How to keep the promise of no glasses after cataract surgery
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“Will I still need glasses after cataract surgery?” The simple answer to this daunting question posed to premium surgeons is never promising no glasses in the first place.
The old adage of “underpromise and overdeliver” remains critical when entering the world of premium IOL technology. My algorithm for maintaining premium IOL outcome success is straightforward but involves selecting patients with perfect subjective criteria and perfect objective criteria while considering adjustable IOL technology. Keeping this promise of no glasses starts preoperatively.
Establish your premium options
In my practice, we base premium options on lifestyle: Basic (basic basic or basic Lensar); Legal to Drive (elite — Light Adjustable Lens up to 2.5 D of corneal cylinder correction; monofocal toric greater than 2.5 D) distance in both eyes or monovision; and Forever Young (extended depth of focus/multifocal, toric or nontoric) — Symfony (Johnson & Johnson Vision), Synergy (Johnson & Johnson Vision), PanOptix (Alcon), Vivity (Alcon), low add multifocals, Crystalens (Bausch + Lomb) and Trulign (Bausch + Lomb).
Establish expectations for each premium option
Our basic options promise glasses are needed 100% of the time postoperatively for all levels of vision (distance, intermediate, near). Basic Lensar allows for femtosecond capsulotomy/fragmentation/astigmatic incisions/Scheimpflug digital imaging but still no promise of any freedom from glasses. Our Legal to Drive options are custom cataract surgery with an advanced aspheric, adjustable and/or toric lens implant with a 100% guarantee for legal to drive vision (20/40 or better) without glasses by 18 months after surgery while still needing glasses for intermediate and/or near vision tasks (computer/reading) 100% of the time unless monovision is planned. If monovision is planned, we tell patients they may need part-time glasses for low light/night vision situations. Our Forever Young option is custom cataract surgery with an advanced presbyopia-correcting lens implant, and the need for glasses for distance, intermediate and/or near vision tasks will be eliminated or reduced, but glasses may still be needed part time for any level of vision.
Perfect objective candidate criteria
The next step is to make sure the patient is a perfect objective candidate based on a wide array of diagnostic testing. The patient must have a pristine ocular surface; osmolarity, MMP-9, OSDI/SPEED and meibomian gland imaging are helpful here. The PHACO study and the Duke study showed at least 80% of patients coming for cataract surgery have signs of dry eye despite being asymptomatic. It is also important to make sure the patient has no macular pathology (OCT imaging).
Plan to correct corneal astigmatism (evaluate anterior and posterior corneal effects) by looking at corneal topography and tomography. Corneal topography/tomography/epithelial mapping will also show the ability to treat residual refractive error postop with PRK, LASIK or SMILE. Looking at angle alpha/kappa effects and selecting patients with less than 0.7 D might reduce some unwarranted multifocal side effects. Use fourth-generation IOL formulas such as Barrett, Hill-RBF, Ladas, Holladay 2, Barrett True-K and ASCRS calculator.
IOLMaster (Carl Zeiss Meditec), Lenstar (Haag-Streit), Argos (Movu) and intraoperative ORA will also help hit the correct postoperative end target. Lastly, look at corneal quality, especially in post-refractive surgery patients, and select premium IOLs if corneal RMS higher-order aberrations remain higher than 0.38. Devices such as OPD-Scan III (Marco) and iTrace (Tracey Technologies) can provide a multitude of these criteria in seconds in the exam lanes.
Lifestyle questionnaire
My favorite part of the premium IOL selection process is the perfect subjective criteria needed by looking at lifestyle questionnaires. My practice uses a modified Dell questionnaire, which looks at a patient’s desire to be without glasses if the choice existed, their selection of activities of daily living (25 choices) from day/night driving, smartphones, reading medicine bottles, etc, and self-grading of personalities from easygoing to perfectionist.
Some of the responses have been surprising and definitely a quick save from mistakenly choosing to place a premium IOL in a patient who would require endless chair time postoperatively. For example, one patient put a question mark on their own personality, one patient asked me to decide on their personality, and another patient wrote I would find out their personality based on their visual outcome. John Hovanasian has developed a visual profile report called MDbackline, which basically digitizes the lifestyle questionnaire responses into a simple upgrade probability and tells what type of premium IOL to consider.
Recently, Vivior technology has come to the U.S. It uses a monitor that connects to the patient’s spectacles and for 36+ hours will evaluate key parameters such as distance, ambient light, UV light, orientation and motion. The monitor does not include a camera so it avoids infringing on patient privacy, but it does clip on prescription or clear glasses and records the patient’s activities. Vivior seems, in my opinion, to quantify the lifestyle questionnaire in real time and helps provide a selection of which premium IOL option would be best for the patient.
Consider adjustable lens technology
The Light Adjustable Lens (RxSight), with its capability to adjust postoperatively, provides better accuracy in hitting the patient’s ideal target. The newest upgrade to this technology is “active shield,” which provides an invisibility feature that I like to call the “Invisible Man” technology. It allows a shutter in the lens to open and close for each adjustment, which provides additional UV protection (along with the UV blocking glasses). This new feature provides peace of mind and confidence until all light treatments are complete.
In summary, remember not to promise no glasses and set realistic expectations for your premium IOL patients. Try to go through the process of perfect objective and subjective criteria to achieve the perfect candidate and perfect premium IOL match to eliminate the dreaded unhappy patient postoperatively. In the end, think you are a Chicagoland surgeon like myself, and I cannot promise a perfect weather day ever. Stay healthy as the COVID pandemic is finally coming to an end.
- References:
- Gupta PK, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.06.026.
- Trattler WB, et al. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S120159.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
Editor’s note: On July 13, 2021, this article was updated to clarify that the Light Adjustable Lens upgraded technology provides additional UV protection postoperatively, along with UV-blocking glasses. The editors regret the error.
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