Presbyopia-correcting IOLs have been a core component of my anterior segment practice since I opened my office in Beverly Hills. Today, about 65% of my cataract patients choose a premium IOL over a standard monofocal. I have implanted all the presbyopia-correcting lenses in the U.S. market, including Crystalens (Bausch + Lomb), ReZoom (Abbott Medical Optics), ReSTOR (Alcon) and Tecnis multifocal (AMO). Along the way, like many of my colleagues, I have struggled with how to set reasonable expectations, limit unwanted visual symptoms, and achieve both the uncorrected acuity and quality of vision that patients really want. The good news is that premium IOL technology has advanced rapidly, to the point that we are achieving outstanding results with the latest generation of lenses.
Latest results
Most recently, I have begun implanting the new Tecnis multifocal one-piece IOL, with good results thus far. As a surgeon, I strongly prefer the ease of handling of one-piece lenses. Like its monofocal counterpart, the Tecnis one-piece multifocal is easy to manipulate in the eye and can be inserted through my typical 2.2-mm to 2.4-mm incision without enlarging the wound and risking cylinder induction. The location of the diffractive optics on the posterior surface of this lens and the fact that they extend across the full diameter of the optic also mean that patients achieve high-quality near vision, even in dim light.
In about 60 eyes that I have implanted with this lens, 94% of patients achieved 20/20 or better uncorrected distance and J2 or better uncorrected near visual acuity, which are the best results I have achieved to date with premium IOLs. This lens is going to be my first choice for many patients. However, I certainly would not limit myself to offering just one type of premium IOL, no matter how good the results. A strong premium IOL practice needs to offer multiple options to ensure that it can meet the needs of a wide variety of patients.
In my opinion, the following three steps are essential to building a premium IOL practice with great visual acuity results and high levels of patient satisfaction.
Technique matters
The first step is simply to practice good surgery. You do not have to be fast – it really does not matter if you do cataract surgery in 7 minutes or 30 minutes – but you do need to be absolutely consistent in every surgical detail. For example, the incision should be made the same way every time, with careful placement on the steep axis if possible. The capsulorrhexis must be round and well-centered. One’s technique should be smooth and as atraumatic as possible to avoid postoperative edema and inflammation that compromise the early visual result. In short, any flaws or inconsistencies in one’s phacoemulsification technique and implantation of conventional IOLs should be addressed first, before beginning to implant premium IOLs. The procedures themselves are identical, but the expectations and stakes are significantly higher when patients are paying thousands of dollars out of pocket for a premium IOL.
For this reason also, the immediate postoperative period is a very important factor in patient satisfaction with the surgeon and the IOL. I use only topical anesthetics, no sutures and no patches so that patients are as comfortable as possible. When the patient sits up in the recovery room exclaiming how well he can see, other patients and family members take notice.
Address astigmatism
Cataract surgeons who have ignored mild cylinder in the past do so at their peril with premium IOLs. Residual astigmatism of as little as 0.5 D to 0.75 D can significantly degrade visual quality, particularly with multifocal optics.
I place my cataract incision on the steeper axis and sometimes perform limbal relaxing incisions. Even with peripheral pachymetry, limbal relaxing incisions can be unpredictable and will not be sufficient to correct larger amounts of astigmatism. My preference, for most patients with significant astigmatism, is to perform laser vision correction approximately 8 weeks after IOL implantation. There is simply no getting around the fact that 10% to 15% of patients will need laser vision correction to achieve the best outcome. As a premium IOL surgeon, if you are not prepared to perform laser vision correction yourself, you should partner with a refractive surgeon to handle those cases for you. In any event, you must either include the secondary laser vision correction as a covered service under your overall fee or be very clear about additional charges from the outset so that patients are not surprised.
Patient selection
Not every patient is a good candidate for presbyopia-correcting IOLs, and not every good candidate is well-suited to all of the IOLs in that category. Preoperatively, the surgeon should be very thorough in looking for any pathology, from dry eye to macular degeneration, that could compromise the postoperative outcome. Preoperative refractive error is also an important factor in the decision. While it is easy to satisfy a 65-year-old 3 D hyperope, a 3 D myope is much more challenging. You will not be able to give that low myope the same natural reading vision she has without glasses preoperatively, so the potential for dissatisfaction is high. These patients can certainly be good candidates, but only if you have an extensive discussion about how near vision will change after surgery.
In fact, I believe that allocating more chair time for cataract surgery consultations is critical to a high conversion rate. In my practice, cataract surgery consultations are grouped together on specific days. I review the patient’s refraction, topography and IOLMaster calculations first and then spend 30 to 45 minutes with the patient, performing my exam and talking about visual needs and expectations.
In order to choose the right lens, one has to understand the patient’s daily activities, work and hobbies. An avid reader, especially one who reads in dim light, is not likely to be fully satisfied with an accommodating lens. By contrast, an amateur pilot or post-hyperopic LASIK patient will probably do better with an accommodating IOL than an aspheric multifocal. I also use my chair time with the patient to express confidence in the technology and the outcomes we are achieving, while at the same time setting realistic expectations. I personally discuss the potential need for reading glasses or a second procedure with the patient, rather than leaving these conversations to a technician.
Surgeons who refine their techniques for greater consistency, address astigmatism and spend the time required to choose the right IOLs for the right candidates will find that they can quickly build a successful premium IOL practice. The extra time spent with the patient on the initial visit pays off in multiple referrals for surgery. I strongly recommend making presentations about your results with new technologies to referring physicians and optometrists so they can help spread the word that you are implanting presbyopic lenses. And when you achieve great results, patients and their doctors will be happy to refer others to you.
A. James Khodabakhsh, MD, is medical director of Beverly Hills Vision Institute in Beverly Hills, Calif. He can be reached at 310-550-7888; e-mail: lasereyedoc@aol.com.