Refractive
June 2022
by Liz Hillman
Editorial Co-Director
Every patient deserves to know about the different IOL choices that are available for different visual outcomes, regardless of their status or candidacy for these options, said Rosa Braga-Mele, MD.
Having a holistic view of IOL offerings, she continued, includes informing the patient of all the options and having a portfolio of lenses that can suit a range of refractive outcomes.
Dr. Braga-Mele, Richard Davidson, MD, and Zarmeena Vendal, MD, discussed how they’ve taken a holistic approach to IOL offerings in their practice and shared tips for onboarding new technology, why they inform patients about all IOL choices even if they’re not being recommended specifically, and more.
Dr. Davidson said his practice was an early adopter of advanced technology IOLs. He said that patients who have received these IOLs, especially those that work to lessen the effects of presbyopia, are some of his happiest patients.
“I know there is still a large percentage of surgeons who are not using these IOLs, but they really should be,” he said.
There are several factors that could be holding surgeons back, Dr. Davidson continued. 1) They are concerned about missing the target. Dr. Davidson admitted that you might need to do a LASIK or PRK enhancement, but he said with good patient selection and biometry, that number should only be around 1–2% of these cases. 2) He said some residency programs are not exposing trainees to the technologies enough to help them be comfortable offering them. 3) Some physicians might be uncomfortable asking patients to pay out of pocket. “It’s unfortunate because patients are willing to pay,” he said. “Patients will pay a thousand dollars a year for glasses, and you’re asking them to pay for a lens that could change their life forever. You’re offering incredible value, and you’re offering incredible improvement in their quality of life. There are certain doctors who are uncomfortable with this conversation, but if you’re doing it the right way, you don’t have to go into numbers. You can say this is an uncovered expense, and an IOL counselor will go over this.”
Dr. Vendal said it is an exciting time to be practicing ophthalmology.
“The surgeon’s toolbox for cataract surgery is bigger than ever before,” she said. “As surgeons, we should never practice as a one-stop shop. We need to know how to work with each one of these lenses and customize the patient’s experience based on which one suits them and their lifestyle needs. For example, a patient may want the most glasses-independent choice possible and be willing to tolerate some nighttime artifact in their vision while another patient may have a concurrent eye condition that requires a non-diffractive option and be comfortable wearing reading glasses for some near activities.
“Each advanced technology IOLs shines in certain areas, and it should be our goal to understand the inner workings/nuances of each lens so that we can match it best with certain patients,” Dr. Vendal added.
When getting started, Dr. Davidson said to choose one lens.
“Maybe it’s the same brand you’ve used as a monofocal lens. Then find the best patients. There are a lot of patients who don’t have other pathologies besides cataract,” he said.
Dr. Davidson said that while his practice offers many different advanced technology IOLs, the surgeons within the practice often only offer two or three.
“You have to do what makes you most comfortable. It can be challenging to keep all these lenses as a consignment, so there are logistical issues, but I would argue that each of these lenses has distinct advantages. You have to figure out what works best in your hands; for example, a lens that works best in my practice may not work as well in someone else’s. … If you get great results with one, offer one. But if you can identify the advantages of certain lenses, you’ll find patients who fall into certain categories and line up better with certain lenses,” he said.
Dr. Braga-Mele said there are patients who choose to go with the standard lens because it’s what they want and/or what they can afford, “but they deserve to know about all the choices so they can make an informed decision.”
“There are those who want the monofocal aspheric, and whether it is distance vision that they want, monovision that they want, or they are low myopes and want to be low myopes again because that’s what they’ve been all their life, you have to give them that choice,” Dr. Braga-Mele said. “If they have astigmatism, it can be unmasked by cataract surgery, too, and patients may be unhappy if you don’t offer them an astigmatic choice. Moving forward from that refractive challenge is the challenge of presbyopia-mitigating IOLs. … We’re trying to minimize the need for glasses but not get rid of glasses completely; that’s how I tend to explain it to my patients. We can get rid of glasses for 85–90% of their tasks but we’re not getting rid of glasses completely.”
Dr. Braga-Mele said she started with Alcon presbyopia-mitigating IOLs because she liked the consistency she experienced with their other IOLs. She said that when getting into these technologies to choose brands that you’re familiar and comfortable with.
Even if patients are not a candidate for a presbyopia-mitigating IOL, Dr. Davidson said that it’s important to discuss with them and share why you’re recommending a specific IOL.
“I say it with every patient because I don’t want them going home thinking, ‘Why didn’t he mention it to me?’ We had that situation in our practice when ReSTOR [Alcon] first came out. We had a couple of physicians who didn’t offer it. We had patients in the waiting room hearing stories, and we had some upset patients because we didn’t offer it to them. We now have a policy in our practice … that if you don’t feel comfortable doing a refractive IOL, you need to at least mention it to the patient, and if the patient wants it, you need to refer to another surgeon in the practice who offers this technology.”
Dr. Davidson further clarified that just because there are several lens options offered at a practice, it still important to come up with a single “best” recommendation because too many choices can be confusing for patients and they look to us as their surgeons for guidance.
“It’s still my job to recommend a single lens to the patient,” he said.
Dr. Braga-Mele also said that she educates patients about all the choices that are available, not focusing on brand names but rather helping them choose the best visual range for their needs.
“Look at the patient, look at their needs and personality, look at their eye anatomy and what’s a fit, then offer what’s available,” she said.
Dr. Braga-Mele said that in order to successfully offer the full range of IOLs, there are certain diagnostic tools that will help ensure success. You need to have a good biometer, good formulas (she prefers the Barrett Universal or the Barrett True K), good refractive outcomes from your monofocal IOLs, and a good topography with multiple sources of corneal astigmatism measurements. For efficiency, in some practices it might make sense to have a tech, she said.
Dr. Vendal said the learning curve among the different advanced technology IOLs is similar. “We are not reinventing the wheel but rather improving our already existing options for patients, so new users should not be hesitant about trying the new advanced technology models. There are pearls that I think can help set us up for success,” she said, offering the following:
- Extra chair time is needed to learn the patient’s needs.
- Preoperative testing is required to uncover subtle retinal disease that could make a difference in lens choice.
- Extra attention should be paid to dry eye and improvement prior to biometry.
- Use multiple measurement modalities to calculate the most accurate IOL power possible.
- Manage astigmatism aggressively.
- Use intraoperative biometry, if available, to add additional data for decision making.
Dr. Braga-Mele said that some physicians, like those in their last 5 years of practice, might not want to get into offering a whole range of relatively new IOLs. However, she thinks they should still let patients know what’s available, and if the patient wants that technology, refer them to a surgeon who offers it. “Even if you don’t do trifocal or multifocal IOLs because you don’t think it’s worth the visual aberration that could occur, you should at least let them know that there is this availability and why you don’t like that technology and let them make that decision,” she said.
ARTICLE SIDEBAR
Ideal candidates for presbyopia-mitigating IOLs
Multifocal and trifocals: Dr. Braga-Mele said it’s important to have a pristine eye for these lenses. Patients cannot have corneal issues like dry eye or EBMD, visual field defects, or retinal pathology or potential for progression of retinal pathology. She will consider a patient who has had a very mild refractive ablation for these lenses. Dr. Davidson said he’ll use these lenses in otherwise healthy eyes. He’s also willing to do them on patients who are post-refractive, provided they have good-looking topography. Astigmatism should be minimal and regular, he said. Ideal patients in Dr. Vendal’s practice for trifocals or multifocal lenses are those with healthy retinas and optic nerves who want as much independence from glasses as possible and who can tolerate some nighttime artifact.
Extended depth of focus (EDOF): These IOLs, Dr. Braga-Mele said, can be offered to patients with mild dry eye, but she veers away from other corneal pathology. She said these lenses can also be offered to patients with mild to moderate glaucoma and those with mild macular degeneration or small epiretinal membrane because contrast sensitivity is not reduced. “The patient [should be] informed that they will get a range of vision that may not be 20/20 because of their ERM but they won’t lose contrast sensitivity, and that’s the key with these lenses,” Dr. Braga-Mele said. Dr. Davidson said if a patient is concerned with glare or halo, these lenses are a better option for them. Dr. Vendal also noted the benefit of good contrast sensitivity at distance and said ideal candidates are those who spend most of their time looking at an intermediate/computer distance and who can tolerate some nighttime artifact. There is a non-diffractive EDOF option now that doesn’t have any nighttime glare/artifact, she said.
“As a cataract/refractive surgeon who also practices glaucoma, it has been exciting to have a non-diffractive option for my subset of glaucoma patients who previously could only choose monofocal implants at the time of cataract surgery,” she said.
“I think it’s very important that when you’re starting to venture into the presbyopia-mitigating IOL portfolio, even with the EDOF lenses, you should start with pristine eyes so you can optimize your outcomes,” Dr. Braga-Mele said.
About the physicians
Rosa Braga-Mele, MD
Professor of Ophthalmology
University of Toronto
Toronto, Canada
Richard Davidson, MD
Professor and Vice Chair for Quality and Clinical Affairs
UCHealth Sue Anschutz-Rodgers Eye Center
University of Colorado
School of Medicine
Aurora, Colorado
Zarmeena Vendal, MD
Founder and Medical Director
Westlake Eye Specialists
Austin, Texas
Relevant disclosures
Braga-Mele: Alcon
Davidson: Alcon, Johnson & Johnson Vision
Vendal: Alcon, Johnson & Johnson Vision
Contact
Braga-Mele: rbragamele@rogers.com
Davidson: richard.davidson@cuanschutz.edu
Vendal: zvendal@westlakeeyes.com
