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Refractive outcome of toric IOLs determines patient satisfaction
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In 1985, while presenting the first major lecture to launch the 3M diffractive multifocal IOL at the European Society of Cataract and Refractive Surgeons meeting in Copenhagen, Denmark, I proposed the concept that, in the future, the success of cataract surgery and the individual cataract surgeon would be judged on the quality of the refractive outcome.
 Richard L. Lindstrom |
I suggested that the cataract surgeon of the future would need to be a “refractive cataract surgeon,” employing careful biometry, IOL power selection and astigmatism management in his patients. In our extensive studies of this pioneering multifocal IOL that has evolved over 25 years into the current generation ReSTOR (Alcon), we performed extensive psychological testing in our 600+ patient clinical trial. We were convinced that patient satisfaction would be significantly affected by the psychological profile of the patient who received the multifocal IOL.
Much to our surprise, we found no correlation with psychological profile, age, occupation, avocation, location or any other such variable. The only factor that correlated with patient satisfaction was the refractive outcome of the patient. If the patient was within 0.5 D of emmetropia, the patient was highly satisfied, would have the procedure again and, more importantly, would recommend it to his or her friends.
Patient satisfaction generated by good outcome
More recent outcomes research on a large series of patients implanted with the Crystalens (Bausch & Lomb), ReSTOR and ReZoom (Abbott Medical Optics) by Guy M. Kezirian, MD, utilizing his DataLink outcomes analysis system confirmed that there is a significant decrease in uncorrected visual acuity with all presbyopia-correcting IOLs if there is a residual defocus of more than 0.5 D, whether it be sphere or cylinder.
My conclusion, after 25 years of studying the premium IOL field, is that the level of patient satisfaction is not dependent on careful patient selection. It is not even dependent on careful patient counseling, although it is a given that this is part of every surgeon’s duty.
Perhaps even more controversial, I do not believe that patient satisfaction is really significantly influenced by extensive efforts to reduce patient expectations. Patient satisfaction is generated by a good outcome. A good outcome is a complication-free procedure that generates a refractive outcome within 0.5 D of emmetropia, period.
Therefore, patient selection is less important than surgeon performance if a reduction in spectacle dependence is the desired outcome. Fortunately, our ability to generate a refractive outcome within 0.5 D of emmetropia has increased exponentially over the past quarter century.
Toric IOLs are an important part of this evolution, and their use must be a part of every refractive cataract surgeon’s skill set. In addition, every refractive cataract surgeon must appreciate that it is the refractive outcome they generate, not the patient or even technology they select, that is the primary determinant of patient satisfaction and word-of-mouth referrals.
Raising our standards
Today, whatever the patient’s goal, whether it be functional uncorrected distance vision or functional uncorrected vision at distance, intermediate and near, we have technology available that can generate a very high level of satisfaction, so long as we, the refractive cataract surgeon, do our job. The job, as I see it, is to generate a refractive outcome within 0.5 D in every patient. We have the technology, especially with the addition of excimer laser enhancement when needed, to do this every time.
I believe that for the premium IOL channel — including toric, multifocal and accommodating IOLs — to achieve its full promise, we refractive cataract surgeons must raise our standards regarding acceptable refractive outcome. The bottom line: Our job is not done until we put the eye in focus. If we do this compulsively for every patient, their satisfaction will result in exponential growth in the premium channel.