Preparation, setting expectations, backup plans: Meeting goals with premium IOLs
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Advances in IOL technology have given patients a range of opportunities for their vision after cataract surgery.
The latest lens options also offer surgeons a chance to optimize each implant and help patients achieve their vision goals. And while there are more possibilities than ever before, when it comes to vision with an artificial lens, it can never be perfect.
Source: Nicole Fram/Advanced Vision Care
“The hardest part of meeting patients’ expectations is that patients sometimes think cataract surgery targeting is ‘magic’ and we just put the optics into a calculator and they’re automatically going to be perfect after surgery,” Healio | OSN Cataract Surgery Section Editor Nicole R. Fram, MD, said. “There are formulas that we use, but I always emphasize that they are probability formulas. We can’t fully predict where the effective lens position is going to be in their eye.”
Fram tells patients that she can hit the refractive targeted vision 85% to 90% of the time with normal axial lengths and corneal curvature. However, there might be some circumstances in which patients will need glasses, such as when they drive at night or read very small print.
“I try not to confuse patients with a menu of options and help guide the technology choice,” she said. “Spending the time to provide realistic expectations is critical for a successful outcome. Then, if you don’t hit your refractive target for whatever reason, they are a partner in the solution.”
The most important part of setting up a patient for success is to find out how they are currently using their eyes and how they want to use them after surgery, Fram said.
“I ask about their occupation or hobbies. Do they wear glasses when they look at their phone or read? Do they wear glasses when they drive? Do they mind wearing reading glasses, or do they prefer to be out of glasses entirely? This initial triage of questions is the blueprint for their cataract surgery planning,” she said. “For example, if a patient comes with mixed astigmatism and is able to see distance and their phone without glasses, it is really important to meet that outcome postoperatively with at least an EDOF or mini-monovision. Another detail I underestimated early on in my career was when to plan a patient for near correction. Some patients have always taken their glasses off to read and value precise near vision. Assuming that all patients want uncorrected distance in this patient population will turn their world upside down.”
Not every patient is satisfied with their IOL surgery. In a study published in Ophthalmology in 2023, researchers collected data from 554 patients using an 86-item questionnaire that they filled out preoperatively and postoperatively at 4 to 6 months. The questionnaire included standardized images that helped assess common symptoms such as glare, starbursts, halos and more.
Overall, most patients were satisfied with their outcomes, and reported visual symptoms decreased after surgery. In the study, 84% of patients reported being somewhat, very or completely satisfied with their vision, matching up with what Fram tells her patients.
“I never promise that they’re not going to have any issues with halo or glare at night with any IOL as we are implanting an artificial plastic IOL. Certain IOLs that split or stretch light will have more photic phenomenon. However, even a monofocal IOL can result in unwanted optical images,” she said. “I tell patients that nothing is better than what Mother Nature gave us. We’re trying to mimic Mother Nature, but we can’t necessarily get there 100%. The key is to be there for the patient if they are having debilitating issues and be a partner in the problem solving.”
Preop diagnostics
Successful premium IOL surgery comes down to proper preparation. Brandon D. Ayres, MD, does not even see patients before he has their topography, biometry and an assessment of their ocular surface.
“I use a digital surgical planner, so it’s quite easy for me to start looking at different lenses — trifocal vs. toric vs. monofocal — and say, ‘Based on the measurements, it looks like you’d be a good candidate for a lens implant that decreases your dependence on reading glasses and should give you good distance vision as well,’” he said. “But I definitely undersell the technology. I never promise that they are going to be glasses free. I tell them we’re going to try and get them as glasses free as possible. I also tell them that some patients may notice some haloing after surgery. If that is a problem, we’ll have to address it, which can mean anything from a mild pair of glasses or artificial tears for dry eye all the way to additional surgery.”
Getting the relevant diagnostic information is particularly important in cases in which patients have had previous LASIK or PRK or if they have keratoconus, Fram said.
“I always do topography, tomography and biometry,” she said. “I have two biometers so I can pick up on errors. If you have two saying the same thing, you feel more confident. I’m looking at angle kappa, coma and trefoil as well as higher-order aberrations in the cornea so that I can counsel patients on what their expectations should be.”
These diagnostics, as well as taking a detailed patient history, go a long way in pointing surgeons toward the lens that will work best for each patient, Healio | OSN Cataract Surgery Board Member Audrey R. Talley Rostov, MD, said.
“If someone had previous myopic LASIK, I almost always recommend a Light Adjustable Lens (LAL, RxSight) because I find that works the best for them,” she said. “On the other hand, sometimes the LAL doesn’t work as well in patients with previous hyperopic LASIK.”
In patients with previous RK, Talley Rostov usually recommends the IC-8 Apthera small aperture IOL (Bausch + Lomb). In patients who underwent a corneal transplant, she usually goes with a monofocal toric lens.
“That’s why it’s so important to get an OCT of the macula,” she said. “We make sure that they don’t have any macular disease or anything that could potentially limit their vision from that standpoint. You want to know what you’re dealing with. The first thing that’s important is to do a thorough workup of the patient and to get the important diagnostics so that you can see what the best technology is for the patient to have.”
Setting expectations
By the time Healio/OSN Board Member Mitchell A. Jackson, MD, sees patients, he already has his/her preferred lenses picked out. He said he likes to limit the options he gives to patients so he can smooth out the process of setting goals and preparing them for vision after surgery.
“I only give two options ever,” he said. “That’s the basic option and an advanced option if they qualify. I’ll look at their objective testing — topography, tomography, OCT of macula, biometry. Then, the biggest thing is their preoperative lifestyle questionnaire. You’ll learn anything and everything about a patient from that.”
For Jackson, the questionnaire is the decision-maker for many patients, even more so than the objective testing.
“We want to know what the patient’s realistic expectations are,” he said. “If they want to be 20 years old again, they’re not realistic, and I demonstrate what they’ll be able to do with near vision capability. Without glasses on the basic option, you will not even be able to reach J10. You’re going to need reading glasses or a prescription bifocal for a full-time, near-vision task. If you think, you’re going to get that with what insurance pays for, nope. I don’t want you crying afterward because I’m going to write a script for you to get glasses.”
Talley Rostov said it can be a balancing act between diagnostics and expectations. If a patient wants a premium IOL, biometry can let the surgeon know if the preferred lens even comes in the needed power.
“If someone had a previous Implantable Collamer Lens (STAAR Surgical), that could be someone who was a very high myope but wants a full range of vision,” she said. “They may or may not be able to achieve that because there may or may not be a lens in the correct power that we need for them. That’s something to keep in mind to help guide both the choice of technology that’s best for them and their expectations.”
Ayres said cataract surgeons do a good job of setting expectations for their patients. The tough part is that some patients will misinterpret or misunderstand the information they have been given.
“There are times when I specifically say, ‘You will need glasses,’ and I hear it later from my own patients, ‘You told me I wouldn’t need glasses,’” he said. “There is so much information that we’re giving to patients about the implants and everything involved, and at the end of the conversation, a patient can look at you and say, ‘Wait, so I need cataract surgery?’”
Ayres said surgeons need to make these discussions more understandable with as few medical terms as possible. In his practice, he is working on an initiative to help patients with this education. Patients are sent home with forms detailing their surgery and what they can expect postoperatively. It is a lot of information to retain, but Ayres said it is important to give them everything they need.
“I always tell them, ‘You’re not a Chevy. You’re a human. I can’t predict what size bolt is going to be needed,’” he said. “Patients probably only remember a small fraction of what we were discussing during those cataract evaluations.”
Correcting issues
Despite surgeons’ best efforts, some patients will not be satisfied with their vision after cataract surgery. Ayres likes to make sure patients are prepared for the eventuality that they might need additional surgery if they do not meet their visual goals.
“I’ve already planted the seed, so they know that if there is an issue, it’s not the end of the road,” he said. “There are more things that we can do, and I like to be very open with patients and be on the same team with them so that we’re working together and coming to decisions together.”
The first step of this process is to repeat topography and refraction to make sure there is minimal residual refractive error, Ayres said. Another common source of unhappiness after premium cataract surgery is dry eye.
“You want to make sure you’ve ruled that out,” he said. “If there’s a little bit of a leftover refractive error, we’ll often try a pair of glasses or a soft contact lens. If that solves the problem and the patient is a good candidate, we’ll do a refractive procedure.”
Refractive surgery such as LASIK can help patients meet their goals, but Fram said that it is becoming less common, at least in her practice, because new diffractive technologies and extended depth of focus (EDOF) lenses have astigmatism correction platforms in them.
“I do femtosecond laser-assisted cataract surgery,” she said. “I probably do one enhancement a year, and I am at a very high percentage of premium, either trifocal, EDOF or toric technology. It means we’re doing pretty well.”
However, because there is still 1% to 3% percent of patients who could have dysphotopsias or other issues, knowing how to do a PRK or LASIK touchup is an important part of being a refractive cataract surgeon.
The LAL is becoming an important tool for many cataract surgeons. Jackson said his practice has a large post-refractive cataract population, and the LAL is often the best fit for these patients.
“Even though the formulas and diagnostics have gotten better, you’re going to be off sometimes,” he said. “I don’t nail the target every time. Luckily, you have a means to enhance them.”
If surgeons do not have access to an excimer laser or the technology to do LASIK, Jackson said it is important to have a good relationship with someone to refer patients to.
“If it’s not an LAL, I still have got to be able to do LASIK, PRK or something on these patients to hit the target,” Jackson said. “But you better do all your preop diagnostic testing to make sure you are capable to enhance them if you miss the target.”
In cases of dissatisfied patients, Talley Rostov said it is critical to have a backup plan.
“The key is to listen to the patient and help them determine what it is that’s making them unhappy,” she said. “Is it something that’s fixable or not fixable? A lot of times it is fixable.”
That could mean refractive surgery, but in other cases, the patient may need a lens exchange, Talley Rostov said. She is generally cautious and gives patients plenty of time to adjust to their new vision. Sometimes, the issue will resolve itself. She described a recent patient who had a perfect profile and received trifocal lenses in both eyes. Although the patient was happy with her range of vision, she had difficulty with glare and halos.
“I told her, ‘Let’s give you a little time to get used to it,’” she said. “We actually waited about 6 months, and she still wasn’t used to it. She decided that she just couldn’t stand the glare and halos, so I did an IOL exchange and implanted an LAL. She was thrilled with it.”
If a patient is unhappy with their premium IOL, Ayres said the best choice for a new lens in most cases is a monofocal or toric IOL. However, sometimes he will exchange a diffractive for a non-diffractive presbyopia-correcting IOL.
“I’ve done exchanges from a diffractive IOL to a non-diffractive IOL,” he said. “I’ve also done exchanges for the same implant. If we’re off on our biometry or we misread the patient’s astigmatism or spherical power, I’ve gone back in with another of the same lens with a different power.”
In his experience, Ayres said patients will see an improvement in their quality of vision after lens exchange in a majority of cases. It might not be the desired outcome, but exchange is an important part of premium cataract surgery.
“You’re going to have somebody who doesn’t like the lens, and you have to be willing to take the lens out,” he said. “You shouldn’t railroad a lens down someone’s throat if they are unhappy. You want to stay on the side of the patient if they don’t think they’re doing well and be willing to troubleshoot with the patient. I’ve said it myself many times: ‘It’s hard to tell who’s going to be a great candidate for these lenses. I thought you were a great candidate, but you’re not doing well. Let’s make things right and get the implant out.’”
Both patients and surgeons want the best vision outcomes after cataract surgery. Advances in premium lens technology have made those outcomes better for many patients. However, Jackson said surgeons cannot be afraid to say no to an upgrade.
“I always say I can do perfect surgery,” he said. “But if they’re not a perfect candidate, they’re not getting a perfect outcome.”
Click here to read the Point/Counter to this Cover Story.
- Reference:
- Masket S, et al. Ophthalmology. 2023;doi:10.1016/j.ophtha.2023.02.027.
- For more information:
- Brandon D. Ayres, MD, of Wills Eye Hospital, Philadelphia, can be reached at bayres@willseye.org.
- Nicole R. Fram, MD, of Advanced Vision Care in Los Angeles, can be reached at drfram@avceye.com.
- Mitchell A. Jackson, MD, of Jacksoneye in Lake Villa, Illinois, can be reached at mjlaserdoc@msn.com.
- Audrey R. Talley Rostov, MD, of Northwest Eye Surgeons in Seattle, can be reached at atalleyrostov@nweyes.com.
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