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Intermediate vision factors into satisfaction of refractive cataract patients
A surgeon explains key skills and strategies for using premium IOLs to achieve patient satisfaction.
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Postoperative intermediate vision may be the determining factor for patient satisfaction in refractive cataract surgery using premium IOLs, Frank A. Bucci Jr., MD, said in a presentation at Hawaiian Eye 2015.
“The goal or end game with premium IOLs is to achieve high patient satisfaction resulting in spectacle independence,” he said.
Key core skills
For successful monofocal surgeons to become successful premium IOL surgeons, they must have three key core skills, Bucci said: communication skills, the skill to select appropriate premium IOLs and the ability to correct residual refractive errors.
Frank A. Bucci Jr.
“You have to have some genuine doctor-patient relationship,” Bucci said. “Preoperatively, you have to determine their visual needs and profile, and then you’re going to match those needs with your knowledge of premium IOLs, the strengths and weaknesses, and apply that to what you learn in step one. … You can’t go ahead without being able to aggressively fix residual refractive error.”
Bucci considers patients, surgeons and premium IOLs to be the “three players in the game.” The goal is to combine these three players to exceed individual thresholds of satisfaction for five visual elements of success: high-quality distance vision, functional intermediate vision, good near vision in both dim and bright light, and acceptable light phenomenon at night.
Therefore, the goal of the surgeon is to find and select the IOL combination that has the least morbidity or highest patient satisfaction, Bucci said. Relating his experience, Bucci said he has come to like the combination of two Tecnis multifocal lenses (Abbott Medical Optics) to correct presbyopia and has implanted more than 1,000 of these IOLs over the past 4 years.
“It turns out that [the Tecnis multifocal IOL] gives me the lowest morbidity or the highest patient satisfaction,” he said.
Patient satisfaction study
In a multivariate regression analysis, Bucci and colleagues studied the predictors of overall patient satisfaction with bilateral visual outcome in patients with diffractive multifocal lenses.
The study consisted of 55 “best case” patients implanted bilaterally with Tecnis multifocal IOLs in whom residual refractive error was treated, a minimum of 6 months for neuroadaptation had elapsed, the ocular surface was well managed, and YAG capsulotomies were completed when necessary.
The study examined 41 variables, with the initial dependent variable being overall patient satisfaction. Other variables included visual outcomes, reading speed, reading accuracy, angle kappa, higher-order aberrations and other postoperative clinical metrics.
All patients reported being either “very satisfied” or “satisfied.”
Overall patient satisfaction was statistically significantly different between very satisfied and satisfied patients for three variables, all related to visual function at intermediate distances.
Bivariate analysis further found a strong correlation between pupil size and intermediate vision “above and beyond the pinhole effect,” Bucci said. Therefore, intermediate vision became the new dependent variable in the study because it was predicting overall patient satisfaction. Mesopic pupil size and IOL centration were then seen to be the significant variables predicting intermediate visual outcomes.
Therefore, there is a strong clinical correlation with preoperative pupil size and postoperative intermediate vision, he said.
Bucci said the mechanism of action for the Tecnis multifocal IOL, including the new low-add multifocal lenses, is that the central 1 mm of the lens is half the power of the near power of the lens; therefore, for a +4.00 multifocal, the add at the central 1 mm button is +2.00.
“I believe that as the pupil diameter decreases, the relative percentage of light going through that 1 mm button increases, thus enhancing the intermediate vision,” Bucci said.
Bucci also predicted that the new low-add Tecnis multifocal lenses will increase patient satisfaction because they enhance intermediate vision. In addition to the effect of the 1-mm central button, they also have increased focal lengths of 17 inches and 20 inches from the patient’s eye for the +3.25 and +2.75 models, respectively, compared with the 14-inch focal length of the +4.00 model, which sometimes compromises intermediate vision in patients with larger pupils, he said. – by Kristie L. Kahl
For more information:
Frank A. Bucci Jr., MD, can be reached at Bucci Laser Vision Institute, 158 Wilkes-Barre Township Blvd., Wilkes Barre, PA 18702; email: buccivision@aol.com.Disclosure: Bucci reports he is a consultant for Abbott, Allergan, Bausch + Lomb, Lensar, PRN, Glaukos, AqueSys, TearScience, Omeros and Alphaeon.