December 2012




Success with premium IOLs

by Marc E. Bosem, M.D.


Mark Bosem, M.D.

Surgical pearl

When implanting multifocal IOLs, have a three-piece lens and a one-piece lens in the correct power ready for the procedure. The one-piece lens is my typical choice because it allows for a smaller wound with less chance of surgically induced astigmatism and because the implantation is simpler and faster. However, I like to have a three-piece IOL ready just in case there is abnormal ocular anatomy or an intraoperative problem with the capsular bag. In such cases, a three-piece lens, which allows for placement of the haptics in the ciliary sulcus, may offer better fixation or stability.

Source: Mark E. Bosem, M.D.

Woman and doctor

Building a refractive cataract practice takes commitment to meticulous surgery, a premium environment, and technology that helps patients achieve their goals

In the 10+ years that I have been implanting premium IOLs, we have seen outstanding advancements, particularly in the quality of multifocal IOLs. We have much higher success rates now with the two diffractive multifocal IOLs on the market than we ever did with the original refractive multifocals.

Some things haven't changed at all, though. The single biggest factor in a successful outcome is achieving a near-perfect distance correctionand for that, nothing replaces meticulous pre-op measurements. Accurate measurements depend on a healthy ocular surface, so every premium cataract patient in our practice is first evaluated for ocular surface disease and treated with the same aggressive protocols we use for our LASIK patients. Depending on the patient's condition, this may include topical cyclosporine or azithromycin, besifloxacin drops or ointment, artificial tears, and/or punctal occlusion. Once we are satisfied that we can obtain accurate biometry, the patient undergoes immersion A-scan, IOLMaster (Carl Zeiss Meditec, Jena, Germany), and Scheimpflug topography. In patients with significant corneal astigmatism (>1.0 D), correction of the cylinder becomes our second priority. We can opt for either a toric lens or a multifocal IOL along with an incisional or excimer laser procedure to correct the astigmatism, but attempting to provide multifocality without correcting astigmatism is a recipe for failure.

Minimize visual quality complaints

No multifocal is completely free of subjective complaints, but we want to reduce the potential for these as much as possible. Complaints of "fuzzy vision," glare, halos, and poor night vision all reduce patient satisfaction. The clarity of distance vision can partially compensate for or reduce the severity of visual complaintsanother reason to aim for a perfect refractive result. I find that glare and halo are much less likely if the patient is slightly hyperopic, so I generally aim for a plano to +0.175 D result. I also seek out the technology that offers the highest degree of material clarity and optical quality. For example, I prefer lathe-cut rather than injection-molded lenses. As acrylic material coalesces into a mold, there is a higher chance that it will form glistenings, vacuoles, or other imperfections. While these may be minor and far fall short of requiring explantation, they can subtly reduce quality of vision. Ideally, I also prefer a clear optic, rather than one with a yellow chromophore. One of the most noticeable benefits of cataract surgery for patients with low-grade cataract is the return of vibrant color vision. However, if we replace a yellowed crystalline lens with a yellow-chromophore lens, the patient's vision improves, but the immediate "wow factor" is reduced, in my experience.

Yellow-chromophore IOLs were designed to block blue light, but blue light plays an important role in healthy circadian rhythm entrainment, which can affect hormone levels, alertness, and mood. Research has shown that improved blue light transmission following cataract surgery actually has a beneficial effect on cognitive function1 and sleep patterns.2-3 My preference, therefore, is for lenses that block UV but maximally transmit blue light. In addition to the refraction and the lens material, proper centration of a multifocal IOL over the visual axis is another important factor in reducing complaints of visual symptoms. Using the Purkinje reflections of the lights from my operating microscope, I make sure the diffractive rings of the lens are well centered over the visual axis at the end of the case, irrespective of the lens position within the capsule.

Think like a refractive surgeon

In our practice, about 70% of cataract patients choose some type of premium IOL. One of the reasons for this high "conversion" rate, I believe, is that my partner and I have a strong refractive surgery background. Everything about the practice is geared toward creating a premium patient experience, from the way the receptionist answers the phone, to the look and feel of the office, and the amenities and services available to patients. But it's not just about the surface appearance or creating a "sales" environment. In fact, we are careful never to surprise the patient with a sudden uncomfortable choice or hard-sell tactics. Rather, we approach lens selection from the perspective of meeting patient goals. We ask patients what they like and don't like about their vision, and what they want to be able to do without glasses after surgery. Then, we determine if there is a technology (or combination of technologies) that will help them achieve those goals. This means that you really need to understand both the patient and the science behind each of the IOLs. I implant five different premium IOLs, with the Tecnis Multifocal (Abbott Medical Optics, Santa Ana, Calif.), AcrySof IQ Toric (Alcon, Fort Worth, Texas), and STAAR Toric (STAAR Surgical, Monrovia, Calif.) being the most common, and the AcrySof ReSTOR (Alcon) and the Crystalens (Bausch + Lomb, Rochester, N.Y.) being less common. Defocus curves can tell you a great deal about how the lenses work. A multifocal lens will have two peaks, with a range in between where vision is not as sharp. The ReSTOR +4 D lens has a large "doughnut hole" in the middle of its near and distance peaks, with poor intermediate vision; the Tecnis Multifocal +4 D lens has a smoother range of vision; and the ReSTOR +3 D lens has two peaks that are closer together, but with less effective near vision. These are real differencesand choosing the best "fit" for the patient is key to satisfying expectations. I typically choose a Tecnis Multifocal for the patient who wants to be able to do near tasks in all light levels without glasses. I've been impressed by the quality of the night vision with this lens, the clarity of the distance, and fewer subjective complaints. For some patients for whom intermediate vision trumps near, I may consider a ReSTOR lens, and for post- refractive patients, I will opt for the Crystalens. I recently saw a patient who had premium IOL surgery elsewhere. In the absence of guidance from the surgeon, she chose based on price alone and hated the result. The lens she got was a good lensit just wasn't appropriate for her goals. It is our role as surgeons to make an educated choice of which technology best suits the patient's needs. We do patients a disservice if we give them lens options without direction or eliminate options that would best serve them.


1. Schmoll C, Tendo C, Aspinall P, Dhillon B. Reaction time as a measure of enhanced blue-light mediated cognitive function following cataract surgery. Br J Ophthalmol 2011;95(12):1656-9.

2. Asplund R, Ejdervik Lindblad B. The development of sleep in persons undergoing cataract surgery. Arch Gerontol Geriatr 2002;35:17987.

3. Asplund R, Lindblad BE. Sleep and sleepiness 1 and 9 months after cataract surgery. Arch Gerontol Geriatr 2004;38:69-75.

Editors' note: Dr. Bosem is medical director, CorrectVision Laser Institute, with locations in Pembroke Pines and Weston, Fla. Dr. Bosem has no financial interests related to this article.

Contact information

Bosem: 954-437-9300,

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