Take steps to maximize success with presbyopia-correcting IOLs

Jessica Pugh

With the advent of the latest generation of multifocal intraocular lenses, options for your cataract patients have never been better. In our practice, about 8% of patients are now selecting our preferred presbyopia-correcting option, bilateral implantation of the AcrySof IQ ReSTOR +3.0 apodized diffractive intraocular lens.

We achieve a high level of patient satisfaction with our patient selection criteria and preoperative and postoperative management. However, no multifocal provides the patient with the vision they had in their 30s, and cataract surgery is not yet a perfect procedure, so we do see a small percentage of patients who are not satisfied with their outcomes. We have found the following approach is the most helpful in maximizing the number of satisfied patients in our practice and minimizing the level of dissatisfaction for those who are not satisfied.

Preoperative discussion critical

One of the most important considerations in regard to discussing outcomes is to not wait until after surgery. A preoperative discussion with the patient is important in helping select their best IOL. Remember, you are far more familiar with the clinical results relative to a monofocal lens than the patient will generally be; you are also familiar with the visual demands and personality of a particular patient. These considerations will guide you in selecting appropriate candidates for presbyopia- correcting IOLs.

In setting preoperative expectations I do not like to “under promise and over deliver.” I would rather use the available data to set realistic expectations, either on the basis of the clinical results for safety and effectiveness that are generated in the study for U.S. Food and Drug Administration approval or – better yet – our own clinical results.

Dr. Pugh’s practice is bilaterally implanting the AcrySof IQ ReSTOR +3.0 apodized diffractive intraocular lens in about 8% of patients. Image: Pugh J

We tell patients that we expect them to be far less dependent on spectacles for near work. We indicate that this lens is their best chance to be able to read at near, but we make it clear that their resulting vision will be different from what they had with reading glasses prior to surgery. We also discuss that some time can be required for adapting to the lens and we mention the potential effects of dry eye on the visual outcome.

The tradeoff for this near vision is an increased likelihood of experiencing glare and halos. When discussing these potential side effects we are able to indicate that a majority of patients find their perception of these decreases over time. Our experience is that the percentage of patients experiencing bothersome glare and halos is low, and that the degree to which they experience them is moderate. In fact, these side effects do not predict satisfaction with the lens in our practice.

If a patient has significant preoperative and anticipated postoperative astigmatism, we discuss the probable need for a second procedure (advanced surface ablation/PRK) to maximize the visual potential after cataract surgery. If the surgeon feels a penetrating limbal relaxing incision (LRI) will take care of the amount of astigmatism, he will perform that at the time of surgery.

For patients who have excellent results with a speedy recovery, the discussion above may not matter; however, for the more challenging patients, any postoperative issues will be less likely to be considered “unexpected” if they have been discussed before surgery.

One-day postop

One day postoperatively we will obtain visual acuity at near and distance but will not refract the patient unless the vision is 20/30 or worse monocularly. My point in avoiding a refraction early on is planting in the patient’s mind that they have a prescription that needs glasses.

We will look for signs of dry eye. We also listen to the patient’s perception of their vision at near and distance. We may assist the patient in finding the appropriate “range of vision,” although this was required more with the earlier ReSTOR +4 lens (where objects needed to be about 12 inches away for clear focus) than for the ReSTOR +3 (where objects from about 20 inches to 14 inches are in focus).

If this is the first eye, we also mention the additive effect of having binocular implantation. We recommend that the second eye be done as soon as possible after the first – typically 1 week – to reduce the potential effects of anisometropia and to get an early start on the binocular adaptation period.

Three weeks postop

At the 3-week follow-up visit we ask the patient about their vision at distance and near and try to elicit specific examples, such as working on the computer, reading, make-up application and smart phone use. We will refract the patient. In cases of appreciable residual refractive error we counsel the patient regarding the need for longer-term follow up before any secondary intervention.

We continue to check for dry eye and will treat aggressively if necessary, with Restasis (cyclosporine A, Allergan) in more pronounced cases. Where reading is problematic we will recommend good lighting and often use a -2.50 D trial frame over-refraction to demonstrate to a patient what their near vision would be like without a multifocal lens implanted. This can often help balance the vision discussion.

Three to 6 months postop

At 3 to 6 months postoperatively, patients with residual refractive error tend to be the least satisfied. If there is a small amount (0.75 DS or less) of residual cylinder, a LRI may be used to reduce it. Where a spherocylindrical error is present, laser refractive surgery may be an option. PRK or LASIK may be considered, though there is an increased potential for transient dry eye with either procedure. We inform patients of this and continue to treat dry eye proactively, to limit any potential impact on vision.

A trial contact lens may be used to evaluate potential visual improvements with refractive surgery. Any secondary correction of residual refractive error must again be presented to the patient in terms of the risks of the procedure vs. the potential benefits.

Small percentage of nonadaptors

Despite the best efforts of the surgeon and the staff, a small percentage of patients may be unsuccessful adapting to these lenses. Early in our experience we found we made several IOL exchanges soon after surgery; these were primarily due to postoperative refractive error. More recently we have changed our approach to aggressively manage any dry eye, then perform advanced surface ablation to correct the residual distance refractive error. We wait 6 months and re-evaluate. Patients we have treated in the latter fashion have not required IOL exchange and all are doing well.

While IOL exchange is recognized as a viable option, it is not always a cure. In one case, we replaced a ReSTOR +4 lens with an AcrySof IQ in the dominant eye, and symptoms appeared to resolve. In another case a patient was experiencing diplopia, and bilateral lens exchange resolved their issue. In another patient the symptoms were debilitating glare. IOL exchange with a monofocal Bausch + Lomb SofPort IOL did not resolve the patient’s glare issues. For one patient complaining of near blur, bilateral monofocal IOL exchange was performed with (naturally) continued near blur.

In short, explantation may be necessary in rare cases, but the likelihood can be significantly reduced through dry eye management and corneal refractive surgery where indicated. Some patients will be sensitive to even minor refractive errors, particularly in the case of astigmatism. We prefer to try to resolve this before considering IOL explantation.

We see the need for Nd:YAG capsulotomy sooner in ReSTOR patients than in patients with monofocal IOLs. I attribute this to the lesser amount of opacification that causes visual symptoms. Earlier YAG capsulotomy tends to dramatically improve visual complaints that do not match the appearance of the IOL as compared to that traditionally seen with monofocals.

There is no doubt that patients opting for a presbyopia-correcting IOL will require more chair time than a patient opting for a monofocal IOL. There is also no doubt that these patients will be more excited about their vision postoperatively. Appropriate preoperative counseling, good patient selection and attentive follow-up will maximize your success with these exciting new IOL options.

• Jessica Pugh, OD, specializes in refractive consulting and postoperative management of premium IOL patients in a large multispecialty ophthalmology/optometry practice in Southern Indiana. She can be reached at 302 West 14th St., Jeffersonville, IN 47130; (812) 284-0660; drjessicapugh@have2020.com.
• Disclosure: Dr. Pugh has no relevant financial interests to disclose.