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Surgeons need to create a strategy for successful accommodating IOL implantation
One practitioner shares his method for achieving patient satisfaction.
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All accommodating IOL patients should understand that the visual restoration that follows lens exchange occurs via an active process — a process in which they must participate if they are to optimize their outcomes. Most patients enjoy a high level of vision within 6 months of implantation, but the happiest patients are usually those with realistic expectations and thorough postoperative management.
In my experience, it is not unusual for patients to have much better vision the day after accommodating IOL implantation, such as with the Crystalens (Bausch + Lomb). In the majority of cases, however, it can take several months for maximal near vision to be achieved. When preoperatively counseling a patient, I often liken their situation to that of a runner who undergoes knee surgery. I explain that just as the runner will be unable to run a marathon the day after knee surgery, a lens exchange patient will not have perfect vision immediately after IOL implantation. Both, however, will be able to carry out their desired activities with patience, time and rehabilitation.
Rehabilitation after surgery
I place much emphasis on the role of rehabilitation after lens exchange. Most patients understand that the eye needs to heal from the trauma of surgery and acclimate to a new lens, but they often forget about the muscles that facilitate vision. I explain that the function of the accommodating IOL is strongly dependent on the actions of the ciliary muscle in the eye. From the age of 40 years, most individuals start to read with glasses — glasses that take over the accommodating function of the ciliary muscle. I explain that most people who present for IOL implantation after years of glasses use therefore may have atrophied ciliary muscles and must exercise these muscles back to full function. I find that once I educate patients about the impact of ciliary muscle health on visual outcomes, they better understand the postoperative process that must occur if optimal results are to be obtained.
I undertake every accommodating IOL implantation with the goal of having a happy patient, and to do this I find it essential to use only the preoperative and postoperative strategies that I know are effective.
Phillips Kirk Labor
Three days before surgery, I start all patients on a multiple eye drop regimen that consists of an antibiotic, a corticosteroid and an NSAID; I use either Nevanac (nepafenac ophthalmic suspension, Alcon) or Bromday (bromfenac ophthalmic solution, Ista Pharmaceuticals). This regimen is continued postoperatively for 6 to 8 weeks or longer if clinically indicated. It is an effective regimen, illustrated by the fact that I have not seen a case of cystoid macular edema occur in any of my patients over the last 2 years.
Perioperative use of atropine is another strategy I implement unfailingly. A single drop is put into the eye after implanting the accommodating IOL and again on postoperative day 1. By inhibiting ciliary muscle contraction, atropine minimizes the risk of lens movement as the capsular bag begins fibrosis around the implant. If such movement occurs and produces anterior vaulting of the lens, the patient is likely to have a myopic outcome, and if posterior vaulting arises, the patient will be hyperopic. As both of these outcomes are undesirable, it is of utmost importance that the lens does not move until the capsular bag has begun significant fibrosis.
I caution patients that the use of atropine may cause their pupils to remain dilated for 1 to 2 weeks, and I reassure them that although the resulting visual blurring may be a nuisance, it is completely normal. To help them see while dilated, I advise them to use their old glasses or over-the-counter reading glasses because this will sharpen their vision without requiring action from the ciliary muscles.
Follow-up visits
The next assessment occurs at 2 weeks. At this check-up I perform a cycloplegic refraction to determine the patient’s true refractive error. This, in turn, guides the lens power selection for the second eye’s IOL implant. I also give the patient reading exercises and encourage him or her to spend 20 to 30 minutes two or three times daily focusing on the biggest and smallest readable newsprint; additionally, I ask them to begin pencil push-ups. This ensures that the ciliary muscle is adequately stimulated and that the implant is given ample opportunity to flex. I do not tell patients to avoid using their glasses at this postoperative stage because I know they will still need to do so for a little while, especially until their second eye is also implanted with an IOL.
The 1-month check-up provides an opportunity to ensure that all is as it should be and that the eye is healing well. At this appointment, I check that there is no residual anterior segment inflammation and no capsular opacification. I also check that the patient is performing his or her reading exercises and reassure that he or she is recovering as expected. Should posterior capsular fibrosis or anterior capsular phimosis become evident, I proceed with YAG capsulotomy sooner rather than later because the functionality of the implant may be affected earlier than that of a traditional monofocal implant.
Patients are often keen to know when they can expect to have maximal vision. I tell them that this is most likely to occur after their second eye has been implanted with an IOL and has recovered from the procedure. This is usually at least 1 month after the second implantation, although vision, particularly near vision, may continue to gradually improve for several years after the procedure.
The effect of setting realistic patient expectations cannot be emphasized enough for accommodating IOL patients. If realistic expectations are set before the procedure is performed, the patient will always feel informed, in control and, most importantly, satisfied. The reality is that while the attainment of 20/20 vision certainly tends to make a happy patient, 20/happy and not necessarily 20/20 is usually attainable with proper patient selection and education. Specifically, encouraging the patient throughout the process, paying great attention to detail and having ancillary treatment modalities available to tweak outcomes, if indicated, will undoubtedly ensure patient satisfaction.
For more information:
- Phillips Kirk Labor, MD, can be reached at Eye Consultants of Texas, 2201 Westgate Plaza, Grapevine, TX 76051; email: plabor@eyecontx.com.
- Disclosure: Dr. Labor is on the speakers bureau for Bausch + Lomb.