Cataract
September 2021
by Ellen Stodola
Editorial Co-Director
Patient education prior to IOL implantation is incredibly important, both for patients to understand the different options and optimal choices for their situation and for physicians to understand patients’ goals to help them make the best choice. Two surgeons discussed how they educate patients about the options available and the process they use to choose a lens.
‘Our job is to provide the vision that people are looking for’
Kerry Solomon, MD, said he has patients start to think about lens options before even coming into the office. “We send information to them via text or direct them to our online resources,” he said. Dr. Solomon mentioned the Ocular Innovations software his practice uses, which provides customized patient education at home before they come in.
He encourages patients to bring a friend or family member on their visit. “I’m a big believer in providing enough information for them to be able to make better decisions,” he said.
Dr. Solomon said he focuses on what a patient’s goal are. He asks if the patient wants to be less dependent on glasses, and if so, do they want to be less dependent for distance or for distance and near? “Based on preferences, we try to find the technology or technologies that would best fit the patient’s needs and lifestyle,” he said.
All of these steps are done in one appointment, Dr. Solomon said, so it’s efficient, but the patient has had the time to think about the choices and talk to family members before coming in.
For the patient who wants distance vision, Dr. Solomon said there are a variety of options, including monofocal lenses, toric IOLs, and the Light Adjustable Lens (RxSight). “The Light Adjustable Lens has been terrific for treating larger amounts of astigmatism,” he said, noting that this can be a good option for patients who have any irregularity or have had previous refractive surgery. “We’re not worried as much on the front end about measurements,” Dr. Solomon said. With this option, careful refractions can be taken after the lens is implanted and the patient is stable. “Then we can treat what they have as a leftover prescription after cataract surgery,” he said.
For patients looking for both distance and near vision, Dr. Solomon said there are multiple options. “In my armamentarium, I go to a trifocal, like PanOptix [Alcon], or extended range of vision lens, like Vivity [Alcon],” he said. The choice in this scenario is also influenced by the patient’s desires and lifestyle. “If the priority is to have the best quality of vision at night and the patient might be more dependent on readers, I might go with Vivity,” he said. “Monovision is another popular option, especially for those patients who have enjoyed monovision with previous refractive surgery or contact lenses. Monofocals, torics, extended range of vision lenses, and the Light Adjustable Lens are all great options to pursue monovision. The Light Adjustable Lens is particularly intriguing in that patients can test drive monovision and have it removed if they don’t like it. They can also have their monovision fine-tuned to their specific needs.”
While Dr. Solomon said he does get some patients who come in wanting one type of technology, he said they often change their mind once they talk it through with him. “I want to better understand their lifestyle, their visual needs, and what they’re looking for,” he said. “Because at the end of the day, our job is to provide the vision that people are looking for so they can lead the lifestyle they desire.”
Dr. Solomon said he doesn’t use any simulation programs to help with this process, but he does use VERACITY Surgical software (Carl Zeiss Meditec). “If a patient is looking for a certain visual outcome, we have to make sure we deliver on that,” he said. With extended range of vision lenses, trifocal lenses, and other options, the preoperative measurements are very important. VERACITY, he said, interfaces with the electronic health record and diagnostic equipment and assimilates all the information together, such as any ocular pathology that may affect an IOL choice, as well as surgically induced astigmatism and posterior corneal astigmatism. “If the patient wants good distance and near vision and to be less dependent on glasses, I know I can accurately achieve that outcome with this software,” Dr. Solomon said. “VERACITY doesn’t make decisions for me. Rather it assimilates all of the information from the electronic health record and diagnostic devices and provides solutions based on my preferences. It also optimizes surgeon factors and tracks outcomes automatically.”
‘There are pluses and minuses to each lens’
Naveen Rao, MD, splits patient education and IOL selection into two visits. For the first visit, he has the technician do a refraction, dilate the eyes, and perform a macular OCT. Then Dr. Rao sees the patient, looks at the testing, and determines if he would consider that patient a candidate for a premium IOL or not.
Dr. Rao explains cataract surgery in general in this first visit and tells patients that they will discuss specific lens options during the second visit. He tells the patients to think about the goals for their vision. For example, options include having vision set for distance and wearing glasses for reading, setting vision for near and wearing glasses for distance, or trying to achieve good vision without glasses for all ranges. Dr. Rao said he makes sure to note to patients that some lenses may be covered by insurance while others are not, and there may be out-of-pocket costs. Some patients jump in at this point to say they don’t want any options that are not covered by insurance, in which case he knows not to talk about that technology.
During this first visit with the patient, Dr. Rao will share the OCT scan to explain why they may not be a candidate for certain lenses.
On the second visit, Dr. Rao said he will have a biometry and topography done but doesn’t do too much additional testing at that visit. “I want to dedicate that time to having a discussion with them,” he said. He will spend time reviewing the scans and showing them the topography. He’ll also discuss astigmatism, if the patient has it.
For those interested in multifocal lenses, Dr. Rao specifically discusses the potential for dysphotopsias, telling patients that they will likely see glare and halos around streetlights and stoplights. “Many patients get used to it and will become less bothered over time, but there are some patients who are very bothered by those distortions, so I want them to understand that if it’s not something they’re willing to accept, it might not be the best choice.”
Dr. Rao said he has a number of patients who come in very educated, having done research on the different IOL options and the potential side effects on their own. For many who come in asking about specific IOLs, Dr. Rao said he has to explain why they might not be the best candidate for certain technologies.
Dr. Rao noted that he also sees a significant number of patients referred for IOL exchange for dysphotopsias after multifocal lenses, so he is careful to discuss these potential dysphotopsias with his own cataract surgery patients. “I want them to make a completely informed decision about whether a multifocal IOL is the right choice for them, so there are no surprises.”
He mentioned newer lens options, like Vivity and Eyhance (Johnson & Johnson Vision). For patients who want good distance vision and want to achieve some mid-range spectacle independence, he recommends Vivity because it does not seem to result in significant glare or halos. “I’m excited about these new lenses and think they have a lot of potential for patients to be happy with less risk of glare, halo, and starbursts and more spectacle independence than our monofocal lenses,” he said.
Dr. Rao said he has tried using models/simulations and videos in the past to explain options to patients, but it was often time consuming and he didn’t find it particularly helpful.
He finds a customized, face-to-face discussion with each patient more effective. With the video program he was using, there were a lot of videos to choose from. He found this hard for the patient as well as the doctor/staff who had to choose which videos to recommend. In addition, with the number of lens options and packages, he doesn’t want the patient to feel like it’s a sales pitch. “I tell the patient that my goal is to help them choose the lens that best suits their needs. It doesn’t matter what their friend or family member got,” he said. “What matters is what they want, and we can tailor their vision to what they want these days. There are pluses and minuses to each lens. I think patients will be happiest if they know what they’re getting into.”
About the physicians
Naveen Rao, MD
Lahey Hospital & Medical Center
Burlington, Massachusetts
Kerry Solomon, MD
Carolina Eyecare Physicians
Mount Pleasant, South Carolina
Relevant disclosures
Rao: None
Solomon: Alcon, Carl Zeiss Meditec
Contact
Rao: naveen.k.rao@lahey.org
Solomon: kerrysolomon@me.com
