Rookie mistakes: Avoid the premium IOL learning curve
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The time for premium IOLs has finally arrived, with many new and exciting options and fewer side effects than earlier-generation technology.
Setting expectations is the most important preoperative consideration with these lenses when talking with prospective patients, but there are many “rookie mistakes” that surgeons may make in the process of patient and premium IOL selection. Over the last 5 years, I have had the privilege to have a 1-year refractive cataract fellow annually through the American Academy of Ophthalmology SF Match program, and the goal has been to take these “rookies” and make them master premium surgeons. Overall, the goal is to make us all masters of our trade, so here are some of my key approaches to avoiding rookie mistakes.
Use correct terminology with patients
Too many times, cataract patients will go home after their evaluation with too many options, and not only do they avoid picking a premium option if they qualify, but they may not schedule surgery at all. Verbiage and terminology are key in the education process. Older terms such as monovision and multifocality need to be replaced with terms such as blended vision and natural vision. Using the word “presbyopia” with a patient is like telling a premium surgeon which valve to use on a pipe in construction. Verbiage such as “A.G.E. syndrome” resonates better with a patient than the medical term of presbyopia.
We deliver premium options in the form of lifestyles as patients want to achieve the capability to read their smartphones without glasses, be legal to drive day or night without glasses, and/or other near/intermediate tasks free of correction. Our upgraded lifestyle options are categorized as Basic (glasses full time for all levels of correction), Legal to Drive (thanks to Jim Loden) in which patients can drive legally day or night without glasses, and Forever Young (created by myself) for our presbyopia option. In reality, no patient wants to be “forever old.”
Select perfect candidates for perfect outcomes
I tell many of my potential premium patients that unless they are a perfect candidate, they will not obtain a perfect outcome despite perfect surgery. It is critical in the process to follow the recipe for selecting a “perfect” candidate.
A pristine ocular surface is needed preoperatively to obtain good biometry and keratometry measurements for IOL power selection, and this must be maintained intraoperatively and postoperatively to avoid dreaded vision fluctuations, especially for near visual tasks, which cause patients to clog up lane time saying they paid for a lens that does not work. Both the PHACO and DUKE studies showed most patients are asymptomatic at the time of their cataract evaluation, but up to 80% of them have objective signs of dry eye disease.
Other important considerations include a pristine macula, a plan to correct corneal astigmatism (as low as 0.75 D), setting patient expectations about glare/halo/dysphotopsia visual side effects postoperatively, and obtaining corneal topography/tomography/epithelial mapping to show the ability to treat residual refractive error postoperatively with PRK, LASIK or SMILE. Further perfect candidate criteria include trying to pick patients with angle kappa/alpha below 0.7 (although this is still controversial) and using fourth-generation formulae for IOL power calculations, such as Barrett, Hill-RBF, Ladas, Barrett True-K and ASCRS calculator, on devices such as the IOLMaster 700 (Zeiss), Lenstar (Haag-Streit), Argos (Movu) and/or ORA (Alcon) intraoperatively.
Lastly, look at corneal quality with devices such as the OPD III (Marco/Nidek) and/or iTrace (Tracey Technologies) and make sure the root mean square factor for higher-order aberrations is not peaking beyond 0.38 or higher. Know the refractive end target for the premium IOL you have selected and nail that target. It is a common mistake not to check eye dominance preoperatively because mini-monovision done in a reverse format, although liked by a minority, will cause unnecessary postoperative unhappiness and chair time. The Light Adjustable Lens (RxSight) fixes a lot of common rookie mistakes because it is fairly easy to adjust, customize and lock in the end target for these patients after all of their surgical healing has stabilized.
In the end, we are all “rookies” some days, and staying on top of our premium game with these pearls can make us masters.
- 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.
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