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BLOG: Premium lenses in patients with maculopathy: Blasphemy?
Today, phacoemulsification is the standard of care for patients undergoing cataract surgery in the U.S., and any surgeon routinely performing the old extracapsular lens removal technique might be considered unethical for exposing patients to the added risk and healing time of this older procedure. But in the late 1980s, when phaco was new, surgeons using the new ultrasound-powered device were the ones under ethical scrutiny. It took until the early 1990s for this ethical scrutiny to disappear and give way to broad acceptance of phaco as a better cataract method. In fact, the American Society of Cataract and Refractive Surgery — the preeminent organization for cataract surgeons today — was borne out of a divide between more conservative surgeons who shunned IOLs and phaco and their more progressive colleagues.
Today, an ethical cloud hangs over the question of using premium lens implants in patients with imperfect eyes. This is partly justified. There are surgeons who cajole patients into paying thousands of dollars for premium lens implants that will do no good for their advanced macular disease, end-stage glaucoma or other pathology that severely restricts visual potential. This practice is clearly an abuse of the trust and confidence that patients place in physicians. But this type of abuse is not what I’m talking about
Are there instances in which a premium lens implant can be safely and beneficially used in patients with imperfect maculas? From the early days of these lenses, my personal rule of thumb was to avoid presbyopia-correcting lenses in patients with Snellen potential acuity less than 20/25. However, in light of newer lenses and greater experience, that cutoff may be too restrictive. We performed a study of patient satisfaction with presbyopia-correcting lenses in our practice. The subset of patients with subtly limited visual potential, usually caused by macular pathology prior to surgery, self-reported their satisfaction with surgery at a rate of about 80% at 5 years after surgery. This was compared with 90% satisfaction for patients who had perfect eyes. That’s somewhat remarkable because many of these imperfect eyes get worse over time, which should skew the results toward worse outcomes. Patients with imperfect maculas also achieved spectacle independence for both reading and distance vision at a similar frequency to patients with healthy eyes. Subject to the limitations of their condition, they did achieve their hoped-for goals, and their narrative responses indicated they would make the same decision again for a premium implant.
If we are going to use a presbyopia-correcting lens in an imperfect eye, which lens should we choose? I have long said that the Crystalens (Bausch + Lomb) is the ideal presbyopia-correcting implant for this tough group of patients, but it’s not the only choice any more. The Crystalens retains a single point of focus, allows a respectable extended depth of focus, corrects astigmatism with greater stability than any presbyopia-correcting lens, and at its worst is no worse than a monofocal lens. Our other lens choices include the low-add multifocals, such as the ReSTOR Active Focus (Alcon), the Johnson & Johnson Vision low-add Tecnis multifocal and the J&J Vision Symfony lens. With these lenses, a growing number of surgeons are treating patients with maculopathy, aberrated corneas, compromised optic nerves and other pathology that restricts vision in the 20/30 to 20/40 range.
Beyond presbyopia correction, astigmatism correction in compromised eyes makes perfect sense. Reducing the blur circle of incoming light benefits any eye with reasonably preserved visual potential. Although still controversial, many would agree it’s reasonable to use a toric monofocal lens (or limbal relaxing incisions) in eyes with visual potential perhaps as low as 20/50.
As refractive cataract surgeons, we understandably prefer to focus our attention and our research on those patients who are capable of perfect outcomes, as opposed to those where the odds are stacked against us. But I believe the measure of a physician is how he or she tries to bring about the best outcome in less than ideal circumstances. Grounded ethics means doing what you would for a family member. For many of us, that means that using today’s tools, and some common sense, to allow spectacle independence is both possible and the right thing to do.
Disclosure: Hovanesian reports he is a consultant to Alcon, Bausch + Lomb and Johnson & Johnson Vision.