April 2020

CATARACT

Yes Connect
Developing the skills for presbyopia-correcting IOLs


by Liz Hillman Editorial Co-Director


Source: 2019 ASCRS Clinical Survey

“If you’re not comfortable
and confident with the cataract
surgery itself, it’s hard to discuss
the next step, the premium
lenses, and be able to offer
them with confidence.”

—Neeti Parikh, MD

There’s more to cataract surgery today than ever before, which leads to a lot of ground to cover in residency and fellowship. Not only do residents have to master the technical skill of cataract surgery, they also need to learn the nuances of IOL choices and advanced technology IOLs. Fortunately, our training programs seem to be making headway in this regard. In the 2019 ASCRS Clinical Survey, 67% of young eye surgeons who took the survey reported they were somewhat or very comfortable with new lens technologies. Although there is still a ways to go, the increasing confidence of the youngest members of our profession in this area will help propel cataract surgery into a new era. For this month’s column, we spoke with two experienced cataract surgeons who work with residents about how they are incorporating advanced technology lenses into their training programs. Read on for the tips and tricks they use when instructing residents and speaking to patients about an advanced technology lens.
­—Julie Schallhorn, MD
YES Connect Co-Editor

While the 2019 ASCRS Clinical Survey revealed that, on average, 10% of cataract cases include a presbyopia-correcting IOL, a strong number of young eye surgeons—those in training, fellowship, or their first 5 years of practice—are getting a good amount of exposure to these advanced technology lenses.
Nearly 67% of young eye surgeons who took the survey said they were confident or very confident, given their training and/or other experience, with the preop workup, implantation, and management of these IOLs. Sixty-six percent of young eye surgeons had implanted at least one presbyopia-correcting IOL.
Preeya Gupta, MD, finds the results from young eye surgeons encouraging. “If we had asked those questions even 5–10 years ago, we would have gotten a different answer. I’m pleasantly surprised that 66% had implanted presbyopia-correcting technology. I would love to see that number closer to 90% because I think everyone should try it at some point and have access to that safe arena where they can be mentored and can try something,” she said.
Having willing faculty and mentors who believe in the value of this technology is one thing; getting the patient on board for this out-of-pocket technology is another. Neeti Parikh, MD, said many residency training institutions have programs that allow the patient to get the advanced technology lens without charge.
“They’re told this is a teaching institution, and if they’re willing to allow the resident to do the case, knowing that the attending is going to be scrubbed in and will step in at any point if needed, the company has a resident program where they don’t have to pay the out-of-pocket fee for the premium lenses,” Dr. Parikh said.
For those new to using presbyopia-correcting lenses, Dr. Parikh said, they first have to be comfortable with the cataract surgery itself.
“If you’re not comfortable and confident with the cataract surgery itself, it’s hard to discuss the next step, the premium lenses, and be able to offer them with confidence,” she said. “A resident doing their first 10–20 cataract cases should not be doing premium lenses.”
After that, it’s important to have an understanding of the different presbyopia-correcting lens options, how they work, and the nuances of patient selection. Both Dr. Gupta and Dr. Parikh said the conversation with the patient is the most important part.
“[Patients] have to understand what the lenses can offer and what things they might have to give up because there are trade-offs with premium lenses,” Dr. Parikh said, adding it often takes more than one conversation with the patient.
Dr. Gupta offered advice on honing these communication skills. “I find that listening to how other people speak to patients about premium technology is helpful. When I was in fellowship, I was comfortable with implanting the lens and over time learned who the most optimal candidate was, but some of the best teaching I had was listening to how my attendings talked to patients. Sometimes we are so focused on the medical aspects … that we forget that part of selecting these patients is listening to them and educating them,” she said. “One simple thing is to observe yourself. Record yourself in a patient conversation. … Reflect on how you’re coming across to the patient and learn more about how you communicate so you can improve your communication skills.”
Dr. Parikh had two specific pieces of advice when it comes to the patient conversation and presbyopia-correcting IOLs: 1) discuss all IOL options with the patient (even if they’re not a candidate) and 2) be sure to set appropriate expectations.
“There is new technology coming out every day, and google.com is the first thing the patient is going to do before coming to you,” she said. “A lot of times, if you don’t talk about the technology, even if you don’t think the patient is a good candidate for a certain type of lens and you don’t offer them that lens, they are going to call you back or ask you about it after the surgery. … Have that discussion with the patient and explain whether you think they are or are not a candidate. … If you don’t mention them, they’ll think that it was looked over or you didn’t know about it.”
Patients opting for an advanced technology lens have higher expectations, which Dr. Parikh said puts more pressure on the surgeon.
“A lot of it is not lowering their expectations but making sure the patient’s expectations are realistic from the beginning,” she said. “For every step of the process patients need to be prepared ahead of time. Then some of the anxiety on their part is a less, which in turn will lower the surgeon’s anxiety.”
For some final takeaways for those getting started with these IOLs, Dr. Gupta said make sure the patient has realistic expectations of the IOL’s capabilities, don’t use them in patients with ocular surface disease, and develop a comprehensive skillset to troubleshoot any postop issues.
“If you’re going to start doing these lenses, you may want to learn how to do PRK, for example, so you can touch up any refractive misses. Or you might want to know how to do an LRI at the slit lamp if there is any residual astigmatism,” she said. “Have your tool bag ready to troubleshoot. I think that if you can handle most things, you should be confident that you’re going to make the patient happy.”

About the doctors

Preeya Gupta, MD
Associate professor
of ophthalmology
Duke University School
of Medicine
Durham, North Carolina

Neeti Parikh, MD
Assistant professor
of ophthalmology
University of California, San
Francisco School of Medicine
San Francisco, California

Relevant disclosures

Gupta: Johnson & Johnson Vision, Alcon
Parikh: None

Contact

Gupta: preeya.gupta@duke.edu
Parikh: neeti.parikh@ucsf.edu

Developing the skills for presbyopia-correcting IOLs Developing the skills for presbyopia-correcting IOLs
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