Cataract: Evolving
Winter 2024

by Liz Hillman
Editorial Co-Director

With great opportunity in the world of IOLs—there are so many choices available to fit different patient scenarios and visual outcomes—also comes a challenge: how to discuss these options efficiently in a targeted manner without overwhelming or causing confusion for the patient.

EyeWorld spoke with three members of its Cataract Editorial Board to learn how they manage this discussion (multiple times a day) and gain insights on how their patient conversations have evolved over the years. 

‘It sure does add up’

Rosa Braga-Mele, MD

Dr. Braga-Mele begins her process of IOL selection and the patient conversation by narrowing down what she needs to focus on based on the patient’s eye anatomy. She noted there are several things that could preclude patients from having certain advanced-technology IOLs. 

“Having said that, my patients are all given a sheet that shares what lenses are available, and it’s a broad brushstroke of lenses. Before they even see me, before they get anything done and are sitting in the waiting room, they’re reading this list,” Dr. Braga-Mele said. “They have time to digest that before they see me, and they may have some questions they want to ask, but if they’re eligible for everything, the first question I ask them is do they mind wearing glasses or do they want the opportunity to get rid of glasses for 90–95% of their tasks?” 

If the patient says they’re OK wearing glasses, the conversation about their lens option can take about 1 minute. If the patient has astigmatism and is willing to pay for the lens, Dr. Braga-Mele said a toric IOL is a “no brainer.”  

“I think the hardest category is the presbyopia-correcting lens category because it now becomes halo and glare that you have to discuss with your patient,” she said, noting that her conversation with patients interested in presbyopia-correcting IOLs takes about 5 minutes, and they usually require an additional tele-consultation.

If the patient is interested in a full range of vision and says they would tolerate halo and glare, Dr. Braga-Mele discusses trifocal options. If they’re interested in some range of vision but are less tolerant of halo and glare, she’ll discuss EDOF options. She then lets the patient go home and will schedule a phone consultation with them if they want to review the lens options further. 

Dr. Braga-Mele said her conversation with patients about these options can be revealing as well. 

“Depending on the patient’s questions, their astuteness, and their level of anxiety, sometimes their questions make me go, ‘Maybe this patient is not good for a trifocal IOL because nothing is going to make them happy,’” she said. 

To further understand patient personalities, Dr. Braga-Mele said she’ll often reveal a bit about her own. 

“Sometimes I say to patients, ‘I’m OCD and I like things to be a certain way. I am just meeting you for the first time, so can you tell me what your personality is like because then I’ll know what kind of lens suits you best?’ If you say it that way, where you put yourself in the position of being high anxiety, high OCD … it shortens the conversation a bit, and the patient is not offended,” she said.

Even with a detailed discussion based on your observations and assessments of the eye and the patient’s visual desires and personality, Dr. Braga-Mele said about 5% of patients either won’t understand or will later regret their choice. “There is only so much you can do. You have to at least broad stroke and spend a couple of minutes telling them what’s out there. You have to let your patients know they’re available, and if they want them, they can go see another doctor if you don’t feel comfortable using those IOLs,” she said. 

IOL options have evolved significantly during Dr. Braga-Mele’s time in practice. She said toric was not available when she first started out; there were monofocal, non-foldable PMMA lenses, making the patient discussion of options virtually non-existent. “It was a lot easier in some ways back then,” she said. 

For those who are just starting to have more of these complex IOL selection conversations, Dr. Braga-Mele said to not be daunted by the initial time it may take. “It does evolve over time. You get more efficient in conveying the message of what the lenses are. I have to say, 80–90% of patients get it,” she said, adding that anything you can do to pre-educate your patients on the different IOL categories helps when they’re in your chair. 

Dr. Braga-Mele said she thinks there will be future iterations of IOLs that will progress the conversation. Some IOLs will likely have less of a dysphotopsia profile, reducing the need for the emphasis on some of the tradeoffs patients might experience, she said, while others might be a new category, like accommodating IOLs, that would add to the conversation in some ways. 

“I don’t think there will ever be a lens that is one size fits all. I don’t think that’s going to come … in my career, though I could be wrong,” Dr. Braga-Mele said. 

Something that she thinks is needed, and that is in the pipeline, are better diagnostics. “As Warren Hill says, ‘Garbage in, garbage out.’ What we need is better diagnostics that give us much more confidence in our lens choices,” she said, adding that these along with AI are coming soon. “We’ll see better diagnostics to make better choices and predictions for our patients. That is going to be the key in making better decisions for what to offer patients.” 

Something she’d like is a simulator that helps show the patient what different lenses and dysphotopsia profiles will be like. 

‘This is one of the most time-consuming responsibilities’

Kendall Donaldson, MD, MS

Dr. Donaldson’s patient education begins before they even meet. 

“I find that it is much easier to discuss lens options if the patient has a little background going into the discussion. I prepared a 7-minute video of myself succinctly explaining what cataract surgery is and what lens options are available,” she said, noting that patients often come in with questions about laser cataract surgery vs. ultrasound cataract surgery but are overall unaware of the various lens options. “The video reviews the basics of what cataract surgery is, as well as answers to the common questions I receive during a typical cataract consultation. I find that this video brings everyone to the same level for our discussion.” 

From there, Dr. Donaldson said that she tries to acquire imaging (topography, biometry, and macular OCT) before performing the slit lamp exam. This helps her determine which lenses the patient might be a candidate for. 

“Once I determine their candidacy with the exam and review of imaging, I discuss the patient’s goals for their surgery. I assess their visual needs by learning about their occupation and pastimes and assess their potential desire for spectacle freedom,” she said. 

While she and the patient might discuss different lens options, Dr. Donaldson said she always ends the consultation with a concrete lens recommendation, clearly stated in the patient’s chart. 

“This is very important for my staff that will take the conversation to the next level. It delivers one message to the patient, despite who they may be interacting with in the office. My surgical coordinator will then discuss scheduling and finances in more detail following our office visit. If the patient calls with additional questions after our visit, staff can refer back to my note and specific recommendation to make sure we are consistent with our message and not causing patient confusion,” Dr. Donaldson said. 

When Dr. Donaldson started practicing 20 years ago, she said there were basic monofocal lenses, one multifocal lens, and one accommodating lens. The discussion involving lens selection at this time was short, and most patients chose a monofocal lens. Soon two new multifocal lenses joined the pack, but Dr. Donaldson said these and the other lenses that tried to offer more spectacle independence had significant dysphotopsias (associated with high near add powers).

“For the most part, we were not very savvy explaining dysphotopsia profiles, and surgeons quickly became frustrated with unpredictable visual side effects,” she said. “We had many happy patients, but just a single unhappy patient could be devastating to clinic flow and to surgeon confidence. This limited the penetration of premium lens technology into the market.

“Today, we are very fortunate to have a plethora of lens options with much improved dysphotopsia profiles,” she continued. “However, lens discussions can consume a great deal of chair time. In larger, high-volume premium practices, specialized staff may whisk the patient away for a full review of the lens options, but it is still the doctor’s responsibility to help the patient decide what best suits their ocular health and their lifestyle. In most practices, this is one of the most time-consuming responsibilities of the typical cataract surgeon.” 

Looking forward, Dr. Donaldson said she thinks AI and realistic vision simulators will play a role in lens selection. 

“AI could combine patient lifestyle information, desires for spectacle freedom, and financial concerns with clinical data (including macular health, astigmatism, and degree of myopia or hyperopia) to produce a lens recommendation. The more information input into the system, the more robust the algorithm would become,” she said, adding later that “improved patient educational tools, including realistic simulators, could help provide an opportunity to trial various lens options before surgery. This would increase surgeon and patient confidence with lens choices. It would also help patients better understand potential dysphotopsias.”

‘There is an art to this’

Jonathan Rubenstein, MD

When it comes to making an IOL recommendation to the patient, informing the patient to select their best option is, Dr. Rubenstein said, “a combination of art and science.” 

“There is an art to this. … You have to try to figure out what the patient’s needs are. There are two ways to look at this: one is what does the eye require and the second is what does the patient require,” he said. 

It starts with what the eye needs. Does the patient have astigmatism? Do they have a current comorbidity (ocular surface disease, a problem with the macula, glaucoma, previous refractive surgery)? “You have to assess the eye because that will narrow down your IOL choices right there,” Dr. Rubenstein said. 

Once you’ve narrowed down lens options based on the patient’s ocular situation, you move onto assessing the needs of the patient. 

“You need to interview the patient to assess their needs based on their vocation and avocation,” Dr. Rubenstein said. “Are they interested in distance vision only, and therefore happy with wearing glasses for computer, intermediate, and near, or do they want to have less of a need for glasses and be able to see distance plus intermediate vision without correction, or lastly, do they want uncorrected vision for distance, intermediate, and near? That’s a discussion you have with the patient based on your perception of their needs and their declared needs.”

Dr. Rubenstein said that with more experience in these conversations, you get more of a feel for what the patient may want and need for their best performance. “After a while, you start assessing the patient almost the moment you walk into the room. You can see what type of person they are and what they might want. … Then comes the discussion, trying to figure out what the patient’s needs are. … You use your experience to target your discussion to what you think is the best fit for the patient. Obviously, that’s going to vary based on the experience of the surgeon.”

At this point, the discussion gets into the lens options that are available and that match the patient’s ocular needs as well as their personal refractive desires. Even if a patient is not eligible for a certain type of lens (or if a certain type of lens is inadvisable due to personality or perceived intolerance of dysphotopsias), Dr. Rubenstein still mentions these lens options briefly because patients have often heard about them from their own research or from friends/family who have experience with them. 

Dr. Rubenstein said that in his practice, he is the one who talks about lens specifics with the patient, but he does have a surgical coordinator who goes into detailed questions about the surgery, scheduling, and payment based on the IOL recommendation that Dr. Rubenstein has made. 

As more lens options have come to the market over the last two decades, Dr. Rubenstein said it has been important for the doctor to drive the conversation to the best choice for the patient, based on the ocular assessment and the patient’s visual desires. “You don’t have time to talk about every possible option, and too many options can get confusing to the patient. So I think you have to make an editorial decision yourself. … You have to think about what information you are going to present in an honest and fair way to give the patient the best informed consent possible and hopefully get them to have their best visual result and be as happy as possible.” 

Going forward, Dr. Rubenstein said there is likely a place for visual simulators to demonstrate the visual experience from the different IOLs as well as increasing pre-education for patients. He said industry is getting more involved in what they can provide surgeons to serve as their partners in providing pre-educational materials for patients about their lenses. 

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About the physicians 

Rosa Braga-Mele, MD
Professor of Ophthalmology
University of Toronto
Toronto, Canada

Kendall Donaldson, MD, MS
Medical Director
Bascom Palmer Eye Institute, Plantation
Professor of Clinical Ophthalmology
Rodgers Clark Endowed Chair in Ophthalmology
Plantation and Miami, Florida

Jonathan Rubenstein
Chairman and Deutsch Family Endowed Professor
Department of Ophthalmology
Rush University Medical Center
Chicago, Illinois

Relevant disclosures

Braga-Mele: Alcon
Donaldson: AbbVie, Alcon, Bausch + Lomb, BioTissue, BVI, Carl Zeiss Meditec, Dompe, Eyevance, Glaukos, iOR, Johnson & Johnson Vision, Kala, LENSAR, Lumenis, Novartis, Omeros, Oyster Point, Quidel, PRN, Rayner, Science Based Health, Sun, Tarsus, Versea
Rubenstein: Alcon

Contact 

Braga-Mele: rbragamele@rogers.com
Donaldson: KDonaldson@med.miami.edu
Rubenstein: Jonathan_Rubenstein@rush.edu