perfect surgery, the act of performing intraocular surgery may contribute to the development of cystoid macular edema. There are published studies that show that topical use of NSAIDs can prevent and treat cystoid macular edema in addition to resolving postop inflammation and discomfort. For these reasons, I give preoperative and postoperative NSAIDs to 100% of my patients, both routine cataract patients and presbyopic premium IOL patients.
Our future: refractive cataract surgery
I. Howard Fine, MD, calls refractive cataract surgery the quadruple win: (1) Patients win by getting access to the best-quality and highest-technology products; (2) surgeons win by being paid for their expertise, skill and work; (3) the ophthalmic industry wins by being rewarded for developing better and more advanced technologies; and most important, (4) the U.S. government wins by having a large number of patients being happily pseudophakic before reaching Medicare age, thereby reducing the financial strain of paying for cataract surgery. I have no doubt that Dr. Fine is right.
For more information:
- Uday Devgan, MD, FACS, is in private practice at Devgan Eye Surgery in Los Angeles, Beverly Hills, and Newport Beach, California. Dr. Devgan is Chief of Ophthalmology at Olive View UCLA Medical Center and an Associate Clinical Professor at the Jules Stein Eye Institute at the UCLA School of Medicine. Dr. Devgan can be reached at 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; 800-337-1969; fax: 310-388-3028; e-mail: devgan@gmail.com; Web site: www.DevganEye.com. Dr.Devgan is a consultant to Abbott Medical Optics and Bausch & Lomb, and is a stockholder in Alcon Laboratories and formerly in Advanced Medical Optics.