Should patients be given a menu of different IOL options, or should the surgeon find the best fit and recommend that one?

Issue: January 25, 2009

Discussion of presbyopia-correcting IOLs is a must

Alan B. Aker

With the availability of premium IOLs that are capable of correcting presbyopia, I feel that these options must be discussed with patients preoperatively.

Any surgeon who fails to discuss presbyopia-correcting IOLs is likely to find himself dealing with very disappointed patients once they find out they could have opted for this kind of lens.

I routinely see patients with standard monofocal lenses who want to have their lenses exchanged for the Crystalens. When we explain that the Crystalens should be done at the time of their initial procedure, these patients are extremely unhappy this option was not offered to them prior to their cataract surgery. We are in the early days of these IOLs, but I would not be surprised to see a patient bring legal action against a surgeon for failing to provide them with an informed consent because this option was not discussed.

I have a fairly strong referral practice and routinely have patients referred specifically for Crystalens implants from other ophthalmologists. We truly enjoy helping patients receive the benefits of presbyopia-correcting cataract surgery; the patients are thrilled at receiving postop results that exceed their expectations; and the referring ophthalmologist has a very happy patient back in his practice for co-management in the postop period. This certainly represents a triple-win situation.

I believe toric IOLs should be discussed with astigmatic patients preoperatively as well. However, because astigmatic errors can be addressed a number of ways in the postoperative period, the need is somewhat different from that of presbyopia correction. When the range of correctible astigmatism with Alcon’s toric IOLs is expanded this year, this will only get better for our astigmatic patients.

While it is important to discuss toric IOLs prior to surgery, discussion of presbyopia-correcting IOLs is a must.

Alan B. Aker, MD, is founder and medical director of Aker-Kasten Cataract & Laser Institute, Boca-Raton, Fla.

What would you want in your own eyes?

Vance M. Thompson

I believe patients deserve to hear about all their surgical and non-surgical options. I like to use the phrase, “If it were my eyes, what would I want to know?”

If the fully educated patient chooses a procedure we are comfortable with, we can offer to perform it. If the patient prefers a procedure we are not comfortable with, we can recommend referral.

When it comes to cataract surgery implants, I would want to know the advantages and disadvantages of monofocal, aspheric monofocal, multifocal and accommodating lens implant technology. If the center I was consulting with did not feel comfortable with educating me on all these options in a comprehensive fashion, I would want to be referred to a center that did.

All ophthalmologists can educate patients fully on premium implants or refer to a center that is comfortable with this education. Then, with patient consent, the surgeon has a choice to perform or refer the cataract extraction and premium implant procedure. If necessary, the surgeon also has the choice to perform or refer the laser or astigmatic keratotomy enhancement surgery. At a minimum, the cataract patient needs to be educated on all their surgical and non-surgical options, including a balanced discussion on premium implants.

Vance M. Thompson, MD, is an OSN Refractive Surgery Section Member.

Custom solution required for each patient

Kenneth R. Kenyon

Although I maintain a menu of IOL options, my approach is to carefully assess the patient and offer a specific strategy that I believe affords an individualized best fit. I specifically concur with Matteo Piovella's notion that like refractive surgery, contemporary cataract surgery is personalized surgery. However, as patients seek our professional opinion, I respond by offering a specific recommendation and action plan. And especially in the Information Age, I seek to avoid the cascade of TMI (Too Much Information) Syndrome, leading to overly extended deliberations, analysis paralysis and ultimate indecision.

In limiting this discussion to cataract patients (as distinct from refractive lens exchange patients), I first segregate individuals who are already doing monovision with contact lenses or refractive surgery and/or who are at least wearing contacts and for whom a contact lens monovision trial is readily accomplished. For baby boomers like myself (already benefiting from 10 years of monovision LASIK), the recommendation is self-evident: Simply replicate or create monovision with a standard monofocal IOL. From my refractive surgical experience, contact lens trials almost invariably disclose that patients desire their non-dominant eye to be targeted at approximately -2 D. The cost saving to the patient plus the non-risk of multifocal IOL night vision distortions make monovision a no-brainer for this increasingly prevalent group of active but aging contact lens wearers.

For the remaining patients who are potential multifocal IOL candidates, I discuss their specific visual preferences and needs. Thus, for the near vision person who is interested in reading, crafts or other near to intermediate tasks, I recommend the ReSTOR (Alcon), as its near dominant design affords an advantageous 3.2 D add. For the distance vision person who is more concerned perhaps with recreational sports, the 2.6 D add of the distance dominant ReZoom (Advanced Medical Optics) is my choice. And for perhaps a pilot or driver whose night vision needs are not tolerant of night vision distortion risks of the refractive IOLs, I offer the pseudoaccommodative Crystalens (Bausch & Lomb). (I have yet to gain experience with the diffractive multifocal Tecnis IOL from AMO.) Recognizing that many expert surgeons favor the mix-and-match approach of combining multifocal IOL styles to bridge the overall focal range, I have not yet chosen to pursue this "double-edged sword" approach.

The final aspect of the action plan that I propose to each patient is the recognition that as cataract surgery is increasingly becoming refractive surgery, I am committed to take all appropriate steps to optimize the functional visual outcome. This translates to first operating on the non-dominant eye in which the acuity result may be less critical, followed by the dominant eye within 4 weeks or less. Should visual distortions develop, and assuming accurate IOL power and centration, then early YAG capsulotomy is warranted, followed by spectacle prescription for minimal refractive errors (especially for night driving) and with the option to pursue laser vision correction after 3 months should residual refractive error of any degree by responsible for a less than "20/happy" outcome.

There is obviously nothing unique about my approach apart from the keen sense of the obvious lesson that as our menu of choices continues to expand, a "one-size-fits-all" approach to contemporary cataract surgery is as inappropriate as has long been known for refractive surgery. Thus as the master tailor, we are responsible to "size up" each individual and offer a custom-tailored solution to their highly personalized needs, styles and expectations.

Kenneth R. Kenyon, MD, is Editor Emeritus, OSN Cornea/External Disease Section.